Chapter 65: Controversies: Ventilator Weaning—Which Strategy is Better? RT-RN Versus Physician Driven

INTRODUCTION

The advent of invasive mechanical ventilation (IMV) has been one of the greatest achievements in the field of respiratory and critical care medicine. In the United States alone, there were 790,257 hospitalizations involving IMV in 2005, and that number is expected to steadily increase, outpacing population growth by 2026.^1,2 Although advances in medical technology have facilitated the management of patients who require ventilatory support, mechanical ventilation remains associated with risks and complications.³ Thus, once clinical improvement occurs, significant emphasis is placed on rapidly weaning the patient from IMV. Over the past 25 years, numerous trials have evaluated the most effective approach to liberate patients from IMV, including the use of protocol-based weaning (PBW). Compared to physician-directed weaning, protocolized strategies driven by nurses and/or respiratory therapists (RTs) have gained general acceptance in many intensive care units (ICUs) because of reduction in morbidity, mortality, and health-care costs (Table 65–1).^4,5,6

PAST AND PRESENT WEANING APPROACHES

Prior to the adoption of protocols, conventional weaning was at the sole discretion of the ICU physician(s) overseeing the patient’s care.⁷ Conventional weaning (ie, no protocol) was highly based on clinical experiences and institutional practices. Thus, the weaning of a particular patient varied considerably among physicians and across institutions. This broad range of traditions and practice patterns underscored an imperfect process of IMV termination. Data from the mid-to-late 1990s highlighted that clinical judgment alone was not always accurate in predicting successful extubation and that physicians were more likely to keep patients on IMV for longer periods than necessary.^6,8,9

The availability of registered nurses (RNs), RTs, and ancillary staff at the bedside in the ICU coupled with their intimate knowledge of patient’s characteristics offered an alternative pathway to liberation from IMV. Subsequent efforts focused on developing conventional, structured, reproducible, and safe methods of liberating patients from IMV, not only to improve patient outcomes but also to decrease existing variations in practice among healthcare providers. Protocol-driven weaning was thus born.⁴

WEANING AND COMPONENTS OF A PROTOCOL

Liberation from IMV is a ...