Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation

Daniel R. Ouellette, Sheena Patel, Timothy D. Girard, Peter E. Morris, Gregory A. Schmidt, Jonathon D. Truwit, Waleed Alhazzani, Suzanne M. Burns, Scott K. Epstein, Andres Esteban, Eddy Fan, Miguel Ferrer, Gilles L. Fraser, Michelle Ng Gong, Catherine L. Hough, Sangeeta Mehta, Rahul Nanchal, Amy J. Pawlik, William D. Schweickert, Curtis N. SesslerThomas Strøm, John P. Kress

Research output: Contribution to journalArticle

82 Scopus citations

Abstract

Background An update of evidence-based guidelines concerning liberation from mechanical ventilation is needed as new evidence has become available. The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have collaborated to provide recommendations to clinicians concerning liberation from the ventilator. Methods Comprehensive evidence syntheses, including meta-analyses, were performed to summarize all available evidence relevant to the guideline panel's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, and the results were summarized in evidence profiles. The evidence syntheses were discussed and recommendations developed and approved by a multidisciplinary committee of experts in mechanical ventilation. Results Recommendations for three population, intervention, comparator, outcome (PICO) questions concerning ventilator liberation are presented in this document. The guideline panel considered the balance of desirable (benefits) and undesirable (burdens, adverse effects, costs) consequences, quality of evidence, feasibility, and acceptability of various interventions with respect to the selected questions. Conditional (weak) recommendations were made to use inspiratory pressure augmentation in the initial spontaneous breathing trial (SBT) and to use protocols to minimize sedation for patients ventilated for more than 24 h. A strong recommendation was made to use preventive noninvasive ventilation (NIV) for high-risk patients ventilated for more than 24 h immediately after extubation to improve selected outcomes. The recommendations were limited by the quality of the available evidence. Conclusions The guideline panel provided recommendations for inspiratory pressure augmentation during an initial SBT, protocols minimizing sedation, and preventative NIV, in relation to ventilator liberation.

Original languageEnglish (US)
Pages (from-to)166-180
Number of pages15
JournalChest
Volume151
Issue number1
DOIs
StatePublished - Jan 1 2017

Keywords

  • evidence-based medicine
  • guidelines
  • mechanical ventilation

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine
  • Cardiology and Cardiovascular Medicine

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    Ouellette, D. R., Patel, S., Girard, T. D., Morris, P. E., Schmidt, G. A., Truwit, J. D., Alhazzani, W., Burns, S. M., Epstein, S. K., Esteban, A., Fan, E., Ferrer, M., Fraser, G. L., Gong, M. N., Hough, C. L., Mehta, S., Nanchal, R., Pawlik, A. J., Schweickert, W. D., ... Kress, J. P. (2017). Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest, 151(1), 166-180. https://doi.org/10.1016/j.chest.2016.10.036