Clinical Application of Modified Burns Wean Assessment Program Scores at First Spontaneous Breathing Trial in Weaning Patients from Mechanical Ventilation

Clinical prediction scores predicting weaning failure from invasive mechanical ventilation: Role and limitations

Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.

Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses

BACKGROUND

No assessment tool for predicting ventilator withdrawal success is currently available in Japan. Thus, an accessible and valid assessment tool to address this issue is needed. The Burns Wean Assessment Program (BWAP) has been validated as a reliable predictor of ventilator withdrawal outcomes. However, nurses must be familiar with this tool to ensure its efficient utilization in clinical settings.

PURPOSE

This study was designed to examine the effect of a 26-item Japanese version of BWAP (J-BWAP) e-learning materials on ventilator withdrawal in a sample of intensive care unit nurses in Japan.

METHODS

The BWAP was translated into Japanese, checked, and verified as the J-BWAP. Nonrandomized intensive care unit nurses from six hospitals were assigned to three groups, including Intervention Group 1 (e-learning in one session), Intervention Group 2 (e-learning over three sessions during 1 week), and the control group. The participants underwent pretests and posttests using web-based, simulated patients. The primary outcome measure was the difference in online pretest and posttest total scores among the two intervention groups and the control group. The feasibility of the J-BWAP and its e-learning materials was evaluated using four frameworks: acceptability, demand, implementation, and adaptation.

RESULTS

Of the 48 participants in the study, 32 completed the posttest and were included in the analysis (dropout rate: 33.3%). The difference between pretest and posttest scores was significantly higher in the intervention groups than the control group (2 vs. -1, p = .0191) and in Intervention Group 2 than the control group (2.0 vs. -0.5, p = .049). The feasibility frameworks for the J-BWAP and its e-learning materials were mostly positive.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The development of the J-BWAP and training nurses using e-learning were shown to be feasible in this study. The J-BWAP contents are appropriate for predicting the outcome of mechanical ventilation withdrawal. The J-BWAP has the potential to become a common tool among Japanese medical professionals after the contents are further simplified for daily application in clinical practice. Subsequent studies should verify the reliability and validity of this tool and test the real-world utility of the J-BWAP using randomized controlled trials in Japanese clinical settings.

What do we know about experiencing end-of-life in burn intensive care units? A scoping review

OBJECTIVES

The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units.

METHODS

Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021.

RESULTS

A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care.

SIGNIFICANCE OF RESULTS

End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.

The Effect of Nursing Interventions Based on Burns Wean Assessment Program on Successful Weaning from Mechanical Ventilation: A Randomized Controlled Clinical Trial

Background:

The effective design and implementation of the nursing interventions to evaluate the patients' readiness for ventilator weaning will reduce their connection time to the ventilator and the complications of their connection to it. This study was conducted to examine the effect of nursing interventions based on the Burns Wean Assessment Program (BWAP) on successful weaning from Mechanical Ventilation (MV).

Materials and Methods:

In this clinical trial, 70 patients undergoing MV in the Intensive Care Units (ICUs) of Golestan Hospital (Ahvaz, Iran) in 2018 were randomly assigned to intervention and control groups. The nursing interventions designed based on BWAP were implemented on the patients in the intervention group, who were later weaned from the device according to this program. The recorded data included demographic information, BWAP score, vital signs, and laboratory values, which were analyzed using the Pearson correlation coefficient, Chi-Square, Fisher, and Mann-Whitney U tests.

Results:

There was a statistically significant and inverse correlation between the BWAP score and the MV duration such that a high BWAP score was associated with a shorter MV time (p = 0.041). Also, the mean number of re-intubation (p = 0.001) and the number of re-connection to the ventilator in the intervention group were significantly lower (p = 0.005).

Conclusions:

The results showed that nurses' assessment of patient's readiness for weaning from MV based on this tool and designed nursing care reduced the duration of MV, re-intubation, and re-connection.

Value of modified Burns Wean Assessment Program scores in the respiratory intensive care unit: an Egyptian study

Background

There is no consensus on the most useful predictive indicator for weaning patients from mechanical ventilation (MV). We aimed to evaluate the utility of the modified Burns Wean Assessment Program (m-BWAP) in predicting the weaning success in patients with respiratory disorders admitted to the respiratory intensive care unit (RICU).

Methods

Patients with respiratory failure requiring MV for longer than 48 hours were included. They were weaned by pressure support ventilation and spontaneous breathing trails. Patients were divided into successful and unsuccessful weaning groups according to their outcomes.

Results

A total of 91 patients were enrolled. The majority had chronic obstructive pulmonary diseases (COPD): 40%, overlap syndrome (24%), and obesity hypoventilation syndrome (OHS): 15%. The successful group had significantly higher m-BWAP scores than that in the unsuccessful group (median 65; range 35 to 80 vs. median 45; range 30 to 65; p=0.000), with area under the curve (AUC) of 0.854; 95% CI 0.766 to 0.919), p<0.001. At cut-off value of ≥55, the sensitivity and specificity of m-BWAP to predict successful weaning were 73.77% and 84.85%, respectively. The AUC for m-BWAP was significantly higher than that for rapid shallow breathing index (RSBI).

Conclusion

We conclude that m-BWAP scores represent a good predictor of weaning success among patients with chronic respiratory disorders in the RICU. The m-BWAP checklist has many factors that are closely related to the weaning outcomes of patients with chronic respiratory disorders. Further, large-scale, multicenter studies are warranted.

Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review

BACKGROUND

Use of a high-flow nasal cannula (HFNC) reduced postextubation respiratory failure (PERF) and reintubation rate compared to use of a low-flow oxygen system (LFOS) in low-risk patients. However, no obvious conclusion was reached for high-risk patients. Here, we sought to present the current status of HFNC use as adjunctive oxygen therapy in a clinical setting and to elucidate the nature of the protective effect following extubation.

METHODS

The medical records of 855 patients who were admitted to the intensive care unit of single university hospital during a period of 5.5 years were analyzed retrospectively, with only 118 patients ultimately included in the present research. The baseline characteristics of these patients and the occurrence of PERF and reintubation along with physiologic changes were analyzed.

RESULTS

Eighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of high-risk features including old age, neurologic disease, moderate to severe chronic obstructive pulmonary disease, a long duration of mechanical ventilation, low baseline arterial partial pressure of oxygen to fraction of inspired oxygen ratio, and a high baseline alveolar-arterial oxygen difference. The reintubation rate at 72 hours after extubation was not different (9.5% vs. 8.8%; P=1.000). Hypoxic respiratory failure was slightly higher in the nonreintubation group than in the reintubation group (31.9% vs. 6.7%; P=0.058). Regarding physiologic effects, heart rate was only stabilized after 24 hours of extubation in the HFNC group.

CONCLUSIONS

No difference was found in the occurrence of PERF and reintubation between both groups. It is worth noting that similar PERF and reintubation ratios were shown in the HFNC group in those with certain exacerbating risk factors versus not. Caution is needed regarding delayed reintubation in the HFNC group.