Chest
Volume 151, Issue 1, January 2017, Pages 166-180
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Evidence-Based Medicine
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

https://doi.org/10.1016/j.chest.2016.10.036Get rights and content

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.

Section snippets

Summary of Recommendations

1. For acutely hospitalized patients ventilated more than 24 h, we suggest that the initial SBT be conducted with inspiratory pressure augmentation (5-8 cm H2O) rather than without (T-piece or CPAP) (Conditional Recommendation, Moderate-Quality Evidence)

Remarks: This recommendation relates to how to conduct the initial SBT but does not inform how to ventilate patients between unsuccessful SBTs.

2. For acutely hospitalized patients ventilated for more than 24 h, we suggest protocols attempting to

Expert Panel Composition

CHEST’s Professional Standards Committee, Guidelines Oversight Committee (GOC), and the ATS’s Document Development and Implementation Committee selected and approved the cochairs of the panel. Prospective panelists were selected by the cochairs based on their expertise relative to the proposed guideline questions. The panelists were reviewed by representatives from both the ATS and CHEST for possible conflicts of interest and credentials. The GOC then reviewed all panelists for final approval.

Recommendations

The panel developed recommendations for each of the PICO questions based on the GRADE evidence profiles. We used the Evidence to Decision (EtD) framework to guide the discussions that ultimately led to the development of a recommendation (e-Tables 3-5). Panel members made decisions regarding the balance between benefits and harm, impact of patients’ values and preferences, cost, health equity, feasibility, and acceptability of the intervention. Pertinent points were recorded during the

Results

Question 1: In acutely hospitalized patients ventilated more than 24 h, should the SBT be conducted with or without inspiratory pressure augmentation?

Summary

These clinical practice guidelines include a strong recommendation that patients who are at high risk for extubation failure and who have passed an SBT be extubated to preventive NIV. Moderate-quality evidence exists that clinically important outcomes are improved by this strategy. Conditional recommendations are to use inspiratory pressure augmentation during the initial SBT and to use protocols to minimize sedation in patients ventilated for more than 24 h. The latter two recommendations are

Acknowledgments

Author contributions: All authors participated in confirmation of literature review, evidence to decision process, authorship and editing of document. The six co-chairs (T. D. G., P. E. M., J. D. T., J. P. K., D. R. O., G. A. S.) proposed the PICO questions. W. A. and S. P. were also methodologists. J. P. K. is the guarantor of the paper.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: K. C. W. reports being employed by the ATS as the Chief of Documents and

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    DISCLAIMER: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/CHEST-Guidelines.

    FUNDING/SUPPORT: This study was funded in total by internal funds from the American College of Chest Physicians.

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