Automatic Tube Compensation During Weaning From Mechanical Ventilation

An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients

BACKGROUND

Studies of nighttime intensivist staffing have yielded mixed results.

GOALS

To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients.

METHODS

We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.

RESULTS

Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes.

CONCLUSIONS

Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.

Weaning from mechanical ventilation: why are we still looking for alternative methods?

Most patients who require mechanical ventilation for longer than 24 hours, and who improve the condition leading to the indication of ventilatory support, can be weaned after passing a first spontaneous breathing test. The challenge is to improve the weaning of patients who fail that first test. We have methods that can be referred to as traditional, such as the T-tube, pressure support or synchronized intermittent mandatory ventilation (SIMV). In recent years, however, new applications of usual techniques as noninvasive ventilation, new ventilation methods such as automatic tube compensation (ATC), mandatory minute ventilation (MMV), adaptive support ventilation or automatic weaning systems based on pressure support have been described. Their possible role in weaning from mechanical ventilation among patients with difficult or prolonged weaning remains to be established.

Overview of mechanical ventilatory support and management of patient- and ventilator-related responses

Nurses must be knowledgeable about the function and limitations of ventilator modes, causes of respiratory distress and dyssynchrony with the ventilator, and appropriate management in order to provide high-quality patient-centered care. Prompt recognition of problems and action by the nurse may resolve acute respiratory distress, dyspnea, and increased work of breathing and prevent adverse events. This article presents an overview of mechanical ventilation modes and the assessment and management of dyspnea and patient-ventilator dyssynchrony. Strategies to manage patients' responses to mechanical ventilatory support and recommendations for staff education also are presented.