Implementation of a standardised weaning protocol in patients with prolonged mechanical ventilation in a post-acute care ICU

Introduction

Due to the improvement of nearly all fields of acute care in the past decades, the burden of long-term dependency from mechanical ventilation (MV) increases incessantly. The aim of this study was to implement and test a standardised weaning protocol in patients suffering from long-term mechanical ventilation.

Methods

After approval by the local ethics committee and informed consent, 644 patients were enrolled in a prospective cohort study in 1 year. The mean time on the ventilator before inclusion was 39.4 (6 to 357) days. The reasons for long-term MV were: cerebral 33.1%; cardiovascular 31.5%; pulmonary 28.7% and 5.6% neuromuscular diseases. The weaning protocol started with 6 × 5 minutes spontaneous breathing (intermission of mechanical ventilation) on day 1 and was increased stepwise up to 24 hours spontaneous breathing on day 22. If there was no improvement in weaning steps over 5 days or there were more than three steps backwards the patient was switched to the individual weaning approach. The weaning protocol was carried out by the previously trained ICU staff as well as by specialized physiotherapists.

Results

A total of 77.3% (n = 498) of the patients could be weaned off the ventilator by the first effort. Out of these, 85.9% of the patients were weaned by the protocol whereas 14.1% needed an individual approach. The mean time of weaning was 17 (5 to 67) days using the protocol and 29 (1 to 88) days due to the individual approach. In 12.6% both weaning procedures failed and these patients were discharged from the hospital into a home-care ventilation program. In total, 10.1% of the patients died on mechanical ventilation during their ICU stay. Patients who had needed a second weaning effort (n = 111) were weaned in 36.4% by the protocol, transferred to home-care ventilation (28.8%) or died (35.1%).

Conclusions

Using the standardised weaning protocol, more than three-quarters of the prolonged mechanically ventilated patients could be weaned off the ventilator in a mean of 17 days. Only 14.1% needed an individual strategy that takes 29 days until complete release from the ventilator. Therefore we suggest this kind of weaning protocol as a useful tool in patients with prolonged mechanical ventilation in a post-acute care facility.