Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation

Daniel R Ouellette; Sheena Patel; Timothy D Girard; Peter E Morris; Gregory A Schmidt; Jonathon D Truwit; Waleed Alhazzani; Suzanne M Burns; Scott K Epstein; Andres Esteban; Eddy Fan; Miguel Ferrer; Gilles L Fraser; Michelle Ng Gong; Catherine L Hough; Sangeeta Mehta; Rahul Nanchal; Amy J Pawlik; William D Schweickert; Curtis N Sessler; Thomas Strøm; John P Kress

doi:10.1016/j.chest.2016.10.036

Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation

Chest. 2017 Jan;151(1):166-180. doi: 10.1016/j.chest.2016.10.036. Epub 2016 Nov 3.

Authors

Daniel R Ouellette¹, Sheena Patel², Timothy D Girard³, Peter E Morris⁴, Gregory A Schmidt⁵, Jonathon D Truwit⁶, Waleed Alhazzani⁷, Suzanne M Burns⁸, Scott K Epstein⁹, Andres Esteban¹⁰, Eddy Fan¹¹, Miguel Ferrer¹², Gilles L Fraser¹³, Michelle Ng Gong¹⁴, Catherine L Hough¹⁵, Sangeeta Mehta¹⁶, Rahul Nanchal¹⁷, Amy J Pawlik¹⁸, William D Schweickert¹⁹, Curtis N Sessler²⁰, Thomas Strøm²¹, John P Kress²²

Affiliations

¹ Henry Ford Health System, Detroit, MI. Electronic address: [email protected].
² CHEST, Glenview, IL.
³ University of Pittsburgh, Pittsburgh, PA.
⁴ University of Kentucky, Lexington, KY.
⁵ Division of Pulmonary, Critical Care & Occupational Medicine, University of Iowa, Iowa City, IA.
⁶ Froedtert and Medical College of Wisconsin, Milwaukee, WI.
⁷ McMaster University, Hamilton, ON, Canada.
⁸ University of Virginia Health System, Charlottesville, VA.
⁹ Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA.
¹⁰ Unidad de Cuidados Intensivos, University Hospital of Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain.
¹¹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹² Department of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, CibeRes (CB06/06/0028), University of Barcelona, Barcelona, Spain.
¹³ Maine Medical Center, Portland, ME.
¹⁴ Departments of Medicine and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
¹⁵ Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
¹⁶ Division of Respirology, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, New York, NY.
¹⁷ Medical College of Wisconsin, Milwaukee, WI.
¹⁸ Department of Therapy Services, University of Chicago Medical Center, Chicago, IL.
¹⁹ Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
²⁰ Virginia Commonwealth University, Richmond, VA.
²¹ Department of Anaesthesia and Intensive Care Medicine, University of Southern Denmark, Odense, Denmark.
²² Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.

PMID: 27818331
DOI: 10.1016/j.chest.2016.10.036

Abstract

Background: An update of evidence-based guidelines concerning liberation from mechanical ventilation is needed as new evidence has become available. The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have collaborated to provide recommendations to clinicians concerning liberation from the ventilator.

Methods: Comprehensive evidence syntheses, including meta-analyses, were performed to summarize all available evidence relevant to the guideline panel's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, and the results were summarized in evidence profiles. The evidence syntheses were discussed and recommendations developed and approved by a multidisciplinary committee of experts in mechanical ventilation.

Results: Recommendations for three population, intervention, comparator, outcome (PICO) questions concerning ventilator liberation are presented in this document. The guideline panel considered the balance of desirable (benefits) and undesirable (burdens, adverse effects, costs) consequences, quality of evidence, feasibility, and acceptability of various interventions with respect to the selected questions. Conditional (weak) recommendations were made to use inspiratory pressure augmentation in the initial spontaneous breathing trial (SBT) and to use protocols to minimize sedation for patients ventilated for more than 24 h. A strong recommendation was made to use preventive noninvasive ventilation (NIV) for high-risk patients ventilated for more than 24 h immediately after extubation to improve selected outcomes. The recommendations were limited by the quality of the available evidence.

Conclusions: The guideline panel provided recommendations for inspiratory pressure augmentation during an initial SBT, protocols minimizing sedation, and preventative NIV, in relation to ventilator liberation.

Keywords: evidence-based medicine; guidelines; mechanical ventilation.

Publication types

Practice Guideline

MeSH terms

Adult
Aged
Airway Extubation / methods
Conscious Sedation / methods
Critical Care / methods
Critical Care / standards
Critical Illness / therapy*
Evidence-Based Emergency Medicine / methods
Humans
Noninvasive Ventilation / methods
Respiration, Artificial / methods*
United States
Ventilator Weaning / methods