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# Criteria for Weaning from Mechanical Ventilation

*Evidence Reports/Technology Assessments, No. 23*

Investigators: Deborah Cook, MD, Principal Investigator, Maureen Meade, MD, Gordon Guyatt, MD, Lauren Griffith, MSc, and Lynda Booker, BA.

Agency for Healthcare Research and Quality (US)2000 Nov
Report No.: 01-E0101-58763-011-7

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## Structured Abstract

#### Objectives:

               Because mechanical ventilation incurs significant morbidity, mortality, and costs                    and because premature extubation as well as delayed extubation can cause harm,                    weaning that is both expeditious and safe is highly desirable. We sought to                    determine whether the current literature elucidates when and how weaning should                    begin, proceed, and end.

#### Search Strategy:

                We used five computerized bibliographic databases, hand searching, bibliographic                    references, expert consultation, and a duplicate independent review process to                    identify relevant articles.

#### Selection Criteria:

                Our eligibility criteria were broad. We selected studies evaluating any weaning                    modes, algorithms, or other interventions to facilitate weaning; studies of                    weaning predictors; and studies evaluating patient and nursing experiences                    during weaning.

#### Data Collection and Analysis:

                We developed generic forms to abstract data from all studies, in addition to                    forms specific to randomized trials, nonrandomized controlled studies, and                    studies of weaning predictors. We developed an instruction manual and trained                    eight individuals to abstract data related to study characteristics and results                    using duplicate, independent review. Quantitative data were abstracted using                    several metrics. We pooled results across randomized trials and across studies                    of weaning predictors only when our assessment of the patients, interventions,                    and outcomes indicated that pooling was legitimate.

#### Main Results:

                We reviewed 154 articles. For stepwise reductions in mechanical support, pressure                    support mode or multiple daily T-piece trials may be superior to synchronized                    intermittent mandatory ventilation. For trials of unassisted breathing, low                    levels of pressure support may be beneficial. There may be substantial benefits                    to early extubation and institution of noninvasive positive pressure ventilation                    before patients are ready to breathe without mechanical assistance. The value of                    differing modes as reflected in these studies depends on the thresholds for                    initiating, progressing through, and terminating weans in the specific study                    protocols. Unfortunately, these thresholds involve more than objective data and                    appear to be related to physician judgment.

The implementation of nurse-driven or respiratory therapist-driven weaning                    protocols, regardless of what modes are employed, significantly expedites                    weaning and is probably safe. Following cardiac surgery, early extubation is                    unequivocably achieved with a variety of anesthetic interventions and intensive                    care unit protocols; however, the corresponding reduction in intensive care unit                    stay is generally small and the impact on complications, though rare, remains                    unclear. The role of computerized protocols has not been established.

We did not uncover any consistently powerful weaning predictors. The most                    frequently studied and one of the most helpful tests is the rapid shallow                    breathing index; however, the pooled likelihood ratio for a positive test ranged                    from 1.3 to 2.8. Two other predictors, occlusion pressure/maximum inspiratory                    pressure and the compliance, rate, oxygenation, and pressure index, are more                    powerful, though less intensively studied. In general, the probable reason for                    the poor performance of weaning predictors is that physicians have already                    considered the results of these predictors when they select patients for                    study.

#### Conclusions:

               Future research initiatives should include: determining the optimal tradeoff                    between prolonged time on a ventilator and reintubation in specific patient                    groups, further evaluation of weaning protocols (What types of patients are most                    likely to benefit? Which protocols are most effective? How large are the                    associated cost reductions? Is there a role for computers?), and clarification                    of the risk-benefit of early extubation with noninvasive positive pressure                    ventilation.

## Contents

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                        - Preface
                        - Acknowledgments
                        - Summary
                        - 1. Introduction                           - Organization
                          - Mechanical Ventilation and Weaning from Mechanical Ventilation
                          - Questions On Weaning From Mechanical Ventilation
                          - Importance of Optimizing the Weaning Process
                          - How Can Clinicians Conduct an Optimal Wean?
                        - 2. Methodology                           - Eligibility Criteria
                          - Search for Relevant Studies
                          - Data Abstraction and Assessment of Methodologic Quality
                          - Statistical Synthesis
                          - Controlled Comparisons of Alternative Treatments
                          - Observational Studies Addressing Prediction of Successful Weaning and Duration of Ventilation
                          - Methodology For Pooling Study Results
                          - Other Types of Studies
                        - 3. Results                           - Randomized and Nonrandomized Controlled Trials
                          - Controlled Trials of Discontinuation Assessment Strategies
                          - Controlled Trials of Progressive Reduction in Mechanical Support
                          - Controlled Trials Comparing Alternative Ventilation Modes for Weans Lasting Less Than 48 Hours
                          - Controlled Trials Comparing Weaning Protocols to Physician-Directed Weaning
                          - Controlled Trials of Early Versus Late Extubation Following Cardiac Surgery
                          - Controlled Trials of Corticosteroids to Prevent Post-Extubation Airway Complications
                          - Controlled Trials of Enteral Nutrition
                          - Randomized Trials of Miscellaneous Studies
                          - Observational Studies Addressing Prediction of Successful Weaning and Duration of Ventilation
                          - Qualitative Studies of Weaning From Mechanical Ventilation
                          - Observational Studies Describing Patient Experience During Weaning
                        - 4. Conclusions and Future Research                           - Controlled Trials of Unassisted Ventilation
                          - Controlled Trials of Progressive Reduction in Mechanical Support
                          - Controlled Trials Comparing Alternative Ventilation Modes for Weans Lasting Less Than 48 Hours
                          - Controlled Trials Comparing Weaning Protocols to Physician-Directed Weaning
                          - Controlled Trials of Early Versus Late Extubation Following Cardiac Surgery
                          - Controlled Trials of Corticosteroids to Prevent Postextubation Airway Complications
                          - Controlled Trials of Enteral Nutrition
                          - Controlled Trials: Miscellaneous Studies
                          - Observational Studies Addressing Prediction of Successful Weaning and Duration of Ventilation
                          - Observational Studies Describing Patient Experience During Weaning
                          - Strengths and Limitations of This Review
                          - Summary of Inferences From This Review
                          - Summary of Recommendations for Future Research
                        - Evidence Tables
                        - Appendixes                           - Appendix A. Search Strategy: MEDLINE and HealthSTAR for Intervention Studies
                          - Appendix B. Search Strategy: MEDLINE AND HealthSTAR for Observational Studies
                          - Appendix C. Search Strategy: CINAHL for Intervention Studies
                          - Appendix D. Search Strategy: CINAHL for Observational Studies
                          - Appendix E. Search Strategy: EMBASE for Intervention Studies
                          - Appendix F. Search Strategy: EMBASE for Observational Studies
                          - Appendix G. Relevance Form: Weaning from Mechanical Ventilation
                          - Appendix H. Selection Criteria for Articles About Weaning
                          - Appendix I. Extraction Form for General Characteristics fo All Studies
                          - Appendix J. Extraction Form for Randomized Clinical Trials
                          - Appendix K. Extraction Form for Nonrandomized Controlled Clinical Trials
                          - Appendix L. Extraction Form for Observational Studies
                          - Appendix M. Acronyms and Abbreviations
                        - References
                        - Bibliography

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Prepared for: Agency for Healthcare Research and Quality, U.S. Department                of Health and Human Services.1                 Contract No. 290-97-0017.                Prepared by: Department of Medicine                    and Clinical Epidemiology & Biostatistics, McMaster University,                    Hamilton, Ontario, Canada.

#### Suggested citation:

Cook D, Meade M, Guyatt G, et al. Criteria for                    Weaning From Mechanical Ventilation. Evidence Report/Technology Assessment No.                    23 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ                    Publication No. 01-E010. Rockville MD: Agency for Healthcare Research and                    Quality. November 2000.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and                Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and                Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost,                quality, and outcomes of health care, and expands its role to improve patient safety                and address medical errors.

This report may be used, in whole or in part, as the basis for development of                clinical practice guidelines and other quality enhancement tools, or a basis for                reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human                Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements in the report                should not be construed as endorsement by the Agency for Healthcare Research and                Quality or the U.S. Department of Health and Human Services of a particular drug,                test, treatment, or other clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK33323

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                    - Cite this Page Cook D, Meade M, Guyatt G, et al. Criteria for Weaning from Mechanical Ventilation. Rockville (MD): Agency for Healthcare Research and Quality (US); 2000 Nov. (Evidence Reports/Technology Assessments, No. 23.)

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