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In critically ill patients who receive invasive mechanical ventilation, how is invasive mechanical ventilation discontinued and do discontinuation practices differ internationally?
In this prospective observational study that included 1868 patients from 142 intensive care units in Canada, Europe, the US, India, the UK, and Australia/New Zealand from November 2013 to December 2016, 22.7% of patients underwent direct extubation, 49.8% underwent an initial spontaneous breathing trial (of which 81.8% had successful extubation), 8.0% had a direct tracheostomy, and 19.5% died before a weaning attempt. There was notable variation in several aspects of mechanical ventilation weaning practices.
Mechanical ventilation weaning practices varied internationally, with nearly 50% of patients undergoing an initial spontaneous breathing trial.
Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.
To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs).
Design, Setting, and Participants
Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US).
Main Outcomes and Measures
Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes.
Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]).
Conclusions and Relevance
In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally.
ClinicalTrials.gov Identifier: NCT03955874
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Corresponding Author: Karen E. A. Burns, MD, MSc (Epid), Interdepartmental Division of Critical Care Medicine, Unity Health Toronto, St Michael's Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON M5B 1W8, Canada (firstname.lastname@example.org).
Accepted for Publication: February 9, 2021.
Author Contributions: Drs Burns and Lebovic had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Burns, Cook, Dodek, Villar, Epstein, Pelosi, Meade.
Acquisition, analysis, or interpretation of data: Burns, Rizvi, Cook, Lebovic, Villar, Slutsky, Jones, Kapadia, Gattas, Epstein, Kefala, Meade.
Drafting of the manuscript: Burns, Rizvi, Villar.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Lebovic, Villar.
Obtained funding: Burns, Meade.
Administrative, technical, or material support: Burns, Rizvi, Cook, Jones, Epstein.
Supervision: Burns, Villar, Pelosi.
Other - coordinated India contribution: Kapadia.
Other - detailed data review: Cook.
Other - project management - including the following activities: training sites on protocol, data collection form development, data management, developing data analytical plan, and manuscript development: Rizvi.
Conflict of Interest Disclosures: Dr Burns reported receiving grants from Fisher & Paykel, Covidien, and GE Healthcare Ltd during the conduct of the study. Dr Lebovic reported receiving grants from the Canadian Institutes for Health Research during the conduct of the study. Dr Villar reported receiving grants from Maquet/Getinge outside the submitted work. Dr Slutsky reported personal fees for consultancy in relation to extracorporeal membrane oxygenation from Baxter and Novalung/Xenios outside the submitted work. No other disclosures were reported.
Funding/Support: This study was funded through a peer-reviewed industry-partnered grant from the Canadian Institutes of Health Research with contributions from Fisher & Paykel, Covidien, and GE Healthcare Ltd.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. One industry partner (Fisher & Paykel) reviewed the information being collected on humidification devices during data collection form development.
Meeting Presentation: Data from this study were presented in abstract form at the 2020 American Thoracic Society Conference; May 15-20, 2020.
Additional Contributions: We thank the members of the Canadian Critical Care Trials Group (CCCTG) for their contributions to the study design and guidance during study implementation. In particular, we wish to thank Niall Ferguson, MD, MSc (Unity Health Network, Toronto, Canada), and Philippe Jouvet, MD, PhD (St Justine Hospital, Montreal, Canada), for peer reviewing our manuscript on behalf of the CCCTG Grants and Manuscript Committee. We also thank Shujun (Diana) Ya, HBSc (Applied Health Research Centre, Toronto), for her assistance with the statistical analyses. None of these individuals received compensation for their role in the study. We thank the site investigators and research personnel who participated in the Ventilator Weaning and Discontinuation Practices for Critically Ill Patients study. The individuals listed below were research personnel, some of whom are also members of the CCTG.
Research Collaborators: Canada: Hamilton General Hospital (Dr M. Meade, L. Hand); St. Michael’s Hospital (Dr K. Burns, Dr J. Marshall, O. Smith, M. Wang, & J. Lee); The Ottawa Hospital (Dr L. McIntyre, I. Watpool, L. Leclair, R. Porteous, T. McArdle); St. Paul’s Hospital (Dr P. Dodek, B. Ashley); St. Joseph’s Hospital (Dr D. Cook, F. Clarke); Thunder Bay Regional Health Sciences Centre (Dr M. Scott, C. Pelletier, S. Stoger, C. Cryderman, M. Roussos, A. Holts); Kingston General Hospital (Dr J. Muscedere, J. Podilchak, M. Hunt, S. Fleury); Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ) (Dr F. Lellouche, P. Lizotte, PA. Bouchard, MC. Ferland, K. Collard); CSSS Champlain—Charles-Le Moyne (Charles LeMoyne Hospital) (Dr G. Poirier, S. Spearson, I. Neas); Montreal Heart Institute (Dr A. Denault, MM. Pires, S. Grenier); Capital Health - Queen Elizabeth II Health Sciences Centre (Dr R. Hall, L. Julien); McGill University Health Centre (Dr K. Khwaja, J. Campisi, C. Keropian, Dr LC. Banici, L. Garcia); Mount Sinai Hospital (Dr S. Mehta, B. Giacomino, S. Shah, M. Jakab); Hopital de l'enfant Jesus (Dr A. Turgeon, SJ. Breton, N. Langis, MC. Temblay); Universite de Sherbrook (Dr M. Mayette, QM. Hector); Toronto General Hospital (Dr M. Herridge, A. Matte); Oakville Trafalgar Memorial Hospital (Dr S. Kohli, L. Sterling, K. Khwaja); Centre hospitalier de l'Université de Montréal (Dr P. Aslanina, R. Rigal, F. Benettaib, C. Dube, S. Furdui); Centre de santé et de services sociaux de Trois-Rivières (Dr E. Charbonney, M. Bergeron). India: Saifee Hospital (Dr D. Aggarwal, M Patel); Medanta-The Medicity (Dr D. Govil, Dr S Gupta); Sri Ramachandra Medical Centre (Dr R. Prabakar); Apollo Hospitals (Dr S. Haranath, Dr Padmaja); Hinduja Hospital (Dr F. Kapadia, R. Kumar); Convenient Hospital Ltd (Dr N. Jain, M. Pahuja); Fortis Hospital (Dr M. Sircar, J. Shukla); Apollo Hospitals Bhubaneswar (Dr S. Sahu, M. Singh); Rajasthan Hospitals (Dr M. Harunbhai);Health care Global Multispecialty Hospital (Dr B. Shah, N. Ponkia, P. Khatri); Sanjeevan Hospital (Dr S. Dixit, Dr R. Rhayakar); Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) (Dr M. Gurjar); Saket City Hospital (Dr P. Saxena, B. Sharma); Jamdar Hospital PVT. LTD. (Dr C. B. Oak); Terna Sahyadri Speciality Hospital (Dr V. Kumar). UK: Oxford University Hospitals: John Radcliffe (JR) and Churchill (CH) Hospital (Dr JL. Millo, A. Chadwick); Royal Surrey County Hospital (Dr B. Creagh-Brown, L. Montague, D. Hull); James Cook University Hospital (Dr IM. Gonzalez, C. Emanuel, A. Inma, S. Bonner); Hull and East Yorkshire Hospital NHS Trust (Dr AP. Gratrix, ND Smith, C. Abernathy); Royal Liverpool University Hospital (Dr PA. Hampshire, K. Williams, A. Walker); Medway NHS Foundation (Dr P. Hayden, C. Plowright, J. Cullinane, R. Box, R. Box, T. Hatton); Morriston Hospital (Dr H. Jones, T. Ghuman, C. Fagan); Royal Sussex Country Hospital (Dr O. Boyd, L. Ortiz-Ruiz de Gordoa); Royal Infirmary of Edinburgh (Dr K. Kefala, DP. Hope); University Hospital Lewisham (Dr BO rose, RA Rosie, D. Grannell, C. Harris); Royal Victoria Hospital (Dr J. Silversides, M. Maguire); Belfast City Hospital (Dr J. Silversides, Dr A. Callaghan, Dr C. McClure); Great Western Hospital (Dr RE. Prout, H. Brown, S. Hughes, L. Matter, A. Leslie, RE. Jones); Wirral University Teaching Hospital (Dr J. Gannon, R. Jacob, S. Christopher, P. Brassey); St George’s Hospital NHS Trust (Dr S. Leaver, C. Ryan, J. Mellinghoff); Sunderland Royal Hospital (Dr P. Hersey, J. Furneval, G. Whitehead); Watford General Hospital (Dr VJ. Page, C. Annalisa); Antrim Area Hospital (Dr CL. Nutt, O. O’Neill, E. McKay); Barnet Hospital, Royal Free London Hospitals NHS Foundation Trust (Dr RR. Jha, Dr N.Hooker); Craigavon Area Hospital (Dr J. Ferguson, L. Espie); Aberdeen Royal Infirmary (Dr C. Kaye, T. Scott). Europe: Bashkir Republic Hospital G.G. Kuvatov (Dr K. Zolotukhin); Hospital General Castellon (Dr AB. Muncharaz); Centre Hospitalier Universitaire -Mont-Godinne (Dr P. Bulpa, S. Bouhon, A. Romnee); Mater Dei Hospital (Dr S. Sciberras, L. Chircop); Centre Hospitalier Universitaire Amiens (Dr D. Herve, Dr M. Stephanie); Medisch Spectrum Twente (Dr A. Beishuizen, Dr JW. Vermeijden); Inselspital, Bern University Hospital (Dr J. Takala, Dr S. Jakob, P. Venetz, T. Merz); Groupe Hospitalier Paris Saint Joseph (Dr B. Misset, J. Fournier); Charité – University Medicine Berlin (Dr St. Weber-Carstens, Dr A. Goldmann); Hospital Beatriz Angelo (Drs. A. Messias, M. Aguiar); San Raffaele Scientific Institute (Dr G. Landoni, Dr P. Bergonzi); Centre Hospitalier Universitaire - Estaing (Dr S. Perbet, Dr JM Constantin, C. Bigot, Dr R. Chabanne, Dr S. Colomb); Xeral-Cies Universitary Hospital (Dr A. Castro); Hospital Univeristari Mutua de Terrassa (Dr M. Fernandez, A. Pous); Hospital Universitario Araba-sede Txagorritxu (Dr JML. Sanchez); St Vincent’s University Hospital (Dr A. Nichol, E. Meaney, K. Brickell); Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliera Universitaria San Martino – IST (Dr Pelosi, C. Micalizzi, M. Mandelli); Città della Salute e della Scienza (Dr L. Brazzi, A. Trompeo, Dr L. Amendolia, Dr S. Dalmasso, Dr E. Di Cristofaro, Dr D. Ferrero); Ospedali Riuniti di Foggia (Dr L. Mirabella, Z. Difiore); Azienda Ospedaliera Universitaria Arcispedale Sant’ Anna Ferrara (Dr S. Spadaro, Dr E. Ferri). Australia/New Zealand: Sir Charles Gairdner Hospital (Dr S. Baker, B. Roberts); Royal Hobart Hospital (Dr PD. Cooper, RE. McAllister); Canberra Hospital (Dr F. van Haren, H. Rodgers, M. Nourse); Wellington Hospital (Dr P. Young, L. Andrew, A. Hunt, S. Hurford); Hawke's Bay Hospital (Dr R. Freebairn, L. Chadwick, L. Thomas); Royal Adelaide Hospital (Dr M. Chapman, S. O’Connor, K. Glasby); Royal Prince Alfred Hospital (Dr DJ. Gattas, H. Buhr, D. Hutch); Westmead Hospital (Dr V. Nayyar, C. Skelly, J. Kong); Auckland City Hospital (Dr C. McArther, L. Newby, Y. Chen); Nepean Hospital (Dr N. Nguyen, L. Weisbrodt, R. Gresham); Royal North Shore Hospital (Dr L. Quinn, F. Bass); Barwon Health, The Geelong Hospital (Dr N. Orford, A. Bone); Christchurch Hospital (Dr S. Henderson, JE. Mehrtens); Concord Hospital (Dr M. Kol, Dr D. Milliss, H. Wong); Blacktown Hospital (Dr G. Reece, T. Sara, K. Nand); The Queen Elizabeth Hospital (Dr S. Peake, J. McIntyre, T. Williams); Royal Darwin Hospital (Dr LT. Campbell, J. Thomas); Middlemore Hospital (Dr A. Williams, C. Hogan, R. Song, A. Tisley); Flinders Medical Centre (Dr S. Bihari, E. Matheson, K. Schwartz). US: Creighton University Medical Center (Dr A. Modrykamien, M. Pote); Mayo Clinic - St. Mary’s Hospital (Dr R. Hubmayr, S. Holets); University of Michigan Health System (Dr R. Hyzy, C. Haas, K. Nelson, R. Eakin); Los Angeles County-University of Southern California Medical Center (Dr J. Leibler, J. Zhu, S. Milstein); United Hospital Systems (Dr A. Answar, J. Baughman, J. Rosen); Saint Barnabas Medical Center (Dr P. Yodice, ME. Dimi); Loma Linda University Medical Center (Dr T. O’Callaghan, X. Luo-Owen); Grady Memorial Hospital (Dr E. Honig, S. Lawoyin, LB. Abderson); Freeman Health System (J. Keener); St. John Medical Center (Dr MS. Charles); Spectrum Health Hospital (Dr S. Fitch, A. Dutkiewicz, F. Carrier, A. Boersen, N. Graff); The University of Kansas Hospital (Dr S. Berry, J. Penn, A. Dalton); University of California at Los Angeles Medical Center, San Monica (Dr S. Chang); Charleston Area Medical Center (Dr R. Crisalli, K. Sutphin A. Barnes); Thomas Jefferson University Hospital (Dr F. Rincon, Dr U. Mukhtar, J. Jaeger, J. Reyes); Nebraska Medical Center (Dr K. Buesing, K. Peterson); Swedish Health Services (Dr K. Koo, J. Wallick).
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