Pressure support versus T-tube for weaning from mechanical ventilation in adults

BackgroundMechanical ventilation is important in caring for patients with critical illness. Clinical complications, increased mortality, and high costs of health care are associated with prolonged ventilatory support or premature discontinuation of mechanical ventilation. Weaning refers to the process of gradually or abruptly withdrawing mechanical ventilation. the weaning process begins after partial or complete resolution of the underlying pathophysiology precipitating respiratory failure and ends with weaning success (successful extubation in intubated patients or permanent withdrawal of ventilatory support in tracheostomized patients).ObjectivesTo evaluate the effectiveness and safety of two strategies, a T-tube and pressure support ventilation, for weaning adult patients with respiratory failure that required invasive mechanical ventilation for at least 24 hours, measuring weaning success and other clinically important outcomes.Search methodsWe searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); MEDLINE (via PubMed) (1966 to June 2012); EMBASE (January 1980 to June 2012); LILACS (1986 to June 2012); CINAHL (1982 to June 2012); SciELO (from 1997 to August 2012); thesis repository of CAPES (Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior) (http://capesdw.capes.gov.br/capesdw/) (August 2012); and Current Controlled Trials (August 2012).We reran the search in December 2013. We will deal with any studies of interest when we update the review.Selection criteriaWe included randomized controlled trials (RCTs) that compared a T-tube with pressure support (PS) for the conduct of spontaneous breathing trials and as methods of gradual weaning of adult patients with respiratory failure of various aetiologies who received invasive mechanical ventilation for at least 24 hours.Data collection and analysisTwo authors extracted data and assessed the methodological quality of the included studies. Meta-analyses using the random-effects model were conducted for nine outcomes. Relative risk (RR) and mean difference (MD) or standardized mean difference (SMD) were used to estimate the treatment effect, with 95% confidence intervals (CI).Main resultsWe included nine RCTs with 1208 patients; 622 patients were randomized to a PS spontaneous breathing trial (SBT) and 586 to a T-tube SBT. the studies were classified into three categories of weaning: simple, difficult, and prolonged. Four studies placed patients in two categories of weaning. Pressure support ventilation (PSV) and a T-tube were used directly as SBTs in four studies (844 patients, 69.9% of the sample). in 186 patients (15.4%) both interventions were used along with gradual weaning from mechanical ventilation; the PS was gradually decreased, twice a day, until it was minimal and periods with a T-tube were gradually increased to two and eight hours for patients with difficult and prolonged weaning. in two studies (14.7% of patients) the PS was lowered to 2 to 4 cm H2O and 3 to 5 cm H2O based on ventilatory parameters until the minimal PS levels were reached. PS was then compared to the trial with the T-tube (TT).We identified 33 different reported outcomes in the included studies; we took 14 of them into consideration and performed meta-analyses on nine. With regard to the sequence of allocation generation, allocation concealment, selective reporting and attrition bias, no study presented a high risk of bias. We found no clear evidence of a difference between PS and TT for weaning success (RR 1.07, 95% CI 0.97 to 1.17, 9 studies, low quality of evidence), intensive care unit (ICU) mortality (RR 0.81, 95% CI 0.53 to 1.23, 5 studies, low quality of evidence), reintubation (RR 0.92, 95% CI 0.66 to 1.26, 7 studies, low quality evidence), ICU and long-term weaning unit (LWU) length of stay (MD -7.08 days, 95% CI -16.26 to 2.1, 2 studies, low quality of evidence) and pneumonia (RR 0.67, 95% CI 0.08 to 5.85, 2 studies, low quality of evidence). PS was significantly superior to the TT for successful SBTs (RR 1.09, 95% CI 1.02 to 1.17, 4 studies, moderate quality of evidence). Four studies reported on weaning duration, however we were unable to combined the study data because of differences in how the studies presented their data. One study was at high risk of other bias and four studies were at high risk for detection bias. Three studies reported that the weaning duration was shorter with PS, and in one study the duration was shorter in patients with a TT.Authors' conclusionsTo date, we have found evidence of generally low quality from studies comparing pressure support ventilation (PSV) and with a T-tube. the effects on weaning success, ICU mortality, reintubation, ICU and LWU length of stay, and pneumonia were imprecise. However, PSV was more effective than a T-tube for successful spontaneous breathing trials (SBTs) among patients with simple weaning. Based on the findings of single trials, three studies presented a shorter weaning duration in the group undergoing PS SBT, however a fourth study found a shorter weaning duration with a T-tube.

Evaluation of resources to support production of high quality health information for patients and the public. Final report for NHS Research Outputs Programme

Durbin, J., Urquhart, C. & Yeoman, A. (2003). Evaluation of resources to support production of high quality health information for patients and the public. Final report for NHS Research Outputs Programme. Aberystwyth: Department of Information Studies, University of Wales Aberystwyth. Sponsorship: Department of Health

Thinking with and outside the box: developing computer support for evidence teaching

B. Schafer, J. Keppens and Q. Shen. Thinking with and outside the Box: Developing Computer Support for Evidence Teaching. P. Robert and M. Redmayne (Eds.), Innovations in Evidence and Proof: Integrating Theory, Research and Teaching, pp. 139-158, 2007.

A scenario-driven decision support system for serious crime investigation

Q. Shen, J. Keppens, C. Aitken, B. Schafer, and M. Lee. A scenario driven decision support system for serious crime investigation. Law, Probability and Risk, 5(2):87-117, 2006. Sponsorship: UK Engineering and Physical Sciences Research Council grant GR/S63267; partially supported by grant GR/S98603

Compositional Bayesian modelling and its application to decision support in crime investigation

J. Keppens, Q. Shen and M. Lee. Compositional Bayesian modelling and its application to decision support in crime investigation. Proceedings of the 19th International Workshop on Qualitative Reasoning, pages 138-148.

Political Leadership and Public Support In Belarus: Forward to the Past?

Korosteleva-Polglase Elena, White, S., 'Political Leadership and Public Support In Belarus: Forward to the Past?', In: 'The EU and Belarus: Between Moscow and Brussels', (London: Kogan Page), pp.51-71, 2001 RAE2008

Evidence in support of a role for plant-mediated proteolysis in the rumens of grazing animals

Kingston-Smith, A. H., Merry, R. J., Leemans, D. K., Thomas, Howard, Theodorou, M. K. (2005). Evidence in support of a role for plant-mediated proteolysis in the rumens of grazing animals. British Journal of Nutrition, 93(1), 73-79. Sponsorship: DEFRA / BBSRC RAE2008

The nature of emotional support and counselling provision for people with sight loss in the United Kingdom

People with sight loss in the United Kingdom are known to have lower levels of emotional wellbeing and to be at higher risk of depression. Consequently ‘having someone to talk to’ is an important priority for people with visual impairment. An on-line survey of the provision of emotional support and counselling for people affected by sight loss across the UK was undertaken. The survey was distributed widely and received 182 responses. There were more services offering ‘emotional support’, in the form of listening and information and advice giving, than offered ‘counselling’. Services were delivered by providers with differing qualifications in a variety of formats. Waiting times were fairly short and clients presented with a wide range of issues. Funding came from a range of sources, but many felt their funding was vulnerable. Conclusions have been drawn about the need for a national standardised framework for the provision of emotional support and counselling services for blind and partially sighted people in the UK

Address to the pious and benevolent, proposing an annual subscription for the support of missionaries in the Highlands and adjacent islands of Scotland, the isles of Jersey, Guernsey, and Newfoundland, the West Indies, and the provinces of Nova Scotia and Quebec.

Reproduction of copy held by Special Collections, Bridewell Library, Perkins School of Theology, Southern Methodist University. Includes both DjVu and PDF files for download. Mode of access: World Wide Web.

Services to support BU Authors with Open Access Issues

A working paper written for Boston University Libraries to foster discussion about how to provide better support for BU faculty authors.

OS Support for Portable Bulk Synchronous Parallel Programs

Predictability -- the ability to foretell that an implementation will not violate a set of specified reliability and timeliness requirements -- is a crucial, highly desirable property of responsive embedded systems. This paper overviews a development methodology for responsive systems, which enhances predictability by eliminating potential hazards resulting from physically-unsound specifications. The backbone of our methodology is the Time-constrained Reactive Automaton (TRA) formalism, which adopts a fundamental notion of space and time that restricts expressiveness in a way that allows the specification of only reactive, spontaneous, and causal computation. Using the TRA model, unrealistic systems – possessing properties such as clairvoyance, caprice, infinite capacity, or perfect timing -- cannot even be specified. We argue that this "ounce of prevention" at the specification level is likely to spare a lot of time and energy in the development cycle of responsive systems -- not to mention the elimination of potential hazards that would have gone, otherwise, unnoticed. The TRA model is presented to system developers through the Cleopatra programming language. Cleopatra features a C-like imperative syntax for the description of computation, which makes it easier to incorporate in applications already using C. It is event-driven, and thus appropriate for embedded process control applications. It is object-oriented and compositional, thus advocating modularity and reusability. Cleopatra is semantically sound; its objects can be transformed, mechanically and unambiguously, into formal TRA automata for verification purposes, which can be pursued using model-checking or theorem proving techniques. Since 1989, an ancestor of Cleopatra has been in use as a specification and simulation language for embedded time-critical robotic processes.

Angels: In Network Support for Minimum Distribution Time in P2P Overlays

This paper proposes the use of in-network caches (which we call Angels) to reduce the Minimum Distribution Time (MDT) of a file from a seeder – a node that possesses the file – to a set of leechers – nodes who are interested in downloading the file. An Angel is not a leecher in the sense that it is not interested in receiving the entire file, but rather it is interested in minimizing the MDT to all leechers, and as such uses its storage and up/down-link capacity to cache and forward parts of the file to other peers. We extend the analytical results by Kumar and Ross [1] to account for the presence of angels by deriving a new lower bound for the MDT. We show that this newly derived lower bound is tight by proposing a distribution strategy under assumptions of a fluid model. We present a GroupTree heuristic that addresses the impracticalities of the fluid model. We evaluate our designs through simulations that show that our Group-Tree heuristic outperforms other heuristics, that it scales well with the increase of the number of leechers, and that it closely approaches the optimal theoretical bounds.

Angels: In-Network Support for Minimum Distribution Time in P2P Overlays

This thesis proposes the use of in-network caches (which we call Angels) to reduce the Minimum Distribution Time (MDT) of a file from a seeder – a node that possesses the file – to a set of leechers – nodes who are interested in downloading the file. An Angel is not a leecher in the sense that it is not interested in receiving the entire file, but rather it is interested in minimizing the MDT to all leechers, and as such uses its storage and up/down-link capacity to cache and forward parts of the file to other peers. We extend the analytical results by Kumar and Ross (Kumar and Ross, 2006) to account for the presence of angels by deriving a new lower bound for the MDT. We show that this newly derived lower bound is tight by proposing a distribution strategy under assumptions of a fluid model. We present a GroupTree heuristic that addresses the impracticalities of the fluid model. We evaluate our designs through simulations that show that our GroupTree heuristic outperforms other heuristics, that it scales well with the increase of the number of leechers, and that it closely approaches the optimal theoretical bounds.

Efficient Support for Common Relations in Lightweight Formal Reasoning Systems

In work that involves mathematical rigor, there are numerous benefits to adopting a representation of models and arguments that can be supplied to a formal reasoning or verification system: reusability, automatic evaluation of examples, and verification of consistency and correctness. However, accessibility has not been a priority in the design of formal verification tools that can provide these benefits. In earlier work [Lap09a], we attempt to address this broad problem by proposing several specific design criteria organized around the notion of a natural context: the sphere of awareness a working human user maintains of the relevant constructs, arguments, experiences, and background materials necessary to accomplish the task at hand. This work expands one aspect of the earlier work by considering more extensively an essential capability for any formal reasoning system whose design is oriented around simulating the natural context: native support for a collection of mathematical relations that deal with common constructs in arithmetic and set theory. We provide a formal definition for a context of relations that can be used to both validate and assist formal reasoning activities. We provide a proof that any algorithm that implements this formal structure faithfully will necessary converge. Finally, we consider the efficiency of an implementation of this formal structure that leverages modular implementations of well-known data structures: balanced search trees and transitive closures of hypergraphs.