Effect of Protocolized Weaning With Early Extubation to Non-invasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial

This article by Perkins and colleagues was published in JAMA during November 2018.
Importance:  In adults in whom weaning from invasive mechanical ventilation is difficult, non-invasive ventilation may facilitate early liberation, but there is uncertainty about its effectiveness in a general intensive care patient population.
Objective:  To investigate among patients with difficulty weaning the effects of protocolized weaning with early extubation to non-invasive ventilation on time to liberation from ventilation compared with protocolized invasive weaning.
Design,Setting, and Participants:  Randomized,allocation-concealed, open-label, multicenter clinical trial enrolling patients between March 2013 and October 2016 from 41 intensive care units in the UK National Health Service. Follow-up continued until April 2017. Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed were enrolled.
Interventions:  Patients were randomized to receive either protocolized weaning via early extubation to non-invasive ventilation (n = 182)or protocolized standard weaning (continued invasive ventilation until successful spontaneous breathing trial, followed by extubation) (n = 182).
Main Outcomes and Measures:  Primary outcome was time from randomization to successful liberation from all forms of mechanical ventilation among survivors, measured in days, with the minimal clinically important difference defined as 1 day. Secondary outcomes were duration of invasive and total ventilation (days), reintubation or tracheostomyrates, and survival.
Results:  Among 364 randomized patients (mean age, 63.1[SD, 14.8] years; 50.5% male), 319 were evaluable for the primary effectiveness outcome (41 died before liberation, 2 withdrew, and 2 were discharged with ongoing ventilation). The median time to liberation was 4.3 days in the non-invasive group vs 4.5 days in the invasive group (adjusted hazard ratio, 1.1; 95% CI, 0.89-1.40).Competing risk analysis accounting for deaths had a similar result (adjusted hazard ratio, 1.1; 95% CI, 0.86-1.34). The non-invasive group received less invasive ventilation (median, 1 day vs 4 days; incidence rate ratio, 0.6; 95%CI, 0.47-0.87) and fewer total ventilator days (median, 3 days vs 4 days;incidence rate ratio, 0.8; 95% CI, 0.62-1.0). There was no significant difference in reintubation, tracheostomy rates, or survival. Adverse events occurred in 45 patients (24.7%) in the non-invasive group compared with 47(25.8%) in the invasive group.
Conclusions and Relevance:  Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed, early extubation to non-invasive ventilation did not shorten time to liberation from any ventilation.
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Neuromuscular electrical stimulation combined with exercise decreases duration of mechanical ventilation in ICU patients: A randomized controlled trial.

This article by Dos Santos and colleagues was published in “Physiotherapy Theory and Practice”
Background:  Early mobilization can be employed to minimize the duration of intensive care. However, a protocol combining neuromuscular electrical stimulation (NMES) with early mobilization has not yet been tested in ICU patients. Our aim was to assess the efficacy of NMES, exercise (EX), and combined therapy (NMES + EX) on duration of mechanical ventilation (MV) in critically ill patients.
Methods:  The participants in this randomized double-blind trial were prospectively recruited within 24 hours following admission to the intensive care unit of a tertiary hospital. Eligible patients had 18 years of age or older; MV for less than 72 hours; and no known neuromuscular disease. Computer-generated permuted block randomization was used to assign patients to NMES, EX, NMES + EX, or standard care (control group). The main endpoint was duration of MV. Clinical characteristics were also evaluated and intention to treat analysis was employed.
Results:  One hundred forty-four patients were assessed for eligibility to participate in the trial, 51 of whom were enrolled and randomly allocated into four groups: 11 patients in the NMES group, 13 in the EX group, 12 in the NMES + EX group, and 15 in the control group (CG). Duration of MV (days) was significantly shorter in the combined therapy (5.7 ± 1.1) and NMEN (9.0 ± 7.0) groups in comparison to CG (14.8 ± 5.4).
Conclusions:  NMES + EX consisting of NMES and active EXs was well tolerated and resulted in shorter duration of MV in comparison to standard care or isolated therapy (NMES or EX alone).
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Education on invasive mechanical ventilation involving intensive care nurses: a systematic review.

This paper by Guilhermino, Inder and Sundin was published in Nursing in Critical Care in September 2018.
Background:  Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses’ knowledge and skills, potentially improving patient outcomes.
Aims:  The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.
Methods:  Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.
Results:  Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay.
Conclusion:  Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.
Relevance to clinical practice:  Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

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Unplanned extubations in an intensive care unit: Findings from a critical incident technique

This article by Daniels et al was published in the August 2018 issue of “Intensive and Critical Care Nursing”.
Background:  Patients on mechanical ventilation are at risk of experiencing a potentially life-threatening unplanned extubation in the intensive care unit, which can lead to arrhythmias, bronchial aspiration, difficulty in reintubation or even sudden cardiac arrest. Although incidence and outcomes of the phenomenon have been documented in several quantitative studies, no studies have investigated the antecedents as experienced by critical care nurses.
Objectives:  To gain a greater understanding of the antecedents of unplanned extubations.
Methods:  A qualitative study design involving the critical-incident technique. A total of 10 registered nurses who reported one or more episodes of unplanned extubations were involved in an in-depth interview.
Findings:  According to the nurses’ experience, episodes of unplanned extubations are determined by predisposing, precipitating and mediating factors. The predisposing factors have been recognised in the (a) weaning programme (expected/unexpected decreased sedation) and in the (b) patient factors (increased needs due to discomfort, restlessness and desire to communicate). The precipitating factors have been divided into (a) organisational (failures in multi-professional communication), (b) environmental (excessive environmental chaos and barriers preventing direct surveillance) and (c) nursing care factors (ensuring privacy by creating barriers, avoiding disturbing other patients and poor nurse-to-patient ratio). Among the mediating factors, which are affected by the precipitating factors, decreased surveillance and mechanical restraints’ use have been identified.
Conlcusion:  Identifying risk factors of unplanned extubation, specifically those that are modifiable, such as increasing interprofessional communication, reducing excessive environment chaos, implementing strategies aimed at overcoming barriers threatening direct surveillance and ensuring appropriate nurse-to-patient ratio, can prevent the occurrence of these events.
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Attention-seeking actions by patients on mechanical ventilation in intensive care units: A qualitative study

This article by Wallander was published in the July 2018 issue of the Journal of Clinical Nursing.
Aims and Objectives:  The aim of this study was to explore the interaction between mechanically ventilated patients and healthcare personnel in intensive care units, with a special emphasis on patients’ initiative to communicate.
Background:  Patients on mechanical ventilation in intensive care units tend to be less sedated today compared to standard care in the past. Their experiences of being voiceless may cause emotional distress, and for many patients, communication is difficult. Healthcare personnel are reported to be the main initiators of the communication exchanges that occur.
Design:  An observational study with a phenomenological-hermeneutical approach.
Methods:  Video recording was used to collect data on the naturally occurring communication and interaction. Ten conscious and alert patients from two Norwegian intensive care units were recruited. Two relatives and a total of sixty healthcare personnel participated. Content analysis was conducted, with focus on both the manifest and latent content meaning.
Results:  We found a total of 66 situations in which patients attempted to attract the attention of others on their own initiative in order to express themselves. Attention-seeking actions, defined as the act of seeking attention and understanding without a voice, became an essential theme. Four patterns of interaction were identified: immediately responded to, delayed response or understanding, intensified attempts, or giving up. Patients had a variety of reasons for seeking attention, which were classified into four domains: psychological expressions, physical expressions, social expressions, and medical treatment.
Conclusions:  Patients’ attention-seeking actions varied in content, form, and the types of responses they elicited. The patients had to fight to first gain joint attention and then joint understanding. This was both energy draining and time consuming.
Relevance to Clinical Practice:  Healthcare personnel need to spend more time for communication purposes, giving attention and being more alert to bodily or symbolic gestures to understand the patient’s needs. This article is protected by copyright. All rights reserved.
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Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study

This research by Jabaley et al was published in the July 2018 issue of BMC Research Notes.
Objective:  As evidence-based guidance to aid clinicians with mechanical ventilation mode selection is scant, we sought to characterize the epidemiology thereof within a university healthcare system and hypothesized that nonconforming approaches could be readily identified. We conducted an exploratory retrospective observational database study of routinely recorded mechanical ventilation parameters between January 1, 2010 and December 31, 2016 from 12 intensive care units. Mode epoch count proportions were examined using Chi squared and Fisher exact tests as appropriate on an inter-unit basis with outlier detection for two test cases via post hoc pairwise analyses of a binomial regression model.  Results:  Final analysis included 559,734 mode epoch values. Significant heterogeneity was demonstrated between individual units (P < 0.05 for all comparisons). One unit demonstrated heightened utilization of high-frequency oscillatory ventilation, and three units demonstrated frequent synchronized intermittent mandatory ventilation utilization. Assist control ventilation was the most commonly recorded mode (51%), followed by adaptive support ventilation (23.1%). Volume-controlled modes were about twice as common as pressure-controlled modes (64.4% versus 35.6%). Our methodology provides a means by which to characterize the epidemiology of mechanical ventilation approaches and identify nonconforming practices. The observed variability warrants further clinical study about contributors and the impact on relevant outcomes.

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Intensive care doctors’ preferences for arterial oxygen tension levels in mechanically ventilated patients

This article by Schjorring and others was published in Acta Anaesthesioligica Scandinavica in June 2018.
Background:  Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors’ preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors’ preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients.
Methods:  In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016.
Results:  The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2 ) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2 ); and 23% preferred SaO2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets.
Conclusion:  Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients.
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