Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada.
JAMA. 2021 Mar 23;325(12):1173-1184. doi: 10.1001/jama.2021.2384.
Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.
To 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 PARTICIPANTS: Prospective, 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).
Receiving IMV.
Primary 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.
Among 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]).
In 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.
ClinicalTrials.gov Identifier: NCT03955874.
尽管大多数危重症患者接受有创机械通气（IMV），但很少有研究描述 IMV 在实践中是如何停止的。
描述国际上 IMV 停止的实践差异，初始停止事件与结局的关联，以及与选择的停止策略和初始自主呼吸试验（SBT）失败相关的因素。
设计、地点和参与者：这是一项前瞻性、多国、观察性研究，纳入了来自 6 个地区的 19 个国家的 142 个重症监护病房（ICU）中至少接受 24 小时 IMV 的成年危重症患者（加拿大 27 例、印度 23 例、英国 22 例、欧洲 26 例、澳大利亚/新西兰 21 例、美国 23 例）。
接受 IMV。
主要分析描述了初始 IMV 停止事件（拔管、SBT 或气管切开术）的类型及其与临床结局（包括通气时间、ICU 和医院死亡率以及 ICU 和医院住院时间）的关联。次要分析检查了 SBT 结果与 SBT 时机和临床结局的关联。
在 1868 例患者中（中位数[四分位数间距]年龄，61.8[48.9-73.1]岁；1173 例[62.8%]为男性），424 例（22.7%）直接拔管，930 例（49.8%）进行了初始 SBT（761 例[81.8%]成功），150 例（8.0%）直接行气管切开术，364 例（19.5%）在尝试撤机前死亡。在不同地区，用于指导护理的书面医嘱、每日筛查、SBT 技术、呼吸机模式以及参与撤机的临床医生的角色等方面存在差异。与直接初始拔管相比，进行初始 SBT 的患者 ICU 死亡率更高（20 例[4.7%]比 96 例[10.3%]；绝对差异，5.6%[95%CI，2.6%-8.6%]），通气时间更长（中位数 2.9 比 4.1 天；绝对差异，1.2 天[95%CI，0.7-1.6]），ICU 住院时间更长（中位数 6.7 比 8.1 天；绝对差异，1.4 天[95%CI，0.8-2.4]）。初始 SBT 失败（而非成功）的患者 ICU 死亡率更高（29 例[17.2%]比 67 例[8.8%]；绝对差异，8.4%[95%CI，2.0%-14.7%]），通气时间更长（中位数 6.1 比 3.5 天；绝对差异，2.6 天[95%CI，1.6-3.6]），ICU 住院时间更长（中位数 10.6 比 7.7 天；绝对差异，2.8 天[95%CI，1.1-5.2]）。与早期初始 SBT 相比，晚期初始 SBT（气管插管后>2.3 天）患者的通气时间更长（中位数 2.1 比 6.1 天；绝对差异，4.0 天[95%CI，3.7-4.5]），ICU 住院时间更长（中位数 5.9 比 10.8 天；绝对差异，4.9 天[95%CI，4.0-6.3]），住院时间更长（中位数 14.3 比 22.8 天；绝对差异，8.5 天[95%CI，6.0-11.0]）。
在这项 2013 年至 2016 年期间，对来自加拿大、印度、英国、欧洲、澳大利亚/新西兰和美国的 142 个 ICU 中接受有创机械通气的 1868 例患者的观察性研究中，我们发现撤机实践存在国际差异。
ClinicalTrials.gov 标识符：NCT03955874。
