OBJECTIVE: To assess the outcome of a clinical judgement-based approach to weaning and extubation and to adduce the predictive accuracy of various mechanical respiratory indices measured in parallel. DESIGN: Prospective study. SETTING: Multidisciplinary intensive care unit at a university teaching hospital. PATIENTS: 163 consecutive mechanically ventilated patients, excluding tracheotomy, for weaning trial and extubation. INTERVENTIONS: Using bedside clinical assessment, aided by arterial gas analysis, patients were weaned from mechanical ventilation to spontaneous ventilation via to continuous positive airway pressure (CPAP) circuit (with pressure support) of a microprocessor-controlled ventilator. Extubation occurred from the CPAP circuit at 7 cmH2O pressure support, fractional inspired oxygen (FIO2) < or = 0.5 and CPAP level of < or = 5 cmH2O, such that the partial pressure of oxygen in arterial blood (PaO2) was > or = 65 mmHg. Before extubation, observation for a 1-h (T0 and T60) trial period allowed measurement of vital capacity (VC), expired minute volume (VE), respiratory rate/tidal volume (f/VT) and maximal inspiratory pressure (MIP) using a one-way valve technique over 25 s. MEASUREMENTS AND MAIN RESULTS: Over 7 months, 163 patients (62 females and 101 males; mean (SD) age 64(15) years) were considered. There were 91 surgical (18 with chronic obstructive pulmonary disease; COPD) and 72 medical (28 with COPD) patients. Ventilation was for > or = 1 day (median 5 days, range 1-31) in 115 [group I; APACHE II score 23(8)] and < or = 1 day in 48 [Group II; APACHE II score 17(6)]. Three patients (all Group I: 2 surgical, 1 medical) were reintubated within 24 h, an overall extubation failure rate of 1.8%. In group I, at T0, PaO2/FIO2 was 238(65), f/VT 50(26), MIP 44(21) cmH2O, VE 10.6(3.7) l/min, VC 13(5) ml/kg. Cardiorespiratory variables did not change significantly in either group, T0 to T60. For prediction of reintubation (n = 163), only VE (threshold > 10 l/min) and f/VT (threshold > 100) demonstrated moderate sensitivity and specificity at T60: 67 and 52% and 33 and 94%, respectively. CONCLUSIONS: Bedside clinical judgement of weaning and extubation produces satisfactory outcomes. As a routine, mechanical predictive indices have limited utility.
OBJECTIVE: To assess the outcome of a clinical judgement-based approach to weaning and extubation and to adduce the predictive accuracy of various mechanical respiratory indices measured in parallel. DESIGN: Prospective study. SETTING: Multidisciplinary intensive care unit at a university teaching hospital. PATIENTS: 163 consecutive mechanically ventilated patients, excluding tracheotomy, for weaning trial and extubation. INTERVENTIONS: Using bedside clinical assessment, aided by arterial gas analysis, patients were weaned from mechanical ventilation to spontaneous ventilation via to continuous positive airway pressure (CPAP) circuit (with pressure support) of a microprocessor-controlled ventilator. Extubation occurred from the CPAP circuit at 7 cmH2O pressure support, fractional inspired oxygen (FIO2) < or = 0.5 and CPAP level of < or = 5 cmH2O, such that the partial pressure of oxygen in arterial blood (PaO2) was > or = 65 mmHg. Before extubation, observation for a 1-h (T0 and T60) trial period allowed measurement of vital capacity (VC), expired minute volume (VE), respiratory rate/tidal volume (f/VT) and maximal inspiratory pressure (MIP) using a one-way valve technique over 25 s. MEASUREMENTS AND MAIN RESULTS: Over 7 months, 163 patients (62 females and 101 males; mean (SD) age 64(15) years) were considered. There were 91 surgical (18 with chronic obstructive pulmonary disease; COPD) and 72 medical (28 with COPD) patients. Ventilation was for > or = 1 day (median 5 days, range 1-31) in 115 [group I; APACHE II score 23(8)] and < or = 1 day in 48 [Group II; APACHE II score 17(6)]. Three patients (all Group I: 2 surgical, 1 medical) were reintubated within 24 h, an overall extubation failure rate of 1.8%. In group I, at T0, PaO2/FIO2 was 238(65), f/VT 50(26), MIP 44(21) cmH2O, VE 10.6(3.7) l/min, VC 13(5) ml/kg. Cardiorespiratory variables did not change significantly in either group, T0 to T60. For prediction of reintubation (n = 163), only VE (threshold > 10 l/min) and f/VT (threshold > 100) demonstrated moderate sensitivity and specificity at T60: 67 and 52% and 33 and 94%, respectively. CONCLUSIONS: Bedside clinical judgement of weaning and extubation produces satisfactory outcomes. As a routine, mechanical predictive indices have limited utility.
Authors: A Esteban; F Frutos; M J Tobin; I Alía; J F Solsona; I Valverdú; R Fernández; M A de la Cal; S Benito; R Tomás Journal: N Engl J Med Date: 1995-02-09 Impact factor: 91.245
Authors: J P Baker; A S Detsky; D E Wesson; S L Wolman; S Stewart; J Whitewell; B Langer; K N Jeejeebhoy Journal: N Engl J Med Date: 1982-04-22 Impact factor: 91.245
Authors: I L Cohen; N Bari; M A Strosberg; P F Weinberg; R M Wacksman; B H Millstein; I A Fein Journal: Crit Care Med Date: 1991-10 Impact factor: 7.598
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