Critical Care Medicine-Neurologic Disorders>>>>>Mechanical Ventilation
Question 4#

A 70-year-old woman is intubated in the ICU for respiratory failure following an episode of aspiration with resulting pneumonitis.

Which of the following practices is most likely to decrease her duration of mechanical ventilation?

a. Spontaneous breathing trial performed when supervised by the attending physician
b. Paired daily spontaneous breathing trial and spontaneous awakening trial
c. Decremental pressure support wean as directed by respiratory therapist
d. Early tracheostomy
e. Spontaneous breathing trial performed when directed by the bedside nurse

Correct Answer is B

Comment:

Correct Answer: B

Routine, protocolized implementation of a spontaneous breathing trial, paired with a spontaneous awakening trial, or interruption of sedation, results in a decreased duration of mechanical ventilation when compared with spontaneous breathing trial alone. Spontaneous breathing trials should be performed as a routine practice based on protocol, rather than when directed only by a medical provider (answers A and E are incorrect). Studies examining early tracheostomy have not demonstrated a decreased time on the ventilator, though this approach may be appropriate in select cases when reversal of the underlying process is not expected within several weeks (answer D is incorrect). In comparison with a decremental pressure support-based ventilator liberation strategy, spontaneous breathing trial is superior in ability to decrease the duration of mechanical ventilation (answer C is incorrect).

References:

  1. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134.
  2. Andriolo BNG, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients (Review). Cochrane Database Syst Rev. 2015;(1):CD007271.
  3. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995;332(6):345-350.