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Desconexión protocolizada versus no protocolizada para la reducción de la duración de la ventilación mecánica en pacientes adultos graves

Appendices

Appendix 1. Ovid MEDLINE(R) in‐process and other non‐indexed citations and Ovid MEDLINE(R) (1950 to week 04 January 2014)

#1 exp Ventilator Weaning/
#2 mechanical ventilat$ weaning.mp.
#3 mechanical ventilation.mp.
#4 (protocol$ adj weaning).mp.
#5 (ventilat$ adj weaning).mp.
#6 exp Ventilators, Mechanical/
#7 exp Ventilators, Negative‐Pressure/
#8 (mechanical adj ventilat$).mp.
#9 (mechanical adj weaning).mp.
#10 ventilat$.ab,ti.
#11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10
#12 protocol$.mp.
#13 exp Clinical Protocols/
#14 exp Patient Care Management/
#15 Practice Guidelines/
#16 #12 or #13 or #14 or #15
#17 #11 and #16
#18 clinical trial.pt.
#19 randomized.ab.
#20 placebo.ab.
#21exp Clinical Trials/
#22 randomly.ab.
#23 trial.ti.
#24 #18 or #19 or #20 or #21 or #22 or #23
#25 Animals/
#26 Humans/
#27 #25 not (#25 and #26)
#28 #24 not #27
#29 #17 and #28

Appendix 2. EMBASE (1988 to week 04 January 2014)

#1 exp Ventilator Weaning/
#2 mechanical ventilat$ weaning.mp.
#3 mechanical ventilation.mp.
#4 (protocol$ adj weaning).mp.
#5 (ventilat$ adj weaning).mp.
#6 exp Ventilators, Mechanical/
#7 exp Ventilators, Negative‐Pressure/
#8 (mechanical adj ventilat$).mp.
#9 (mechanical adj weaning).mp.
#10 ventilat$.ab,ti.
#11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10
#12 protocol$.mp.
#13 exp Clinical Protocols/
#14 exp Patient Care Management/
#15 Practice Guidelines/
#16 #12 or #13 or #14 or #15
#17 #11 and #16
#18 clinical trial.pt.
#19 randomized.ab.
#20 placebo.ab.
#21exp Clinical Trials/
#22 randomly.ab.
#23 trial.ti.
#24 #18 or #19 or #20 or #21 or #22 or #23
#25 Animals/
#26 Humans/
#27 #25 not (#25 and #26)
#28 #24 not #27
#29 #17 and #28

Appendix 3. LILACS (via BIREME interface) (1982 to January 2014)

# 1 "WEANING" or "MECHANICAL VENTILATION" or “VENTILATOR" or "NEGATIVE‐PRESSURE" [Words] or "ventilat* weaning" or "mechanical ventilator*" or "destetar mecánico" or "desmamar mecânico" [Words]

Appendix 4. CINAHL Plus EBSCO host (1937 to January 2014)

#1 (MM "Ventilators, Mechanical") or (MM "Ventilator Weaning") or (MH”Respiration, artificial+”)

#2 (“mechanical ventilat$ weaning”) or (“MH Ventilator Weaning”) or (MH “Mechanical Ventilatory Weaning (Iowa NIC)”) or (MH “Ventilatory Weaning Impairment (Saba CCC)”)

#3 “mechanical ventilation”

#4 “weaning protocol”

#5 #1 or #2 or #3 or #4

#6 (“protocol$”) or (MM “Nursing Protocols+”)

#7 (MM “Practice Guidelines”)

#8 #6 or #7

#9 #5 and #8

#10 (MM “Clinical Trials+”)

#11 (MH “Random Assignment”)

#12 “randomly”

#13 “trial”

#14 #10 or #11 or #12 or #13

#15 #9 and #14

Appendix 5. CENTRAL (The Cochrane Library Issue 1, 2014)

#1  MeSH descriptor Ventilator Weaning explode all trees

#2  mechanical ventilat* weaning

#3  protocol* near weaning

#4  ventilat* near weaning

#5  MeSH descriptor Ventilators, Mechanical explode all trees

#6  MeSH descriptor Ventilators, Negative‐Pressure explode all trees

#7  (mechanical ventilat*):ab

#8  mechanical near weaning

#9  ventilat*:ti

#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)

#11 protocol*:ti,ab

#12 MeSH descriptor Clinical Protocols explode all trees

#13 MeSH descriptor Patient Care Management explode all trees

#14 MeSH descriptor Practice Guidelines explode all trees

#15 (#11 OR #12 OR #13 OR #14)

#16 (#10 AND #15)

Appendix 6. ISI Web of Science with Conference Proceedings (1970 to February 2014)

#1 TS=mechanical ventilat*

#3 TS=(ventilat* SAME weaning)

#2 TS=(protocol* SAME weaning)

#4  TS=Ventilator* Negative‐Pressure

#5  TS=(mechanical SAME weaning)

#6  TS=ventilat*

#7 #6 OR #5 OR #4 OR #3 OR #2 OR #1

#8  TS=protocol*

#9  TS=(Care SAME Manag*)

#10   TS=(Patient* SAME Management )

#11  TS=(Practice Guideline*)

#12   #11 OR #10 OR #9 OR #8

#13  #12 AND #7

#14  TS=clinical trial*

#15 TS=random*

#16  TS=placebo*

#17  #16 OR #15 OR #14

#18  #17 AND #13

Appendix 7. Data extraction form

Study Selection, Quality Assessment & Data Extraction Form

Name of author extracting data: ____________________________

Date form completed: ____________________________

Study ID

Title

Study ID for RevMan

(Family name of first author and year of publication + letter if more than one per year, e.g. Smith2001b)

Are there other articles of same study? (YES, NO, Unclear. If Yes, write Study IDs)

Study Eligibility

(please circle)

Type of study

Can the study be described as randomized?

Yes, Unclear, No

Participants

1. Were the participants adults (at least 18 years & over) and in ICUs?

2. Were participants intubated (naso/orotracheal) and receiving invasive mechanical ventilation (MV)?

Yes, Unclear, No

Yes, Unclear, No

Interventions

1. Was one group weaned using a formal weaning protocol1?

2. Was the other group weaned without reference to a formal protocol?

Yes, Unclear, No

Yes, Unclear, No

Outcomes: Did the study report any one of –

1. Total duration of MV (time from initiation of MV to MV discontinuation)?

2. Weaning duration (time from identification of weaning readiness to MV discontinuation)?

3. ICU length of stay

Yes, Unclear, No

Yes, Unclear, No

Yes, Unclear, No

Conclusion: Do not proceed if any of the above answers are ‘No’.

If study to be ‘included’ or ‘excluded & listed in excluded table’, record below the information to be inserted into tables.

If included – continue to page 2

Included, or

Excluded and should be listed in the excluded table

More information needed before inclusion decision (specify):

Record for tables:

1Protocol = a written set of rules, criteria, guidelines or algorithm for deciding if a patient is ready to tolerate MV discontinuation & for reducing ventilatory support.

PARTICIPANTS

Inclusion/Exclusion Criteria

INTERVENTION

CONTROL

Number randomized

Number analyzed

Age, mean (SD)

med (IQR)

Age, mean (SD)
med (IQR)

Male n (%)

Male n (%)

Name severity of illness measure (e.g. APACHE, SAPS, PELOD)

mean (SD)

med (IQR)

Name severity of illness measure (e.g. APACHE, SAPS, PELOD)

mean (SD)

med (IQR)

Setting

Participating site country(ies):

Academic hospital

Non‐teaching hospital

Not reported

Any other information about hospital (e.g. number of beds)

Number of ICUs and types

(e.g. medical; surgical; mixed; neuro. Include number of beds if reported)

Closed ICU structure

Open ICU structure

Not reported

Nurse staffing for vent patients

1:1

1:2

1:3

1:4

Not reported

Physician staffing (describe)

Not reported

INTERVENTION

Describe weaning protocol and, if appropriate, who delivered it (verbatim)

Describe sedation strategies in intervention arm (tick all that apply):

sedation score

sedation protocol

daily interruption

not reported

CONTROL

Describe usual/standard weaning (verbatim)

Describe sedation strategies in control arm (tick all that apply): as above

sedation score

sedation protocol

daily interruption

not reported

Outcomes (list & provide descriptors if they were described in the paper)

Primary

Secondary

Domain

Description (verbatim)

Judgement

Sequence generation

Was the allocation sequence adequately generated?

Yes

No

Unclear

Allocation concealment

Was allocation adequately concealed?

Yes

No

Unclear

Blinding (participants, personnel, outcome)

Was knowledge of the allocated intervention adequately prevented during the study?

Yes

No

Unclear

Incomplete outcome data

Were incomplete outcome data adequately addressed?

State whether attrition and exclusions were reported, the numbers in each intervention group

(compared with total randomized participants), reasons

Total duration of mechanical ventilation (initiation of mechanical ventilation to discontinuation)

Not measured

Yes

No

Unclear

Weaning duration (identification of weaning to mechanical ventilation discontinuation)

Not measured

Yes

No

Unclear

Mechanical ventilation time prior to weaning

(initiation of mechanical ventilation to identification of weaning)

Not measured

Yes

No

Unclear

Time from mechanical ventilation discontinuation to extubation

Not measured

Yes

No

Unclear

ICU length of stay

Not measured

Yes

No

Unclear

Hospital length of stay

Not measured

Yes

No

Unclear

Cost

Not measured

Yes

No

Unclear

Mortality

Not measured

Yes

No

Unclear

Reintubation

Not measured

Yes

No

Unclear

Selfextubation

Not measured

Yes

No

Unclear

Postextubation NIV

Not measured

Yes

No

Unclear

≥ 21 days vented

Not measured

Yes

No

Unclear

Tracheostomy

Not measured

Yes

No

Unclear

Selective outcome reporting.

Are reports of the study free of suggestion of selective outcome reporting?

Yes

No

Unclear

Other sources of bias. Study free from other bias?

Yes

No

Unclear

Outcomes – Continuous Data

Outcomes

Unit measurement

Intervention group

Control group

95% CI or any further details

if outcome only described in text

n

Mean (SD)

Median (IQR)

n

Mean (SD)

Median (IQR)

P‐value

Total duration of mechanical ventilation

(initiation of mechanical ventilation to discontinuation)

Weaning duration

(identification of weaning to mechanical ventilation discontinuation)

Mechanical ventilation time prior to weaning

(initiation of mechanical ventilation to identification of weaning)

Time from mechanical ventilation discontinuation to extubation

ICU length of stay

Hospital length of stay

Cost (state, hospital or ICU)

Outcomes ‐ Dichotomous Data

Outcomes

Intervention group

(n = )

Control group

(n = )

P value

Any further information

Reintubation

Self extubation

Tracheostomy

Mechanical ventilation > 21 days

Mortality

Postextubation NIV

Please specify number of patients in each group experiencing the specified outcomes.

Other information which you feel is relevant to the results:

Indicate if: any data were obtained from the primary author; if results were estimated from graphs etc; or calculated by you using a formula (this should be stated and the formula given).

In general if results not reported in paper(s) are obtained this should be made clear here to be cited in review.

Updated study flow diagram.
Figuras y tablas -
Figure 1

Updated study flow diagram.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figuras y tablas -
Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.3 Total duration of mechanical ventilation by type of protocol [log hours].
Figuras y tablas -
Figure 4

Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.3 Total duration of mechanical ventilation by type of protocol [log hours].

Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.9 Weaning duration by type of approach [log hours].
Figuras y tablas -
Figure 5

Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.9 Weaning duration by type of approach [log hours].

Funnel plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.2 Total duration of MV by type of approach [log hours].
Figuras y tablas -
Figure 6

Funnel plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.2 Total duration of MV by type of approach [log hours].

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 1 Total duration of MV by type of unit.
Figuras y tablas -
Analysis 1.1

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 1 Total duration of MV by type of unit.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 2 Total duration of MV by type of approach.
Figuras y tablas -
Analysis 1.2

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 2 Total duration of MV by type of approach.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 3 Total duration of MV by type of protocol [log hours].
Figuras y tablas -
Analysis 1.3

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 3 Total duration of MV by type of protocol [log hours].

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 4 Mortality.
Figuras y tablas -
Analysis 1.4

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 4 Mortality.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 5 Reintubation.
Figuras y tablas -
Analysis 1.5

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 5 Reintubation.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 6 Self extubation.
Figuras y tablas -
Analysis 1.6

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 6 Self extubation.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 7 Tracheostomy.
Figuras y tablas -
Analysis 1.7

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 7 Tracheostomy.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 8 Weaning duration by type of ICU.
Figuras y tablas -
Analysis 1.8

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 8 Weaning duration by type of ICU.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 9 Weaning duration by type of approach.
Figuras y tablas -
Analysis 1.9

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 9 Weaning duration by type of approach.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 10 Weaning duration by type of protocol [log hours].
Figuras y tablas -
Analysis 1.10

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 10 Weaning duration by type of protocol [log hours].

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 11 ICU length of stay.
Figuras y tablas -
Analysis 1.11

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 11 ICU length of stay.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 12 Hospital length of stay.
Figuras y tablas -
Analysis 1.12

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 12 Hospital length of stay.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 13 ICU costs.
Figuras y tablas -
Analysis 1.13

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 13 ICU costs.

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 14 Hospital costs.
Figuras y tablas -
Analysis 1.14

Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 14 Hospital costs.

Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 1 Total duration of MV.
Figuras y tablas -
Analysis 2.1

Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 1 Total duration of MV.

Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 2 Weaning duration.
Figuras y tablas -
Analysis 2.2

Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 2 Weaning duration.

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 1 Total duration of MV.
Figuras y tablas -
Analysis 3.1

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 1 Total duration of MV.

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 2 Weaning duration.
Figuras y tablas -
Analysis 3.2

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 2 Weaning duration.

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 3 ICU length of stay.
Figuras y tablas -
Analysis 3.3

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 3 ICU length of stay.

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 4 Hospital length of stay.
Figuras y tablas -
Analysis 3.4

Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 4 Hospital length of stay.

Protocolized versus non‐protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients

Patient or population: mechanically ventilated adult patients

Settings: intensive care units

Intervention: protocolized weaning

Comparison: non‐protocolized weaning

Outcomes

Illustrative comparative risks* (95% CI)

Effect Estimates

(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

non‐protocolized weaning

Corresponding risk

protocolized weaning

Total duration of mechanical ventilation

(hours)

Mean 96 hours1

Mean 71 hours (60.5 to 83.5 hours)

Geometric mean difference

‐26% (‐37% to ‐13%)

2205
[14 studies]

+++O
moderate2

Weaning duration

(hours)

Mean 24 hours1

Mean 7 hours (2.8 to 17.5 hours)

Geometric mean difference

‐70% (‐88% to ‐27%)

989
[8 studies]

++OO
low3

ICU length of stay (days)

Mean 8 days1

Mean 7 days (6.5 to 7.8 days)

Geometric mean difference

‐11% (‐19% to ‐3%)

1378

[9 studies]

++OO
low4

ICU mortality

31%1

30% (20% to 42%)

OR 0.97 (0.57 to 1.63)

651

[6 studies]

+++O
moderate5

Reintubation

10%1

(following deliberate extubation)

8% (5% to 12%)

OR 0.74 (0.44 to 1.23)

1487

[11 studies]

++OO
moderate6

*The basis for the assumed risk (e.g. the mean control group risk) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the effect estimate of the intervention (and its 95% CI).

CI: Confidence interval; ICU: intensive care unit; OR: Odds Ratio.

GRADE Working Group grades of evidence
High quality (++++): Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality (+++O): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality (++OO): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality (+OOO): We are very uncertain about the estimate.

1 The assumed risk is derived from the median reported in a large epidemiological study of characteristics and outcomes in patients (N = 4968) receiving mechanical ventilation by Esteban 2008. The reported medians were used as an approximation for the means used for illustrative comparisons of all continuous variables. The table shows the mean duration of mechanical ventilation, weaning and ICU length of stay if patients are not weaning by protocol (non‐protocolized weaning) and what would be expected with protocolized weaning based on the effect estimates from our review.

2 There was considerable variability in effect estimates (I2 = 67%) that could not be explained by subgroup analysis although variability was lower than the previous review. The confidence interval was narrower in this review and the difference at the lower limit would still be clinically significant.

3 There was considerable variability in effect estimates (I2 = 97%) and the wide confidence intervals indicate imprecision in results. The lower limit suggests a one hour difference in weaning that is not clinically significant.

4 There was no heterogeneity among trials effects estimates, but wide confidence intervals indicate imprecision in results.

5 There was moderate variability in effect estimates (I2 = 50%).

6 There was moderate variability in effect estimates (I2 = 43%).

Figuras y tablas -
Table 1. Readiness to wean criteria

Study

Assessment frequency

Oxygenation

Other respiratory factors 

Cardiovascular

Neurological

Inflammatory response

Medication

Other 

Chaiwat 2010

Daily screen

PaO2/FiO2 >/= 200 on FiO2 </= 0.4

SpO2 >/= 94%

PEEP </= 5

Respiratory rate < 35

Rapid Shallow breathing index

</= 105

Static lung compliance >/= 25 mL/cmH2O

Minute volume </= 10L/min

HR < 120 b/min

Awake and easily rousable

Not included

Dopamine </= 5 ug/kg/min

Noradrenaline </= 5 ug/kg/min

Pain score < 4

de Carvalho Oliveira 2002

Not reported

PaO2 < 90 on FiO2 </= 0.4

PEEP < 5

Pimax < ‐ 25 cm H2O

Not included

GCS > 8

Not included

No sedation

No vasopressors

Cause of MV resolved

No planned surgery

Ely 1996

Daily screen

 

PaO2/FiO2 > 200

PEEP </= 5

f/VT </= 105

 Not included

 Not included

 Not included

No vasopressors or sedation

Adequate cough

 

Fan 2013

Daily screen

Not reported

Not reported

Not reported

Not reported

Not reported

Not reported

Not reported

Kollef 1997

Protocol entry criteria

 

PaO2/FiO2 > 200

PEEP </= 5

RR </= 35 b/min

 

HR < 140 b/min

Awake and orientated

 Not included

No vasoactive or inotropic agents

 Not included

Krishnan 2004

Daily screen

 

SpO2 >/= 92%

FiO2 </= 0.5

PEEP </=5

 

Stable CAD

HR < 140 b/min

No raised ICP

 Not included

No paralytics

Cough and gag reflex present

Responsive to stimuli

 

Marelich 2000

x 2 daily screen

 

PaO2/FiO2 >/= 200

 Not included

MAP >/= 60 mmHg

GCS >/= 10 or tracheostomy

 Not included

No vasopressors

Dopamine </= 5 ug/kg/min

Adequate cough not limited by pain

 

Namen 2001

Daily screen

PaO2/FiO2 > 200

PEEP </= 5

f/VT </= 105

 Not included

 Not included

 Not included

No vasopressors or sedation

Adequate cough

 

Navalesi 2008

Daily screen

PaO2/FiO2 > 200

FiO2 </= 0.4

pH >/= 7.35

PaCO2 </= 50 mmHg

PEEP </= 5

 

HR </= 125 b/min

SBP >/= 90 mmHg

GCS >/= 8

T < 38.5oC

No vasopressors

Dopamine </= 5 ug/kg/min

Adequate cough

Suctioning < 2/hr

Normal Na blood values

 

Ogica 2007

Not reported

Not reported

Not reported

Not reported

Not reported

Not reported

Not reported

Not reported

Piotto 2011

Daily screen

PaO2/FiO2 150‐300

FiO2 </= 0.4

PaO2 >/= 60 mmHg

Hb = 8 ‐ 10 g/L

 

 Not included

MAP >/= 60 mmHg

HR </= 140 b/min

Awake

GCS >/= 9

T < 37.8oC

Minimum sedation

No or low vasopressors

Cause of MV resolved

Effective cough

Metabolic stability

No hydroelectrolyte disorders

 

Reardon 2011

Daily screen

SaO2 > 90% or PaO2 > 60 mmHg on FiO2 </= 0.5

Respiratory rate < 35

pH > 7.20

Triggering breaths

SBP > 90 and < 180

HR > 50 and < 130

No cardiac ischaemia

GCS > 8

Not included

Minimal pressure requirements

Improving condition

Absence of excessive secretions

Suctioning < hourly

Deemed ready to wean

Roh 2012

Not reported

FiO2 </= 0.5

RR </= 35

PEEP </= 8

Triggering breaths

SBP >/= 90 mmHg

HR </= 150 b/min

Not included

Not included

No paralytics

No vasopressors

Dopamine </= 5 ug/kg/min

Noradrenaline </= 5 ug/kg/min

Not included

Rose 2008

Inclusion criteria

PaO2/FiO2 > 150 or SaO2 >/= 90% on FiO2 0.5

PEEP </= 8

Plateau pressure </= 30 cmH2O

Successful 30 min SBT using PS 20 cm H2O

to achieve TV > 200 mL

 

Haemodynamically stable

GCS > 4

T = 36 ‐ 39oC

 Not included

No surgery anticipated

MV > 24 hr

 

Simeone 2002

Inclusion criteria

PaO2/FiO2 >/= 200

FiO2 < 0.5

pH 7.3 ‐ 7.5

PaO2 30 ‐ 50 mmHg

SaO2 > 90%

Hb > 8 mg/dL

Pulse oximeter oxygenation stable

Cardiopulmonary bypass time < 150 min

PEEP < 4

RR < 35 b/min

Dynamic compliance > 22 mL/cmH2O

Compliance statica >33 mL/cmH2O

Vital capacity >10 mL/kg

MIP >/= ‐15 cmH2O

 

Haemodynamically stable

Awake and conscious

T > 35 < 38oC

 Not included

Urine output > 100 mL/hr

Normal CXR

Stahl 2009

Inclusion criteria

FiO2 </= 0.5

PaO2 > 75 mmHg or SaO2 > 90%

pH </= 7.2

Hb >/= 7g/dL

PEEP </= 10

Haemodynamically stable

 Not included

 Not included

Dopamine </= 5 ug/kg/min

MV > 24 hr

Breathing spontaneously

Ramsey sedation score =/< 3

 

Strickland 1993

Inclusion criteria

FiO2 </= 0.4

pH >/= 7.3 </= 7.5

PCO2 >/= 30 </= 50

SaO2 >/= 90% on SIMV rate 6 ‐ 10

PS 20 cmH2O

NIF </= ‐ 20 cmH2O

FVC >/= 10 mL/kg

TV 10 ‐ 15 mL/kg

 

Haemodynamically stable

 Not included

T </= 37oC

 Not included

Judged ready to wean by physician

Feeding ‐  parenteral or tube

Stable renal function

Normal electrolytes

 

CAD = coronary artery diease; CXR = chest X‐ray; GCS = Glasgow Coma Scale; FVC = forced vital capacity; Hb = haemoglobin; HR ‐ heart rate; MAP = mean arterial pressure; MIP = maximal inspiratory pressure; MV = mechanical ventilation; NIF = negative inspiratory force; PEEP = positive end expiratory pressure; Pimax = maximal inspiratory mouth pressure; PS = pressure support; RR = respiratory rate; SBP = systolic blood pressure; SIMV = synchronized intermittent mechanical ventilation; T = temperature; TV = tidal volume; f/VT = ratio of respiratory frequency to tidal volume.

Figuras y tablas -
Table 1. Readiness to wean criteria
Table 2. Weaning protocol differences

Study

Time of randomization

Intervention protocol

Extubation criteria 

Comparator (usual practice)

Chaiwat 2010

ICU admission

SBP on PS 7 cmH2O, PEEP 5 cmH2O for 2 hours

Notify MD

Not reported

de Carvalho Oliveira 2002

Not reported

SBP on PS 7 cmH2O, PEEP 5 cmH2O for 2 hours

Yes

Not reported

Ely 1996

Enrolment, time not reported

SBT 2 hour on CPAP 5 cmH2O

Notify MD

Not reported

Fan 2013

Not reported

a) SBT 30 minutes and extubation if passed

b) If failed, daily SBT and stepwise reduction in SIMV and PS until 4 breaths/min and PS 7 cmH2O

Not reported

Not reported

Kollef 1997

ICU admission 

a) SBT 30 to 60 min on CPAP 5 cmH2O, PS 6 cmH2O

b) PS stepwise reduction to 6 cmH2O

c) IMV stepwise reduction to 0 breaths/min, on  PEEP 5 cmH2O and PS 6 cmH2O for 30 to 60 min

a) Yes

 

b) Yes

c) Yes

Not reported

Krishnan 2004

Not reported

SBT 1 hour on CPAP 5 cmH2O

Notify MD

Not reported

Marelich 2000

On meeting weaning criteria

a) < 72‐hour admissions: SBT 30 min on PS </= 8 cmH2O & PEEP </= 8 cmH2O

b) > 72‐hour admissions: PEEP, IMV and PS stepwise reductions to achieve FiO2 0.5,

PEEP </= 8 cmH2O, IMV </= 6 breaths/min, PS </= 8 cmH2O then SBT as above

a) Notify MD

 

b) Notify MD

Not reported

Namen 2001

On meeting weaning criteria

SBT 2 hours on CPAP 5 cmH2O

Notify MD

Not reported

Navalesi 2008

Enrolment, time not reported

SBT 1 hour on CPAP 2 to 3 cmH2O, FiO2 0.4

Yes

Not reported

Ogica 2007

Not reported

SBT (details not reported)

Not reported

Not reported

Piotto 2011

Not reported

SBT 2 hours on PS 7 cmH2O, PEEP 5 cmH2O, FiO2 0.4, RR 1 breath/min

Yes

Stepwise reduction in PS and IMV

Reardon 2011

On meeting weaning criteria

Computer automated SmartCareTM/PS with stepwise reductions to PS 7 cmH2O and PEEP 5 cmH2O

Notify MD

Stepwise reduction in PS and SBT

Roh 2012

On meeting weaning criteria

CPAP trial on 5 cmH2O, then stepwise reductions in PS to 5 cmH2O,

then SBT on T‐piece for 30 minutes

Yes

Not reported

Rose 2008

On meeting weaning criteria

Computer automated SmartCareTM/PS with stepwise reductions to PS 7 cmH2O and PEEP 5 cmH2O

No

Stepwise reduction in PS and PEEP

Simeone 2002

Not reported

SIMV and PS stepwise reductions to SIMV 0 breath/min and PS 4 cmH2O

Yes

Not reported

Stahl 2009

On meeting weaning criteria 

Computer automated SmartCareTM/PS stepwise reductions to PS

Yes

Spepwise reduction in PS and CPAP

Strickland 1993

On meeting weaning criteria

Computer automated Supersport model 2

stepwise reductions in SIMV and PS to RR 2 breaths/min and PS 5 cmH2O

 Not reported

Stepwise reduction in IMV and PS

CPAP = continuous positive airway pressure; IMV = intermittent mechanical ventilation; MD = Medical Doctor; PEEP = positive end expiratory pressure; PS = pressure support; SBT = spontaneous breathing trial; SIMV =synchronized intermittent mechanical ventilation; RR = respiratory rate.

Figuras y tablas -
Table 2. Weaning protocol differences
Comparison 1. Primary analysis: protocolized versus non‐protocolized weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total duration of MV by type of unit Show forest plot

14

2205

Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.46, ‐0.14]

1.1 Mixed ICUs

6

940

Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.44, ‐0.02]

1.2 Neuro ICUs

2

418

Mean Difference (IV, Random, 95% CI)

‐0.01 [‐0.20, 0.18]

1.3 Surgical ICUs

3

201

Mean Difference (IV, Random, 95% CI)

‐0.63 [‐1.05, ‐0.22]

1.4 Medical ICUs

3

646

Mean Difference (IV, Random, 95% CI)

‐0.34 [‐0.61, ‐0.07]

2 Total duration of MV by type of approach Show forest plot

14

2205

Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.46, ‐0.14]

2.1 professional‐led

12

2051

Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.40, ‐0.13]

2.2 computer‐driven

2

154

Mean Difference (IV, Random, 95% CI)

‐0.50 [‐1.42, 0.42]

3 Total duration of MV by type of protocol [log hours] Show forest plot

14

2205

Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.46, ‐0.14]

3.1 SBT protocol

8

1188

Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.36, 0.00]

3.2 Stepwise reduction protocol

6

1017

Mean Difference (IV, Random, 95% CI)

‐0.42 [‐0.66, ‐0.18]

4 Mortality Show forest plot

14

2234

Odds Ratio (M‐H, Fixed, 95% CI)

1.02 [0.82, 1.26]

4.1 Hospital mortality

8

1523

Odds Ratio (M‐H, Fixed, 95% CI)

1.04 [0.82, 1.32]

4.2 ICU mortality

7

711

Odds Ratio (M‐H, Fixed, 95% CI)

0.93 [0.58, 1.48]

5 Reintubation Show forest plot

11

1487

Odds Ratio (M‐H, Random, 95% CI)

0.74 [0.44, 1.23]

6 Self extubation Show forest plot

3

433

Odds Ratio (M‐H, Random, 95% CI)

0.43 [0.14, 1.34]

7 Tracheostomy Show forest plot

8

1346

Odds Ratio (M‐H, Random, 95% CI)

0.85 [0.51, 1.40]

8 Weaning duration by type of ICU Show forest plot

8

989

Mean Difference (IV, Random, 95% CI)

‐1.20 [‐2.10, ‐0.31]

8.1 Surgical ICUs

1

52

Mean Difference (IV, Random, 95% CI)

‐1.29 [‐2.42, ‐0.16]

8.2 Mixed ICUs

3

473

Mean Difference (IV, Random, 95% CI)

‐1.39 [‐3.17, 0.39]

8.3 Medical ICUs

4

464

Mean Difference (IV, Random, 95% CI)

‐1.02 [‐2.08, 0.03]

9 Weaning duration by type of approach Show forest plot

8

989

Mean Difference (IV, Random, 95% CI)

‐1.20 [‐2.10, ‐0.31]

9.1 Professional‐led

4

793

Mean Difference (IV, Random, 95% CI)

‐1.90 [‐3.37, ‐0.43]

9.2 Computer‐driven

4

196

Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.69, ‐0.00]

10 Weaning duration by type of protocol [log hours] Show forest plot

8

989

Mean Difference (IV, Random, 95% CI)

‐1.20 [‐2.10, ‐0.31]

10.1 SBT protocol

2

336

Mean Difference (IV, Random, 95% CI)

‐3.23 [‐3.57, ‐2.89]

10.2 Stepwise reduction protocol

6

653

Mean Difference (IV, Random, 95% CI)

‐0.46 [‐0.81, ‐0.12]

11 ICU length of stay Show forest plot

9

1378

Mean Difference (IV, Fixed, 95% CI)

‐0.12 [‐0.21, ‐0.03]

12 Hospital length of stay Show forest plot

5

977

Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.11, 0.09]

13 ICU costs Show forest plot

2

400

Mean Difference (IV, Random, 95% CI)

3.37 [‐15.02, 21.76]

14 Hospital costs Show forest plot

3

757

Mean Difference (IV, Random, 95% CI)

‐0.59 [‐4.67, 3.49]

Figuras y tablas -
Comparison 1. Primary analysis: protocolized versus non‐protocolized weaning
Comparison 2. Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total duration of MV Show forest plot

12

1945

Mean Difference (IV, Random, 95% CI)

‐0.33 [‐0.50, ‐0.16]

2 Weaning duration Show forest plot

5

499

Mean Difference (IV, Random, 95% CI)

‐1.64 [‐3.18, ‐0.10]

Figuras y tablas -
Comparison 2. Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies
Comparison 3. Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total duration of MV Show forest plot

14

2205

Mean Difference (IV, Random, 95% CI)

‐20.26 [‐35.28, ‐5.24]

2 Weaning duration Show forest plot

7

739

Mean Difference (IV, Random, 95% CI)

‐39.35 [‐67.38, ‐11.32]

3 ICU length of stay Show forest plot

9

1378

Mean Difference (IV, Fixed, 95% CI)

‐9.08 [‐15.85, ‐2.30]

4 Hospital length of stay Show forest plot

5

977

Mean Difference (IV, Fixed, 95% CI)

‐1.32 [‐3.09, 0.44]

Figuras y tablas -
Comparison 3. Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data