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Original Investigation
Caring for the Critically Ill Patient
March 23/30, 2021

Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

Author Affiliations
  • 1Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
  • 2Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
  • 3Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 4Division of Critical Care Medicine, St Joseph’s Hospital, Hamilton, Ontario, Canada
  • 5Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
  • 6Applied Health Research Centre, St Michael’s Hospital, Toronto, Ontario, Canada
  • 7Centre for Health Evaluation and Outcome Sciences, Division of Critical Care Medicine, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
  • 8CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
  • 9Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain
  • 10Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
  • 11Department of Intensive Care, Hinduja National Hospital, Bombay, India
  • 12Intensive Care Unit, Royal Prince Alfred Hospital,, University of Sydney, Camperdown, New South Wales, Australia
  • 13The George Institute for Global Health, Sydney Australia
  • 14Tufts University School of Medicine, Boston, Massachusetts
  • 15Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
  • 16San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
  • 17Anaesthesia, Critical Care and Pain Medicine, Edinburgh Royal Infirmary, Edinburgh, Scotland, United Kingdom
JAMA. 2021;325(12):1173-1184. doi:10.1001/jama.2021.2384
Key Points

Question  In critically ill patients who receive invasive mechanical ventilation, how is invasive mechanical ventilation discontinued and do discontinuation practices differ internationally?

Findings  In this prospective observational study that included 1868 patients from 142 intensive care units in Canada, Europe, the US, India, the UK, and Australia/New Zealand from November 2013 to December 2016, 22.7% of patients underwent direct extubation, 49.8% underwent an initial spontaneous breathing trial (of which 81.8% had successful extubation), 8.0% had a direct tracheostomy, and 19.5% died before a weaning attempt. There was notable variation in several aspects of mechanical ventilation weaning practices.

Meaning  Mechanical ventilation weaning practices varied internationally, with nearly 50% of patients undergoing an initial spontaneous breathing trial.

Abstract

Importance  Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.

Objective  To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs).

Design, Setting, and Participants  Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US).

Exposures  Receiving IMV.

Main Outcomes and Measures  Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes.

Results  Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]).

Conclusions and Relevance  In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally.

Trial Registration  ClinicalTrials.gov Identifier: NCT03955874

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