Ely E W, Baker A M, Dunagan D P, Burke H L, Smith A C, Kelly P T, Johnson M M, Browder R W, Bowton D L, Haponik E F
Department of Internal Medicine, the Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 27157, USA.
N Engl J Med. 1996 Dec 19;335(25):1864-9. doi: 10.1056/NEJM199612193352502.
Prompt recognition of the reversal of respiratory failure may permit earlier discontinuation of mechanical ventilation, without harm to the patient.
We conducted a randomized, controlled trial in 300 adult patients receiving mechanical ventilation in medical and coronary intensive care units. In the intervention group, patients underwent daily screening of respiratory function by physicians, respiratory therapists, and nurses to identify those possibly capable of breathing spontaneously; successful tests were followed by two-hour trials of spontaneous breathing in those who met the criteria. Physicians were notified when their patients successfully completed the trials of spontaneous breathing. The control subjects had daily screening but no other interventions. In both groups, all clinical decisions, including the decision to discontinue mechanical ventilation, were made by the attending physicians.
Although the 149 patients randomly assigned to the intervention group had more severe disease, they received mechanical ventilation for a median of 4.5 days, as compared with 6 days in the 151 patients in the control group (P=0.003). The median interval between the time a patient met the screening criteria and the discontinuation of mechanical ventilation was one day in the intervention group and three days in the control group (P<0.001). Complications -- removal of the breathing tube by the patient, reintubation, tracheostomy, and mechanical ventilation for more than 21 days -- occurred in 20 percent of the intervention group and 41 percent of the control group (P=0.001). The number of days of intensive care and hospital care was similar in the two groups. Total costs for the intensive care unit were lower in the intervention group (median, $15,740, vs. $20,890 in the controls, P=0.03); hospital costs were lower, though not significantly so (median, $26,229 and $29,048, respectively; P=0.3).
Daily screening of the respiratory function of adults receiving mechanical ventilation, followed by trials of spontaneous breathing in appropriate patients and notification of their physicians when the trials were successful, can reduce the duration of mechanical ventilation and the cost of intensive care and is associated with fewer complications than usual care.
及时识别呼吸衰竭的逆转情况可能允许更早地停用机械通气，而不会对患者造成伤害。
我们在300名在医疗和冠心病重症监护病房接受机械通气的成年患者中进行了一项随机对照试验。在干预组中，患者每天由医生、呼吸治疗师和护士进行呼吸功能筛查，以确定那些可能能够自主呼吸的患者；符合标准的患者在成功测试后进行两小时的自主呼吸试验。当患者成功完成自主呼吸试验时通知医生。对照组每天进行筛查但不进行其他干预。在两组中，所有临床决策，包括停用机械通气的决策，均由主治医生做出。
尽管随机分配到干预组的149名患者病情更严重，但他们接受机械通气的中位时间为4.5天，而对照组的151名患者为6天（P = 0.003）。在干预组中，患者达到筛查标准至停用机械通气的中位间隔时间为1天，而对照组为3天（P < 0.001）。并发症——患者自行拔除呼吸管、再次插管、气管切开以及机械通气超过21天——在干预组中发生率为20%，在对照组中为41%（P = 0.001）。两组的重症监护和住院天数相似。干预组重症监护病房的总费用较低（中位数为15,740美元，对照组为20,890美元，P = 0.03）；住院费用较低，尽管差异不显著（中位数分别为26,229美元和29,048美元；P = 0.3）。
对接受机械通气的成年人进行每日呼吸功能筛查，随后对合适的患者进行自主呼吸试验，并在试验成功时通知其医生，可缩短机械通气时间，降低重症监护成本，且与常规护理相比并发症更少。
