Original Investigation Caring for the Critically Ill PatientMarch 23/30, 2021

Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

Karen E. A. Burns, Leena Rizvi, Deborah J. Cook, et al

JAMA. 2021;325(12):1173-1184. doi:10.1001/jama.2021.2384

Abstract

Importance 背景

Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.

尽管多数危重病患者接受有创机械通气(IMV)，但很少有研究对于临床实践中如何终止IMV做出描述。

Objective 目的

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).

描述国际上终止IMV临床实践的差异，初始终止事件与临床结局的相关性，以及选择某些终止策略和初始自主呼吸试验(SBTs)失败的相关因素。

Design, Setting, and Participants 设计，场景及研究对象

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).

这项前瞻性，多国家，观察性研究入选了6个地区19个国家中142个ICU收治的接受IMV至少24小时的危重患者。

Exposures 暴露因素

Receiving IMV.

接受IMV。

Main Outcomes and Measures 主要预后指标

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.

主要分析旨在描述初始IMV终止事件的种类（拔管，SBT，或气管切开）及其与临床结局（包括机械通气时间，ICU和住院病死率，ICU住院日和总住院日）的相关性。次要分析检验SBT结局与SBT时机和临床预后的相关性。

Results 结果

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]).

总共1868名患者 (中位 [四分位区间] 年龄, 61.8 [48.9-73.1] 岁; 1173名 [62.8%] 男性)中，424名 (22.7%) 直接拔除气管插管，930名 (49.8%) 患者接受初始SBT (761名 [81.8%] 成功)，150名 (8.0%) 直接接受气管切开，364名 (19.5%) 患者在尝试脱机前死亡。不同地区在采用书面医嘱指导治疗，每日筛查，SBT技术，呼吸机模式，以及临床医生在脱机过程中所起作用等方面存在显著差异。与初始直接拔管相比，初始接受SBT的患者ICU病死率更高(20 [4.7%] vs 96 [10.3%]; 绝对差异, 5.6% [95% CI, 2.6%-8.6%])，机械通气时间更长 (中位时间 2.9 vs 4.1 天; 绝对差异, 1.2 天 [95% CI, 0.7-1.6])，ICU住院日更长 (中位时间 6.7 vs 8.1 天; 绝对差异, 1.4 天 [95% CI, 0.8-2.4])。初始SBT失败患者(与成功者比较) ICU病死率更高 (29 [17.2%] vs 67 [8.8%]; 绝对差异, 8.4% [95% CI, 2.0%-14.7%])，机械通气时间更长 (中位时间6.1 vs 3.5 天; 绝对差异, 2.6 天 [95% CI, 1.6-3.6])，ICU住院日更长 (中位时间10.6 vs 7.7 天; 绝对差异, 2.8 天 [95% CI, 1.1-5.2])。与早期接受初始SBT的患者相比，晚期接受初始SBT的患者 (气管插管后>2.3 天) 机械通气时间更长 (中位时间 2.1 vs 6.1 天; 绝对差异, 4.0 天 [95% CI, 3.7-4.5])，ICU住院日更长 (中位时间5.9 vs 10.8 days; 绝对差异, 4.9 天 [95% CI, 4.0-6.3])，总住院日更长 (中位时间14.3 vs 22.8 天; 绝对差异, 8.5 天 [95% CI, 6.0-11.0])。

Conclusions and Relevance 结论与意义

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.

2013年至2016年间，在加拿大、印度、英国、欧洲、澳大利亚/新西兰和美国142个ICU进行的这项有创机械通气终止的观察性研究中，各国间脱机的临床实践存在很大差异。

Trial Registration

ClinicalTrials.gov Identifier: NCT03955874