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Respiratory therapist driven protocols for weaning of patients from mechanical ventilation: Experience at a high acuity center with variable patient volumes FREE TO VIEW

Amit Banga, MD; Madhu Sasidhar, MD
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Cleveland Clinic Foundation, Cleveland, OH

Chest. 2013;144(4_MeetingAbstracts):894A. doi:10.1378/chest.1704107
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SESSION TITLE: Ventilatory Strategies in Severe Hypoxemia

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 30, 2013 at 07:30 AM - 09:00 AM

PURPOSE: Therapist driven protocols for weaning from ventilator have been shown to improve outcomes. We here report our experience after establishing an algorithmic approach towards weaning that was based upon selected clinical performance indicators.

METHODS: This study is part of an ongoing registry study involving patients admitted to the medical intensive care unit (MICU, a 53-bed closed unit) at the Cleveland Clinic Hospital. We reviewed all the independent evaluation encounters (n=8350) by respiratory therapists over a one year period (Jan to Dec 2012). We excluded encounters where patient was on ventilator via tracheostomy (n=4325). We describe our processes and evaluate the outcomes of weaning eligibility assessments, spontaneous breathing trials (SBT), extubation screens, overall duration of mechanical ventilation (MV) and extubation failure using the therapist driven protocols.

RESULTS: Patients were initially screened for weaning using the Richmond agitation and sedation scale (RASS). The most frequently encountered level of sedation was RASS score of 0 (n=1076). Criteria for SBT were not met in nearly two-third of the encounters (2415/4025, 60%). High oxygen requirements (FiO2>40%), positive end expiratory pressure (PEEP)>8 cm and hemodynamic instability were the top three causes for failing SBT screen. Among those undergoing spontaneous breathing trial, patients were deemed ready for extubation screen in 220 encounters. The top three causes of failed SBT were tachypnea (respiratory rate>40), rapid shallow breathing index>100 and low oxygen saturations. Extubation screen including physician assessment was the final step before extubation which was done in most of the encounters (n=148). Patients failed extubation screen because of issues related to sensorium (inability to follow commands, protect airway or agitation) or excessive secretions. Despite highly variable monthly volume of patients on MV (100-158 patients/month), duration of MV remained stable (mean duration 5 days-6.4 days). Further, rate of extubation failure also remained low (4.7% overall).

CONCLUSIONS: Therapist driven protocols based upon objective assessments using clinical indicators appear highly effective in reducing time on MV and successfully liberating patients from the ventilator. Outcomes remain good despite highly variable patient volumes.

CLINICAL IMPLICATIONS: Customized therapist driven protocols should be utilized to improve outcomes of patients on MV in high acuity intensive care units with variable patient volumes.

DISCLOSURE: The following authors have nothing to disclose: Amit Banga, Madhu Sasidhar

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