Reuters Health Information

Study Suggests Best Method to Wean From Prolonged Mechanical

Ventilation By Megan Brooks
Feb 19, 2013
NEW YORK (Reuters Health) Feb 19 - Weaning from prolonged mechanical ventilation took less time
with unassisted breathing through a tracheostomy collar than with pressure-support ventilation, in a
randomized controlled trial at one long-term acute care hospital.
Patients requiring mechanical ventilation for more than 21 days are commonly weaned at long-term
acute care hospitals (LTACHs), but the most effective method of weaning has not been investigated.
The new study, published online February 19 in the Journal of the American Medical Association,
shows that "patients requiring prolonged mechanical ventilation should be weaned with daily trials of
unassisted breathing through a trach collar and not with pressure support," first author Dr. Amal
Jubran from Edward Hines Jr VA Hospital in Hines, Illinois told Reuters Health.
The study enrolled 500 patients, all with tracheostomies, transferred to RML Specialty Hospital in
Hinsdale, Illinois, a free-standing 90-bed LTACH where two thirds of the beds are devoted to
ventilator weaning. All 500 patients underwent a five-day trial of completely unassisted breathing and
160 passed the trial and were considered weaned.
Of the remaining subjects, 316 were randomly allocated to one of two groups. One group of 155
patients received around-the-clock pressure-support ventilation with systematic reductions in the level
of pressure support as tolerated, analogous to current guidelines. The other group of 161 patients
received daily unassisted breathing via a tracheostomy tube and full ventilator support at night,
analogous to a "spontaneous breathing trial" that is the usual approach in acute care ICUs.
Patients in the unassisted breathing group experienced significantly shorter median duration of
weaning compared with patients in the pressure-support group (15 days vs 19 days; p=0.004), the
authors report.
After adjusting for baseline clinical variables, successful weaning was more likely in the trach group
(hazard ratio 1.43; p=0.033).
Mortality rates were not significantly different in the pressure-support and tracheostomy collar groups
at six months (53% vs 51%) and 12 months (66% vs 60%).
This study "provides new data that should prove to be informative for caring for patients in LTACH
settings," the authors of a linked editorial say.

Strengths of the study include the "importance of the research question, the careful consideration of
the comparator groups based on strong physiological rationale, and the complete follow-up," write Dr.
Jeremy Kahn of University of Pittsburgh School of Medicine and Dr. Shannon Carson of University of
North Carolina, Chapel Hill.
Several limitations are also worth noting, they say. The primary outcome was duration of ventilator
weaning, which, although important, is not necessarily patient-centered. Truly patient-centered
outcomes such as the percentage of patients successfully weaned and one-year mortality were not
significantly different between groups.
"Additionally, contrary to published protocols, patients in the pressure support group were not rested
on full ventilator support (i.e., 'assist control') at night. The efficacy of daily unassisted breathing
compared with daily reductions in pressure support when both groups are rested on assist control at
night is a critical but unanswered research question. In addition, the study was conducted at a single
LTACH and the generalizability of the findings is unknown," they point out.
Drs. Kahn and Carson also think this study "elegantly" demonstrates the consequences of current
Centers for Medicare & Medicaid Services (CMS) regulations that define LTACHs not by the patients
they admit or the services they provide but their average length of stay, which by rule must exceed an
average of 25 days.
Thirty-two percent of enrolled patients demonstrated an ability to breathe unassisted for five days
during the initial breathing trial, and thus were not randomized in the trial, they explain. This finding,
they say, suggests that many patients sent to LTACHs for "failure to wean" from the ventilator may
have experienced "failure to attempt to wean" from the ventilator.
"Those patients might have remained in an ICU, potentially saving the costs associated with a second
hospitalization. An objective test such as an inability to breathe via tracheostomy tube for a specified
amount of time may be a useful benchmark for LTACH admission. This idea requires external
validation, however, because the patients in this study may have required LTACH care for other
reasons, irrespective of their perceived ventilator dependence," the editorialists conclude.
They also think this trial shows that it's feasible to open the "black box" that clinical care in LTACHs
exists in, where ventilator management and other aspects of patient care are guided by clinical
experience and intuition rather than robust trial data.
"Large-scale clinical trials are not just feasible but essential in defining best practice, developing
admission standards, and better understanding the increasing role of LTACHs for patients recovering
from chronic critical illness," Dr. Kahn and Dr. Carson conclude.
The

National

Institute

of

Nursing

Research

provided

funding

for

SOURCE: http://bit.ly/11Ty0BL and http://bit.ly/11Ty0BL JAMA 2013;671-677,719-720.

the

study.