0
Correspondence |

CHEST-ATS Guidelines on Weaning/Extubation Ignore Scientific Principles FREE TO VIEW

Martin J. Tobin, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following: M. J. T. receives royalties for two books on mechanical ventilation and critical care published by McGraw-Hill Inc, New York.

Division of Pulmonary and Critical Care, Hines VA Medical Center; and Loyola University of Chicago Stritch School of Medicine, Maywood, IL

CORRESPONDENCE TO: Martin J. Tobin, MD, Division of Pulmonary and Critical Care, Hines VA Medical Center, 111N, 5th Ave and Roosevelt Rd, Hines, IL 60141


Copyright 2017, . All Rights Reserved.


Chest. 2017;151(5):1179-1180. doi:10.1016/j.chest.2017.01.039
Text Size: A A A
Published online

The new American College of Chest Physicians/American Thoracic Society guidelines on ventilator weaning/extubation,, fail to take into account well-proven principles of diagnostic testing and basic pulmonary physiology. I invite the committee's response to four points.

  • 1.

    The committee states “weaning predictors…lack sufficient positive and negative predictive value to make them routinely useful.” The assertion is unreferenced. The previous guidelines reached the same conclusion based on a meta-analysis that contained 15 major methodological errors. No error has been defended. Members of the previous committee were contacted repeatedly by the Editor in Chief of Critical Care Medicine but refused to respond. The committee chair merely repeated assertions. On what data does the committee base its assertion?

Bayesian principles pivot around the importance of pretest probability and form the bedrock for the evaluation of any clinical/diagnostic test. Ignoring these principles when rendering recommendations is irresponsible.

  • 2.

    The committee recommends initiating the weaning process with a spontaneous breathing trial (SBT). To begin weaning with a confirmatory test (SBT) rather than a screening test (weaning predictors) goes against every principle of diagnostic testing., Any unnecessary delay in commencing an SBT will cause prolongation of mechanical ventilation. Weaning predictors are not done to forecast a failed SBT; their primary purpose is to alert a physician that a patient might tolerate an SBT sooner than he/she otherwise thinks and move that SBT to an earlier time. By waiting until caregivers have decided to undertake a 30- to 120-min confirmatory test, as opposed to a 1- to 2-min screening test, the committee is axiomatically prolonging the duration of ventilation.

  • 3.

    The committee makes explicit recommendations for weaning/extubation based on the sensitivity/specificity of SBTs. The committee fails to inform readers that such data do not exist and are unobtainable. Collection of such data would require extubating all patients in whom an SBT fails and counting the number who require reintubation—a patently unethical study.

  • 4.

    Randomized trials comparing postextubation outcome following pressure support vs T-tube trials reveal no statistical difference in mortality. But these trials (in aggregate) do not come even remotely close to possessing sufficient statistical power to detect differences in death or catastrophe following extubation. Numerous experimental studies show that work of breathing at pressure support of 5 to 8 cm H2O is approximately 40% less than at pressure support of 0 cm H2O. Ignoring the mathematical difference in the two settings leads to patient deaths.

The new American College of Chest Physicians/American Thoracic Society guidelines risk unnecessary deaths because they ignore the scientific basis of weaning/extubation: Bayesian foundation and physiological principles.

References

Schmidt G.A. .Girard T.D. .Kress J.P. .et al Liberation from mechanical ventilation in critically ill adults: executive summary of an official American College of Chest Physicians/American Thoracic Society clinical practice guideline. Chest. 2017;151:160-165 [PubMed]journal. [CrossRef] [PubMed]
 
Oulettte D.R. .Patel S. .Girard T.D. .et al Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society clinical practice guideline. Chest. 2017;151:166-180 [PubMed]journal. [CrossRef] [PubMed]
 
Girard T.D. .Alhazzani W. .Kress J.P. .et al An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults: rehabilitation protocols, ventilator liberation protocols, and cuff test leaks. Am J Respir Crit Care Med. 2017;195:120-133 [PubMed]journal. [CrossRef] [PubMed]
 
Tobin M.J. .Jubran A. . Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning. Crit Care Med. 2008;36:1-7 [PubMed]journal. [CrossRef] [PubMed]
 
MacIntyre N. . Four questions for Dr. MacIntyre on his editorial (author reply). Crit Care Med. 2008;36:2709-2710 [PubMed]journal. [PubMed]
 
Feinstein A.R. . Clinical Epidemiology: The Architecture of Clinical Research.  1985;:- [PubMed] WB Saunders Philadelphiajournal
 
Tobin M.J. .Jubran A. . Weaning from mechanical ventilation.Tobin M.J.. Principles and Practice of Mechanical Ventilation.  :1185-1220 [PubMed]journal
 
Tobin M.J. . Extubation and the myth of “minimal ventilator settings.”. Am J Respir Crit Care Med. 2012;185:349-350 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Schmidt G.A. .Girard T.D. .Kress J.P. .et al Liberation from mechanical ventilation in critically ill adults: executive summary of an official American College of Chest Physicians/American Thoracic Society clinical practice guideline. Chest. 2017;151:160-165 [PubMed]journal. [CrossRef] [PubMed]
 
Oulettte D.R. .Patel S. .Girard T.D. .et al Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society clinical practice guideline. Chest. 2017;151:166-180 [PubMed]journal. [CrossRef] [PubMed]
 
Girard T.D. .Alhazzani W. .Kress J.P. .et al An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults: rehabilitation protocols, ventilator liberation protocols, and cuff test leaks. Am J Respir Crit Care Med. 2017;195:120-133 [PubMed]journal. [CrossRef] [PubMed]
 
Tobin M.J. .Jubran A. . Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning. Crit Care Med. 2008;36:1-7 [PubMed]journal. [CrossRef] [PubMed]
 
MacIntyre N. . Four questions for Dr. MacIntyre on his editorial (author reply). Crit Care Med. 2008;36:2709-2710 [PubMed]journal. [PubMed]
 
Feinstein A.R. . Clinical Epidemiology: The Architecture of Clinical Research.  1985;:- [PubMed] WB Saunders Philadelphiajournal
 
Tobin M.J. .Jubran A. . Weaning from mechanical ventilation.Tobin M.J.. Principles and Practice of Mechanical Ventilation.  :1185-1220 [PubMed]journal
 
Tobin M.J. . Extubation and the myth of “minimal ventilator settings.”. Am J Respir Crit Care Med. 2012;185:349-350 [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543