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Ventilator Weaning and Discontinuation Practices for Critically Ill Patients

Educational Objective
To understand the risks of weaning from mechanical ventilation.
1 Credit CME
Key Points

Question  In critically ill patients who receive invasive mechanical ventilation, how is invasive mechanical ventilation discontinued and do discontinuation practices differ internationally?

Findings  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.

Meaning  Mechanical ventilation weaning practices varied internationally, with nearly 50% of patients undergoing an initial spontaneous breathing trial.

Abstract

Importance  Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.

Objective  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).

Exposures  Receiving IMV.

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.

Results  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.

Trial Registration  ClinicalTrials.gov Identifier: NCT03955874

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Article Information

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 (karen.burns@unityhealth.to).

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).

References
1.
Wunsch  H , Linde-Zwirble  WT , Angus  DC , Hartman  ME , Milbrandt  EB , Kahn  JM .  The epidemiology of mechanical ventilation use in the United States.   Crit Care Med. 2010;38(10):1947-1953. doi:10.1097/CCM.0b013e3181ef4460PubMedGoogle ScholarCrossref
2.
Carson  SS , Cox  CE , Holmes  GM , Howard  A , Carey  TS .  The changing epidemiology of mechanical ventilation: a population-based study.   J Intensive Care Med. 2006;21(3):173-182. doi:10.1177/0885066605282784PubMedGoogle ScholarCrossref
3.
Needham  DM , Bronskill  SE , Calinawan  JR , Sibbald  WJ , Pronovost  PJ , Laupacis  A .  Projected incidence of mechanical ventilation in Ontario to 2026: preparing for the aging baby boomers.   Crit Care Med. 2005;33(3):574-579. doi:10.1097/01.CCM.0000155992.21174.31PubMedGoogle ScholarCrossref
4.
Wunsch  H , Wagner  J , Herlim  M , Chong  DH , Kramer  AA , Halpern  SD .  ICU occupancy and mechanical ventilator use in the United States.   Crit Care Med. 2013;41(12):2712-2719. doi:10.1097/CCM.0b013e318298a139PubMedGoogle ScholarCrossref
5.
Melsen  WG , Rovers  MM , Groenwold  RHH ,  et al.  Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies.   Lancet Infect Dis. 2013;13(8):665-671. doi:10.1016/S1473-3099(13)70081-1PubMedGoogle ScholarCrossref
6.
Rengel  KF , Hayhurst  CJ , Pandharipande  PP , Hughes  CG .  Long-term cognitive and functional impairments after critical illness.   Anesth Analg. 2019;128(4):772-780. doi:10.1213/ANE.0000000000004066PubMedGoogle ScholarCrossref
7.
MacIntyre  NR , Cook  DJ , Ely  EW  Jr ,  et al; American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine.  Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine.   Chest. 2001;120(6)(suppl):375S-395S. doi:10.1378/chest.120.6_suppl.375SPubMedGoogle ScholarCrossref
8.
Blackwood  B , Burns  K , Cardwell  C , O’Halloran  P.   Protocolized vs. non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients Cochrane systematic review and meta-analysis.   Cochrane Database Syst Rev. 2014;2014(11):CD006904. doi:10.1002/14651858.CD006904.pub3PubMedGoogle Scholar
9.
Burns  KEA , Soliman  I , Adhikari  NKJ ,  et al.  Trials directly comparing alternative spontaneous breathing trial techniques: a systematic review and meta-analysis.   Crit Care. 2017;21(1):127. doi:10.1186/s13054-017-1698-xPubMedGoogle ScholarCrossref
10.
Subirà  C , Hernández  G , Vázquez  A ,  et al.  Effect of pressure support vs t-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: a randomized clinical trial.   JAMA. 2019;321(22):2175-2182. doi:10.1001/jama.2019.7234PubMedGoogle ScholarCrossref
11.
Esteban  A , Frutos  F , Tobin  MJ ,  et al; Spanish Lung Failure Collaborative Group.  A comparison of four methods of weaning patients from mechanical ventilation.   N Engl J Med. 1995;332(6):345-350. doi:10.1056/NEJM199502093320601PubMedGoogle ScholarCrossref
12.
Burns  KEA , Raptis  S , Nisenbaum  R ,  et al; Canadian Critical Care Trials Group.  International practice variation in weaning critically ill adults from invasive mechanical ventilation.   Ann Am Thorac Soc. 2018;15(4):494-502. doi:10.1513/AnnalsATS.201705-410OCPubMedGoogle ScholarCrossref
13.
Esteban  A , Anzueto  A , Frutos  F ,  et al; Mechanical Ventilation International Study Group.  Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study.   JAMA. 2002;287(3):345-355. doi:10.1001/jama.287.3.345PubMedGoogle ScholarCrossref
14.
Esteban  A , Ferguson  ND , Meade  MO ,  et al; VENTILA Group.  Evolution of mechanical ventilation in response to clinical research.   Am J Respir Crit Care Med. 2008;177(2):170-177. doi:10.1164/rccm.200706-893OCPubMedGoogle ScholarCrossref
15.
Esteban  A , Frutos-Vivar  F , Muriel  A ,  et al.  Evolution of mortality over time in patients receiving mechanical ventilation.   Am J Respir Crit Care Med. 2013;188(2):220-230. doi:10.1164/rccm.201212-2169OCPubMedGoogle ScholarCrossref
16.
Burns  KEA , Rizvi  L , Cook  DJ ,  et al; Canadian Critical Care Trials Group.  Variation in the practice of discontinuing mechanical ventilation in critically ill adults: study protocol for an international prospective observational study.   BMJ Open. 2019;9(9):e031775. doi:10.1136/bmjopen-2019-031775PubMedGoogle Scholar
17.
Holm  S, .  A simple sequentially rejective multiple test procedure.   Scand J Stat. 1979:6(2):65-70.Google Scholar
18.
Riker  RR , Picard  JT , Fraser  GL .  Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.   Crit Care Med. 1999;27(7):1325-1329. doi:10.1097/00003246-199907000-00022PubMedGoogle ScholarCrossref
19.
Vincent  JL , de Mendonca  A , Cantraine  F ,  et al.  Use of the SOFA score to assess the incidence of organ dysfunction failure in intensive care units: results of a multicenter, prospective study.   Crit Care Med. 1998;26(11):1793-1800. doi:10.1097/00003246-199811000-00016PubMedGoogle ScholarCrossref
20.
Tallgren  M , Bäcklund  M , Hynninen  M .  Accuracy of Sequential Organ Failure Assessment (SOFA) scoring in clinical practice.   Acta Anaesthesiol Scand. 2009;53(1):39-45. doi:10.1111/j.1399-6576.2008.01825.xPubMedGoogle ScholarCrossref
21.
Harrell  FE  Jr .  Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis. Springer; 2015.
22.
Van Buuren  S .  Flexible Imputation of Missing Data. Chapman & Hall; 2018.
23.
Van Calster  B , McLernon  DJ , van Smeden  M , Wynants  L , Steyerberg  EW .  Calibration: the Achilles heel of predictive analytics.   BMC Med. 2019;17(1):230. doi:10.1186/s12916-019-1466-7 PubMedGoogle ScholarCrossref
24.
Beduneau  G , Pham  T , Schortgen  F ,  et al; WIND (Weaning according to a New Definition) Study Group and the REVA Network.  Epidemiology of weaning outcome according to a new definition: the WIND study.   Am J of Respir Crit Care. 2017;195(6):772-83. doi:10.1164/rccm.201602-0320OCPubMedGoogle ScholarCrossref
25.
Ely  EW , Baker  AM , Evans  GW , Haponik  EF .  The prognostic significance of passing a daily screen of weaning parameters.   Intensive Care Med. 1999;25(6):581-587. doi:10.1007/s001340050906PubMedGoogle ScholarCrossref
26.
Kalassian  KG , Dremsizov  T , Angus  DC .  Translating research evidence into clinical practice: new challenges for critical care.   Crit Care. 2002;6(1):11-14. doi:10.1186/cc1446PubMedGoogle ScholarCrossref
27.
Schultz  MJ , Wolthuis  EK , Moeniralam  HS , Levi  M .  Struggle for implementation of new strategies in intensive care medicine: anticoagulation, insulin, and lower tidal volumes.   J Crit Care. 2005;20(3):199-204. doi:10.1016/j.jcrc.2005.05.007PubMedGoogle ScholarCrossref
28.
Brochard  L , Rauss  A , Benito  S ,  et al.  Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation.   Am J Respir Crit Care Med. 1994;150(4):896-903. doi:10.1164/ajrccm.150.4.7921460PubMedGoogle ScholarCrossref
29.
Tripepi  G , Jager  KJ , Dekker  FW , Zoccali  C .  Selection bias and information bias in clinical research.   Nephron Clin Pract. 2010;115(2):c94-c99. doi:10.1159/000312871PubMedGoogle ScholarCrossref
30.
Ouellette  DR , Patel  S , Girard  TD ,  et al.  Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society clinical practice guideline.   Chest. 2017;151(1):166-180. doi:10.1016/j.chest.2016.10.036PubMedGoogle ScholarCrossref
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