Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.

/pdf/weaning-from-mechanical-ventilation-4yn2mbde5t.pdf

Weaning from mechanical ventilation

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2812%2961148-9.pdf

Mortality after surgery in Europe: a 7 day cohort study

Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature. The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material. This guideline committee developed recommendations for 11 actionable questions in a PICO (population–intervention–comparison–outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation. This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.

https://erj.ersjournals.com/content/erj/50/2/1602426.full.pdf

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

http://emergpa.net/wp/wp-content/uploads/2011/03/NIV.pdf

Non-invasive ventilation in acute respiratory failure

ContextHypoxemia complicates the recovery of 30% to 50% of patients after abdominal
surgery; endotracheal intubation and mechanical ventilation may be required
in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive
care unit and hospital stay.ObjectiveTo determine the effectiveness of continuous positive airway pressure
compared with standard treatment in preventing the need for intubation and
mechanical ventilation in patients who develop acute hypoxemia after elective
major abdominal surgery.Design and SettingRandomized, controlled, unblinded study with concealed allocation conducted
between June 2002 and November 2003 at 15 intensive care units of the Piedmont
Intensive Care Units Network in Italy.PatientsConsecutive patients who developed severe hypoxemia after major elective
abdominal surgery. The trial was stopped for efficacy after 209 patients had
been enrolled.InterventionsPatients were randomly assigned to receive oxygen (n = 104)
or oxygen plus continuous positive airway pressure (n = 105).Main Outcome MeasuresThe primary end point was incidence of endotracheal intubation; secondary
end points were intensive care unit and hospital lengths of stay, incidence
of pneumonia, infection and sepsis, and hospital mortality.ResultsPatients who received oxygen plus continuous positive airway pressure
had a lower intubation rate (1% vs 10%; P = .005;
relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had
a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95%
CI, 0.07-0.94; P = .03), and sepsis (2%
vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03)
than did patients treated with oxygen alone. Patients who received oxygen
plus continuous positive airway pressure also spent fewer mean (SD) days in
the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09)
than patients treated with oxygen alone. The treatments did not affect the
mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus
continuous positive airway pressure died in the hospital while 3 deaths occurred
among those treated with oxygen alone (P = .12).ConclusionContinuous positive airway pressure may decrease the incidence of endotracheal
intubation and other severe complications in patients who develop hypoxemia
after elective major abdominal surgery.

https://jamanetwork.com/journals/jama/articlepdf/200264/jce40057.pdf

Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial

Context Hypoxemia complicates the recovery of 30% to 50% of patients after abdominal surgery; endotracheal intubation and mechanical ventilation may be required in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive care unit and hospital stay. Objective To determine the effectiveness of continuous positive airway pressure compared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery.

/pdf/continuous-positive-airway-pressure-for-treatment-of-4hjd7ivcmq.pdf

Massimiliano Coha

Papers

Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial

Continuous Positive Airway Pressure for Treatment of Postoperative Hypoxemia