To determine if ICU physicians can identify patients for successful extubation that failed the respiratory therapist driven protocol and, thus, can increase the number of patients successfully weaned from mechanical ventilation.
We conducted a retrospective analysis of ICU patients who required mechanical ventilation for more than 24 hours, over a sixty day period. All patients were under the care of one intensivist and were initiated on a respiratory therapist (RT) driven weaning protocol. Medical records were reviewed to determine if patients were extubated the same day that they failed the weaning protocol. Successful extubation was defined as not requiring reintubation for 48 hours. Data was then analyzed in the two groups in terms of initial cause of mechanical ventilation, rates of reintubation and number of days on mechanical ventilation.
Out of a total of 36 mechanically ventilated patients, we identified 7 patients who were extubated despite not fulfilling the respiratory therapist driven protocol. Out of these, one patient with primary cardiorespiratory failure required reintubation whereas six remained successfully extubated. Out of the remaining 6, three patients were intubated for primary neurological process (for airway protection) and three for cardiorespiratory failure. Out of the 29 patients on the RT-driven protocol, 20 were eventually extubated. Nineteen were successful, out of which 4 were intubated for primary neurological process and 15 for cardiorespiratory failure. One patient with cardiorespiratory failure required reintubation. Six patients required tracheostomies and three expired while on mechanical ventilation. The average number of days on mechanical ventilation was lower in the group extubated after failing the RT-driven protocol.
Weaning protocols may be missing a significant number of patients who could be successfully weaned off the ventilator. It is also possible that protocols may be less reliable in patients on ventilation for neurological indications i.e. airway protection.
Weaning protocols have been shown to reduce the number of days of mechanical ventilation. In some cases, though, physician judgment can improve the rates of successful weaning.
Dashant Kavathia, None.