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Published ahead of print on January 15, 2004, doi:10.1164/rccm.200306-761OC

Am. J. Respir. Crit. Care Med., Volume 169, Number 6, March 2004, 673-678

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Submitted on June 9, 2003
Accepted on January 7, 2004

A Prospective, Controlled Trial of a Protocol-Based Strategy to Discontinue Mechanical Ventilation

Henry E Fessler1*, Jerry A Krishnan1, Dana Moore2, Carey Robeson2, and Cynthia S Rand1

1 Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA, 2 Medical Nursing, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA

* To whom correspondence should be addressed. E-mail: hfessler{at}jhmi.edu.

Weaning protocols can improve outcomes, but their efficacy may vary with patient and staff characteristics. In this prospective, controlled trial, we compared protocol-based weaning to usual, physician-directed weaning in a closed Medical Intensive Care Unit with high physician staffing levels and structured, system-based rounds. Adult patients requiring mechanical ventilation for >24 hours were assigned to Usual Care or Protocol weaning based on their hospital identification number. Patients assigned to Usual Care (N=145) were managed at their physicians' discretion. Patients assigned to Protocol (N=154) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention. There were no significant baseline differences in patient characteristics between groups. The proportion of patients (Protocol vs. Usual care) who successfully discontinued mechanical ventilation (74.7% vs. 75.2%, p=0.92), duration of mechanical ventilation (median [interquartile range]: 60.4 hours [28.6-167.0 hours] vs. 68.0 hours [27.1-169.3 hours], p=0.61], ICU (25.3% vs. 28.3%) and hospital mortality (36.4% vs. 33.1%), ICU length of stay (115 hours vs. 146 hours), and rates of re-instituting mechanical ventilation (10.3% vs. 9.0%) were similar. We conclude that protocol-directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds.
Key words: Ventilator weaning; Respirator, artificial; Critical care; Nursing care




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