Weaning from ventilation

Aims/purpose: Getting off the ventilator is an important patient-centred outcome for patients with acute respiratory failure. It signifies an improvement in patient condition, enables easier communication, reduces fear and anxiety and consequently a reduced requirement for sedatives. Weaning from ventilation therefore is a core ICU nursing task that is addressed in this presentation.
Presentation description: There are different schools of thought on when ventilator weaning begins including: (a) from intubation with titration of support; and (b) only when the patient’s condition improves. There are also different schools of thought on how to wean including gradual reductions in ventilator support to: (a) a low level consistent with extubation; or (b) to a level to attempt a spontaneous breathing trial followed by extubation if successful. Regardless of the approach, what is patient-relevant is the need to determine early when the patient may be ‘ready’ to discontinue ventilation. This time point can be assessed using simple criteria and should involve all ICU staff to the level of their experience. This presentation challenges the notion that only senior nurses or nurses with a ‘weaning course’ should be involved in the weaning process and proposes opportunities for engaging nurses with all levels of experience.
Conclusion: An ICU nursing taskforce that is focused and engaged in determining patient readiness for weaning can make a strong contribution to patient-relevant outcomes.

Non-invasive Ventilation of Patients with ARDS: Insights from the LUNG SAFE Study

Background: Non-invasive ventilation (NIV) is increasingly used in patients with Acute Respiratory Distress Syndrome (ARDS). Whether, during NIV, the categorization of ARDS severity based on the PaO2/FiO2 Berlin criteria is useful is unknown. The evidence supporting NIV use in patients with ARDS remains relatively sparse.

Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study described the management of patients with ARDS. This sub-study examines the current practice of NIV use in ARDS, the utility of the PaO2/FiO2 ratio in classifying patients receiving NIV and the impact of NIV on outcome.

Results: Of 2,813 patients with ARDS, 436 (15.5%) were managed with NIV on days 1 and 2 following fulfillment of diagnostic criteria. Classification of ARDS severity based on PaO2/FiO2 ratio was associated with an increase in intensity of ventilatory support, NIV failure, and Intensive Care Unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1 % and 45.4%, respectively. NIV use was independently associated with increased ICU (HR 1.446; [1.159-1.805]), but not hospital mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FiO2 lower than 150 mmHg.

Conclusions: NIV was used in 15% of patients with ARDS, irrespective of severity category. NIV appears to be associated with higher ICU mortality in patients with a PaO2/FiO2 lower than 150 mmHg.

Trial Registration: ClinicalTrials.gov NCT02010073