New recommendations for liberation from mechanical ventilation

Chest/ American thoracic society released new guidelines for liberation from mechanical ventilation.

There are six key recommendations. They all are applicable to patients who are mechanically ventilated for more than 24 hours.

For all recommendations, strength is conditional except recommendation for NIV after extubation where it is strong.

  1. Initial SBT or spontaneous breathing trial should be performed with 5 to 8mm water pressure rather than zero (t-piece or CPAP).

Basis of this recommendation is the fact that with no support, there is high failure detected on SBTs, and delay in extubation. Furthermore, there were more patients who were extubated and remain extubated (not reintubated in 48hrs) with pressure support.

Level of evidence is MODERATE, based on 4 RCTs

Only applies to first SBT.

It will be interesting to look at the reasons for using t-piece as mentioned by Tobin.

 

  1. Protocols attempting to minimize sedation should be used.

Level of evidence is LOW

Based on meta analysis of 6 trials totaling about 1400 patients.

There was no significant difference in the duration of mechanical ventilation

Shorter ICU stay in protocolized patients.

No significant difference in short-term mortality.

No specific protocol recommended.

 

  1. Extubation to preventative NIV

Shown to have favorable effect on duration of ventilation, ventilator-free days, extubation success (liberation > 48 hours), duration of intensive care unit (ICU) stay, short-term mortality (60 days), or long term mortality

Based on 5 RCTs.

Specially useful if patients had risk factors, COPD, CHF, hypercapnia, older age, and a higher severity of illness.

Potential undesirable consequences of NIV include nasal bridge damage, conjunctivitis, and nasal ulceration

Level of evidence is STRONG

Two studies also showed equivalent results with High Flow Nasal cannula(HFNC)

 

  1. Protocolized early mobility

Can lead to shorter duration of mechanical ventilation and were more likely to be able to walk at hospital discharge.

No differences in mortality, ICU length of stay, ability to walk at ICU discharge, six minute walk distance, or ventilator-free days.

No particular protocol recommended

Quality of evidence LOW

 

  1. Use a ventilator liberation protocol

Quality of evidence LOW

No adverse effects noted from protocol.

May be either personnel-driven or computer driven

 

  1. Use Cuff leak test prior to extubation and use steroids at least 4 hours prior to extubation in patients with negative cuff leak

Quality of evidence VERY LOW

Risk factors for post extubation stridor , traumatic intubation, intubation > 6 days, large endotracheal tube, female sex, and reintubation after unplanned extubation