New guidelines from the American Thoracic Society and American College of Chest Physicians may provide additional guidance for clinicians like respiratory therapists who manage patients on mechanical ventilation.
Developed by a committee of experts, the guidelines are an update to the 2001 CHEST guideline on ventilator liberation and are based on the most recent evidence in the medical literature.
The committee’s recommendations for acutely hospitalized adults on mechanical ventilation for more than 24 hours are as follows –
- For patients at high risk for extubation failure who have passed a spontaneous breathing trial (SBT), we recommend extubation to preventative non-invasive ventilation (NIV). The committee found evidence that transitioning to non-invasive ventilation reduced ICU length of stay and short- and long-term mortality. The authors emphasized that in these patients NIV should begin immediately after extubation “to realize the outcome benefits.”
- We suggest that the initial SBT be conducted with inspiratory pressure augmentation rather than T-piece or CPAP. The committee wrote that conducting the initial SBT with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower ICU mortality.
- We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
- We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
- We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
- We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for post-extubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
- For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least four hours before extubation. The committee said that clinical judgment should take priority over test results, and added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
Co-Lead Author Timothy Girard, MD, from the University of Pittsburgh, emphasized that the guidelines are intended not to prescribe approaches to care that should be applied to every patient but rather to help reduce variations in practice. “We sought to summarize the best available evidence in a clear, succinct way so that clinicians know what the evidence says about how to liberate the majority of mechanically ventilated ICU patients quickly and safely,” he was quoted as saying.
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