Chest
Evidence-Based MedicineLiberation 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
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.