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Weaning the “difficult-to-wean” patient FREE TO VIEW

Christine L. D’Arsigny, MD*; Gail-Anne Harris, RN; Wilma M. Hopman, MA; Denis E. O’Donnell, MD
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Queen’s University, Kingston, ON, Canada


Chest. 2004;126(4_MeetingAbstracts):755S-c-756S. doi:10.1378/chest.126.4_MeetingAbstracts.755S-c
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PURPOSE:  Patients who require long-term ventilaton (>14 days) have often “failed to wean” on a hospital’s acute weaning protocol numerous times. We trialed a different weaning protocol on these patients and compared it to a physician directed plan for weaning.

METHODS:  23 prospective chronically ventilated patients from April 2001-April 2002 were enrolled in our study and were weaned twice a day to CPAP + pressure support for target goals of: tidal volume > 5ml/kg and Respiratory rate of < 35/minute. Patients were rested on controlled ventilation overnight if their pressure support was >12cmH2O. Once they tolerated Pressure support of 8cmH2O for four hours, they started tracheostomy/T-piece trials as per a tracheostomy trial chart. 23 retrospective controls were matched for age and disease process. Our primary outcome was time on ventilator, with secondary endpoints being ICU length of stay, hospital length of stay, mortality and disposition after discharge from hospital.

RESULTS:  Mean length of time on mechanical ventilation for study patients was 44.7 days versus 57.4 days for controls, p=0.005. The mean time from CPAP to extubation was 20.7 days for the study patients versus 30.6 days for controls, p=0.0039. ICU length of stay was slightly shorter at 50.5 days versus 59.4 days, p=0.048 but there was no difference in hospital length of stay. Only 2/23 study patients died compared with 10/23 controls, p=0.017. Primary and secondary outcome variables were not different when corrected for survivors. 39.1% of patients where discharged home in the study group compared to only 2/23 in the control group, p=0.035.

CONCLUSION:  The study proves that the use of a specific weaning protocol for patients who are on controlled ventilation for over 14 days does work and decreases time to extubation. It also seems to shorten ICU length of stay and hospital mortality, and increases the number of patients ultimately discharged home.

CLINICAL IMPLICATIONS:  A separate, chronic weaning protocol can successfully liberate patients from mechanical ventilation in a shorter time than physician driven weaning attempts. Day 1Day 2Day 3Day 4Day 5Day 6Day 7Day 830 min BID1 hour TID2 hours TID3 hours TID4 hours TID6 hours BID12-16 hours, stop by 10pm24 hours

DISCLOSURE:  C.L. D’Arsigny, None.

Tuesday, October 26, 2004

12:30 PM- 2:00 PM




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