Ely E W, Meade M O, Haponik E F, Kollef M H, Cook D J, Guyatt G H, Stoller J K
Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
Chest. 2001 Dec;120(6 Suppl):454S-63S. doi: 10.1378/chest.120.6_suppl.454s.
Health-care professionals (HCPs) can provide protocol-based care that has a measurable impact on critically ill patients beyond their liberation from mechanical ventilation (MV). Randomized controlled trials have demonstrated that protocols for liberating patients from MV driven by nonphysician HCPs can reduce the duration of MV. The structure and features of protocols should be adapted from published protocols to incorporate patient-specific needs, clinician preferences, and institutional resources. As a general approach, shortly after patients demonstrate that their condition has been stabilized on the ventilator, a spontaneous breathing trial (SBT) is safe to perform and is indicated. Ventilator management strategies for patients who fail a trial of spontaneous breathing include the following: (1) consideration of all remediable factors (such as electrolyte derangements, bronchospasm, malnutrition, patient positioning, and excess secretions) to enhance the prospects of successful liberation from MV; (2) use of a comfortable, safe, and well-monitored mode of MV (such as pressure support ventilation); and (3) repeating a trial of spontaneous breathing on the following day. For patients who pass the SBT, the decision to extubate must be guided by clinical judgment and objective data to minimize the risk of unnecessary reintubations and self-extubations. Protocols should not represent rigid rules but, rather, guides to patient care. Moreover, the protocols may evolve over time as clinical and institutional experience with them increases. Useful protocols aim to safely and efficiently liberate patients from MV, reducing unnecessary or harmful variations in approach.
医疗保健专业人员（HCPs）可以提供基于方案的护理，这对重症患者产生的影响不仅限于使其脱离机械通气（MV）。随机对照试验表明，由非医生HCPs驱动的患者脱离MV方案可缩短MV持续时间。方案的结构和特征应根据已发表的方案进行调整，以纳入患者的具体需求、临床医生的偏好和机构资源。一般来说，在患者证明其在呼吸机上病情稳定后不久，进行自主呼吸试验（SBT）是安全的且是合适的。对于自主呼吸试验失败的患者，呼吸机管理策略包括以下几点：（1）考虑所有可纠正的因素（如电解质紊乱、支气管痉挛、营养不良、患者体位和分泌物过多），以提高成功脱离MV的可能性；（2）使用舒适、安全且监测良好的MV模式（如压力支持通气）；（3）在次日重复进行自主呼吸试验。对于通过SBT的患者，拔管决策必须以临床判断和客观数据为指导，以尽量减少不必要的重新插管和自行拔管的风险。方案不应是僵化的规则，而应是患者护理的指南。此外，随着临床和机构对方案的经验增加，方案可能会随着时间的推移而演变。有用的方案旨在安全有效地使患者脱离MV，减少方法上不必要或有害的差异。
