Mancebo J
Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain.
Monaldi Arch Chest Dis. 1998 Jun;53(3):350-4.
Every intubated and mechanically-ventilated patient should be clinically evaluated, at least on a daily basis, by a skilled team in order to speed up the weaning process as much as possible. Again, it should be emphasized that the adoption of an active clinical strategy when faced with "difficult" to wean patients is of paramount importance. In one study, performed in Spain, analysing the prevalence of mechanical ventilation in intensive care units [3], reported the mean number of days that patients spent on mechanical ventilation was 27. In a more recent intervention study, in which a specific protocol was followed each day [2], the mean number of days on mechanical ventilation was only 12. These data have been confirmed by several authors [4, 40], and it has also been reported that a protocol-directed weaning strategy leads not only to a significant reduction in the duration of mechanical ventilation but also to a significant decrease in the number of complications and cost [4]. However, even following a protocol-directed weaning strategy, it is possible that weaning duration can be further reduced. In a prospective study performed in our institution [41] during 32 months, we reported that, following an episode of unplanned extubation, the only independent variables associated with the need for reintubation were the number of days of mechanical ventilation and the type of ventilatory support at the time of autoextubation. Indeed, when patients were in the weaning period only 16% (5 out of 32) needed reintubation, whereas reintubation was needed in 82% (22 out of 27) of patients who had an unplanned extubation during full mechanical ventilatory support. These data suggest that there are still some patients being on mechanical ventilation for a longer than necessary period of time. Finally, very recent advances in technological areas such as artificial intelligence, are proving to be useful in the management of the weaning process. When such systems are applied to modern microprocessor-controlled mechanical ventilators they can significantly help in the process of weaning [42] by automatically reducing the ventilatory assistance and by indicating the optimal time to withdraw the patient from the ventilator and proceed with extubation.
每一位接受气管插管并进行机械通气的患者，都应由专业团队至少每天进行一次临床评估，以便尽可能加快撤机进程。再次强调，面对撤机困难的患者时采取积极的临床策略至关重要。在西班牙进行的一项分析重症监护病房机械通气患病率的研究[3]报告称，患者接受机械通气的平均天数为27天。在最近一项每天遵循特定方案的干预研究[2]中，机械通气的平均天数仅为12天。这些数据已得到多位作者的证实[4, 40]，并且有报告称，基于方案的撤机策略不仅能显著缩短机械通气时间，还能显著减少并发症数量并降低成本[4]。然而，即使遵循基于方案的撤机策略，撤机时间仍有可能进一步缩短。在我们机构进行的一项为期32个月的前瞻性研究[41]中，我们报告称，在发生意外拔管事件后，与再次插管需求相关的唯一独立变量是机械通气天数和自主拔管时的通气支持类型。事实上，当患者处于撤机期时，只有16%（32例中的5例）需要再次插管，而在完全机械通气支持期间发生意外拔管的患者中，82%（27例中的22例）需要再次插管。这些数据表明，仍有一些患者接受机械通气的时间超过了必要时长。最后，人工智能等技术领域的最新进展已被证明在撤机过程管理中很有用。当此类系统应用于现代微处理器控制的机械通气器时，它们可以通过自动减少通气辅助并指明将患者撤离呼吸机并进行拔管的最佳时间，从而在撤机过程中提供显著帮助[42]。
