Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

Key PointsQuestionIn critically ill patients who receive invasive mechanical ventilation, how is invasive mechanical ventilation discontinued and do discontinuation practices differ internationally? FindingsIn 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. MeaningMechanical ventilation weaning practices varied internationally, with nearly 50% of patients undergoing an initial spontaneous breathing trial. ImportanceAlthough most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. ObjectiveTo 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 ParticipantsProspective, 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). ExposuresReceiving IMV. Main Outcomes and MeasuresPrimary 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. ResultsAmong 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 RelevanceIn 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 RegistrationClinicalTrials.gov Identifier: NCT03955874 This critical care epidemiology study describes practice variation in invasive mechanical ventilation weaning and discontinuation practices, associations between initial discontinuation events and outcomes, and factors associated with use of select discontinuation strategies and failed initial spontaneous breathing trials among critically ill patients in ICUs in 19 countries.

Automated summary

This study revealed significant practice variation in invasive mechanical ventilation weaning and discontinuation internationally, with nearly 50% of patients undergoing an initial spontaneous breathing trial. Different discontinuation events were associated with clinical outcomes, and the outcomes of spontaneous breathing trials were influenced by timing.