Mechanical ventilation results in progressive contractile dysfunction in the diaphragm. Comparison of pressure support and T-tube weaning from mechanical ventilation: randomized prospective study. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Clinical Relevance of Classification According to Weaning Difficulty Analysis of data from multiclinic trials. Incidence and outcome of weaning from mechanical ventilation according to new categories Echocardiographic evaluation during weaning from mechanical ventilation Effect of an additional 1-hour T-piece trial on weaning outcome at minimal pressure support. Chronic obstructive pulmonary disease and weaning of difficult-to-wean patients from mechanical ventilation: randomized prospective study. [Sinusitis in long-term intubated, intensive care patients: nasal versus oral intubation]. The effects of different weaning modes on the endocrine stress response Low pressure support changes the rapid shallow breathing index (RSBI) in critically ill patients on mechanical ventilation. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU 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 [Comparison among three methods to measure the rapid shallow breathing index in patients submitted to weaning from mechanical ventilation]. Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Extubation after breathing trials with automatic tube compensation, T‐tube, or pressure support ventilation Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days. Pressure-time product during continuous positive airway pressure, pressure support ventilation, and T-piece during weaning from mechanical ventilation. Comparison of pressure support ventilation (PSV) and intermittent mandatory ventilation (IMV) during weaning in patients with acute respiratory failure. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. Prospective evaluation of the risk of upper gastrointestinal bleeding after admission to a medical intensive care unit. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. Factors predicting ventilator-associated pneumonia recurrence Effects of mechanical ventilation on diaphragmatic contractile properties in rats. Effect of failed extubation on the outcome of mechanical ventilation. Pleurodesis by autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial.
These experiments tested the hypothesis that a relatively short duration of controlled mechanical ventilation ( MV ) will impair diaphragmatic maximal specific force generation ( specific P(o ) ) and that this force deficit will be exacerbated with increased time on the ventilator . To test this postulate , adult Sprague-Dawley rats were r and omly divided into one of six experimental groups : 1 ) control  ( n = 12 ) ; 2 ) 12 h of MV ( n = 4 ) ; 3 ) 18 h of MV ( n = 4 ) ; 4 ) 18 h of anesthesia and spontaneous breathing ( n = 4 ) ; 5 ) 24 h of MV ( n = 7 ) ; and 6 ) 24 h of anesthesia and spontaneous breathing ( n = 4 ) . MV animals were anesthetized , tracheostomized , and ventilated with room air . Animals in the control group were acutely anesthetized but were not exposed to MV . Animals in two spontaneous breathing groups were anesthetized and breathed spontaneously for either 18 or 24 h. No differences ( P > 0.05 ) existed in diaphragmatic specific P(o ) between control and the two spontaneous breathing groups . In contrast , compared with control , all duration s of MV result ed in a reduction ( P < 0.05 ) in diaphragmatic specific tension at stimulation frequencies ranging from 15 to 160 Hz . Furthermore , the MV-induced decrease in diaphragmatic specific P(o ) was time dependent , with specific P(o ) being approximately 18 and approximately 46 % lower ( P < 0.05 ) in animals mechanically ventilated for 12 and 24 h , respectively . These data support the hypothesis that relatively short-term MV impairs diaphragmatic contractile function and that the magnitude of MV-induced force deficit increases with time on the ventilator AIM To compare T-tube and pressure support ventilation ( PSV ) as two methods of weaning patients from mechanical ventilation . METHODS A r and omized prospect i ve study included 260 patients who received mechanical ventilation for more than 48 h , and who were admitted to the intensive care unit ( ICU ) at Dr. Josip Bencevic General Hospital in Slavonski Brod , between August 1999 and October 2000 . After fulfilling the clinical criteria for weaning , the patients were r and omly assigned to a 2-h trial of spontaneous breathing either with a T-tube system ( n=110 ) or PSV of 8 cm H2O ( n=150 ) . The patients who fulfilled weaning criteria at the end of the 2-h trial were extubated . If any signs of poor procedure tolerance were observed during the 2-h trial , the mechanical ventilation was reinstituted . In such patients , the same weaning procedure was repeated after 24 h , or when the patient 's clinical condition permitted . Two methods of weaning were compared according to the patient 's clinical characteristics , objective parameters , and procedure outcome . RESULTS Eighty ( 73 % ) patients in the T-tube group and 120 ( 80 % ) patients in PSV group successfully completed the 2-h trial and were extubated . Thirty patients in the T-tube group and 30 in the PSV group had weaning difficulties . Total length of additional mechanical ventilation and total length of stay at ICU were significantly shorter in patients undergoing PSV weaning ( p<0.001 for all , Man-Whitney test ) . For the patients with weaning difficulties and Acute Physiology and Chronic Health Evaluation ( APACHE ) II score > 20 on admission , PSV was the superior method of weaning according to rate of successful extubation , time of weaning from mechanical ventilation , total time of mechanical ventilation , and length of ICU stay ( p<0.001 for all , Man-Whitney test ) . CONCLUSION In patients with weaning difficulties , PSV with 8 cm H(2)O was more successful weaning method than T-tube A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation . However , some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial . We carried out a prospect i ve , r and omized , multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and st and ard weaning parameters . Patients were r and omly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways : with a T-tube system or with pressure support ventilation of 7 cm H2O . If a patient had signs of poor tolerance at any time during the trial , mechanical ventilation was reinstituted . Patients without these features at the end of the trial were extubated . Of the 246 patients assigned to the T-tube group , 192 successfully completed the trial and were extubated ; 36 of them required reintubation . Of the 238 patients in the group receiving pressure support ventilation  , 205 were extubated and 38 of them required reintubation . The percentage of patients who remained extubated after 48 h was not different between the two groups ( 63 % T-tube , 70 % pressure support ventilation , p = 0.14 ) . The percentage of patients falling the trial was significantly higher when the T-tube was used ( 22 versus 14 % , p = 0.03 ) . Clinical evolution during the trial was not different in patients reintubated and successfully extubated . ICU mortality among reintubated patients was significantly higher than in successfully extubated patients ( 27 versus 2.6 % , p < 0.001 ) . Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing OBJECTIVE : To evaluate the clinical relevance of the weaning from mechanical ventilation classification system derived from the 2005 international consensus conference , in patients who receive mechanical ventilation for more than 48 hours , and evaluate its correlation with prognosis . METHODS : We conducted a retrospective cohort study in a 12-bed intensive care unit ( ICU ) in a teaching hospital . We included patients who required > 48 hours of mechanical ventilation and who passed a spontaneous breathing trial ( SBT ) .  Weaning and sedation  were monitored according to st and ardized protocol -directed procedures . We collected data on physiological characteristics , mechanical ventilation duration , ICU and hospital stay , and mortality from the medical records data base . We assessed one-year mortality with a prospect i ve , st and ardized method . Multivariate logistic regression was performed to evaluate the association between weaning categories and outcome . RESULTS : We included 329 ventilation episodes , in which 115 patients passed at least one SBT . Thirty-four patients ( 30 % ) succeeded in their first SBT ( simple weaning group ) , 47 patients ( 40 % ) succeeded in their 2nd or 3rd SBT or in less than 7 days of weaning ( the difficult weaning group ) , and 34 patients ( 30 % ) required more than 3 SBTs or more than 7 days of weaning ( the prolonged weaning group ) . There were significant differences in ICU and hospital mortality between the simple , difficult , and prolonged-weaning groups . Prolonged weaning was an independent risk factor for longer ICU stay ( odds ratio 15.11 , 95 % CI 1.61–141.91 , P = .01 ) and hospital mortality ( odds ratio 3.66 , 95 % CI 0.99–13.51 ) . However , the weaning process did not impact one-year mortality ( odds ratio 2.61 , 95 % CI 0.82–8.35 ) . CONCLUSIONS : The new weaning classification system is clinical ly relevant and correlates to ICU and hospital mortality , but not to one-year mortality Because the clinics in a multiclinic r and omized clinical trial represent neither fixed stratification effects nor r and om classificatory effects , the appropriate analysis of data from such a trial has been the subject of controversy and debate . The following are some of the elements of controversy that are discussed and for which some bases for resolution are proposed . Is it ever valid to ignore the effects of clinics in the analysis ? Is it ever valid to drop clinics from the analysis ? Is a multiclinic clinical trial similar in structure or not to a single-clinic clinical trial in which patients have been stratified on a classificatory factor ? Assuming that clinics will be taken account of in the analysis , should it be the weighted or the unweighted average of within-clinic treatment differences that is to be taken as the best estimate of the overall difference between the treatments ? How should the data be analyzed if there is evidence of treatment-by-clinic interaction Weaning from mechanical ventilation was categorised as simple , difficult or prolonged by an international task force of the American Thoracic Society/European Respiratory Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine/Sociéte de Réanimation de Langue Française in 2007 . This new classification has not been tested in clinical practice . The objective of the present study was to determine the incidence and outcome of weaning according to the new categories . We included medical and surgical patients who required mechanical ventilation in a prospect i ve , multicentre , 6-month cohort study . From an initial cohort of 510 patients , 257 intubated patients started weaning .  Of these patients , the cumulative incidences of simple , difficult , and prolonged weaning were 152 ( 59 % ) , 68 ( 26 % ) and 37 ( 14 % ) , respectively . Hospital mortality was increased in patients with prolonged ( 32 % ) but not difficult ( 9 % ) weaning in comparison with those with simple weaning ( 13 % ) , overall p = 0.0205 . In a multivariate logistic regression model , prolonged but not difficult weaning was associated with an increased risk of death . Ventilator-free days and intensive care unit (ICU)-free days were decreased in both difficult and prolonged weaning . In conclusion , the new weaning category prolonged weaning is associated with increased mortality and morbidity in the ICU . The new category difficult to wean was associated with increased morbidity , but not mortality INTRODUCTION : Echocardiographic , electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation . OBJECTIVES : To analyze changes in cardiac function , using Doppler echocardiogram , in critical patients during weaning from mechanical ventilation  , using two different weaning methods : pressure support ventilation and T‐tube ; and comparing patient subgroups : success vs. failure in weaning . METHODS : R and omized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning . Cardiorespiratory variables , oxygenation , electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T‐tube . Pressure support ventilation vs. T‐tube and weaning success vs. failure were compared using ANOVA and Student 's t‐test . The level of significance was p<0.05 . RESULTS : Twenty‐four adult patients were evaluated . Seven patients failed at the first weaning attempt . No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T‐tube . Weaning failure patients presented increases in left atrium , intraventricular septum thickness , posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time . Successfully weaned patients had higher levels of oxygenation . CONCLUSION : No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables  during pressure support ventilation and T‐tube .  However cardiac structures were smaller , isovolumetric relaxation time was larger , and oxygenation level was greater in successfully weaned patients PURPOSE The purpose of this article was to investigate the effect of an additional 1-hour T-piece trial at the level of minimum pressure support ( PSmin ) on weaning outcome . MATERIAL S AND METHODS Open , r and omized , prospect i ve study of 44 patients who had received mechanical ventilation for more than 3 days . Thirty-six patients satisfied the protocol . There were 42 weaning trials . The patients were r and omized into an intervention group ( additional 1-hour period of T-piece trial ) and a control group ( extubation directly ) at PSmin . Blood gas analysis and estimation of respiratory and hemodynamic variables  were performed at the 15 cm H2O level of pressure support . Measurements were repeated at PSmin and during weaning process ( in intervention group ) . RESULTS Mean PSmin level was 7.6 ( + /- 1.9 ) cm H2O . There were no differences in total ventilation time ( TVT ) , acute physiology and chronic health evaluation ( APACHE ) II score , nutritional indices , and respiratory mechanics on PSmin between the two groups . The weaning success rate and the reintubation rate were similar for the intervention group ( 55 % and 18 % , respectively ) and control group ( 70 % and 20 % , respectively ) . Work of breathing , pressure time product , and tidal volume significantly worsened after a 1-hour T-piece trial when compared with those values measured at PSmin in the intervention group ( P < .05 ) . For the combined patient sample , TVT and tidal volume at PSmin were significantly different between the patients with weaning success ( 246 + /- 195 hours , 0.43 + /- 0.11 L ) and those with weaning failure ( 407 + /- 248 hours , 0.35 + /- 0.10 L ) ( P < .05 in each ) . CONCLUSION There were no advantages in weaning outcome by the addition of a 1-hour T-piece trial compared with prompt extubation at PSmin AIM To compare T-tube and pressure support ventilation ( PSV ) as two methods of mechanical ventilation weaning of patients with chronic obstructive pulmonary disease ( COPD ) after failed extubation . METHODS A prospect i ve r and omized trial carried out at the multidisciplinary intensive care unit ( ICU ) over 2 years included 136 patients with COPD who required mechanical ventilation longer than 24 hours . The patients who could be weaned from mechanical ventilation were r and omized to either a T-tube or PSV 2-hour spontaneous breathing trial . The patients in whom 2-hour trial was successful were extubated and excluded from further research . Patients in whom 2-hour trial failed had mechanical ventilation reinstated and underwent the same weaning procedure after 24 hours in case they fulfilled the weaning criteria . The weaning outcome was assessed according to the following parameters : extubation success , mechanical ventilation duration , time spent in ICU , reintubation rate , and mortality rate . RESULTS Two-hour trial failed in 31 patients in T-tube and 32 patients in PSV group , of whom 17 and 23 , respectively , were successfully extubated ( P<0.001 , chi(2)test ) .  Mechanical ventilation  lasted significantly longer in T-tube than in PSV group ( 187 hours vs 163 hours , respectively , P<0.001 , Mann-Whitney test ) . Also , patients in T-tube group spent significantly more time in ICU than patients in PVS group ( 241 hours [ interquartile range 211 - 268 ] vs 210 hours [ 211 - 268 ] , respectively , P<0.001 , Mann-Whitney test ) . Reintubation was required in 8 and 6 patients in T-tube and PVS group , respectively , and death occurred in 4 and 2 patients , respectively , during ICU stay . CONCLUSION Patients with COPD who failed the 2-hour spontaneous breathing trial had more favorable outcome when PVS rather than T-tube method was used for weaning from mechanical ventilation UNLABELLED Discussion of paranasal sinusitis as a nosocomial infection in the mechanically ventilated intensive care ( ICU ) patient has recently been intensified . Some authors have emphasized nasotracheal intubation as a possible pathogenetic pathway . The aim of this study was to investigate the impact of nasotracheal or orotracheal intubation on the development of sinusitis in ICU patients . METHODS In a prospect i ve study , we followed 44 patients who required mechanical ventilation ( greater than 24 h ) in the ICU because of prolonged recovery from abdominal , thoracic , or posttraumatic surgery . Twenty patients were intubated nasotracheally and 24 orotracheally .  Assignment to the groups was r and om . All were provided with a nasogastric tube and initially treated with systemic antibiotics . They received local antimicrobial prophylaxis of the nose , oropharynx , and stomach . Daily a-scan examinations of the maxillary sinuses were performed from the day of admission to the ICU until extubation , tracheotomy , death , or transfer . The average observation period was 6.9 days in the oral group and 7.1 days in the nasal group . In the case of a pathologic finding , aspiration of the antral sinus was carried out . In this study sinusitis indicated a sonographic finding ; it did not necessarily imply a bacterial infection . RESULTS At the beginning of the observation period , 6 patients in the oral group and 4 in the nasal group already had a pathologic maxillary sinus finding . At the end , in 15 of 24 in the oral group and 19 of 20 in the nasal group unilateral or bilateral sinusitis could be demonstrated . Development of bilateral sinusitis ( 13/20 in the nasotracheal group , 8/24 in the orotracheal group ) was mainly observed after the appearance of unilateral sinusitis . The site corresponded to the site of the nasal tube in 65 % . Unilateral paranasal infection was observed in nasotracheally and orotracheally intubated patients after an average of 2.8 and 2.6 days , respectively , whereas bilateral sinusitis had an average time delay of 4.5 and 5.7 days . Aspiration of the maxillary sinus was performed in 22 of 34 cases with sinusitis . Pathogenic organisms could be demonstrated in 7 of 13 nasotracheally intubated patients but only 2 of 9 with orotracheal tubes . CONCLUSION We found that patients intubated orotracheally developed significantly less sinusitis than those intubated nasotracheally . Edema , local infection of the nasal mucosa , or mechanical obstruction of sinus drainage pathways by the tube are possible explanations . The fact that 63 % of orally intubated patients had a pathologic maxillary sinus finding as well suggests that in addition to other reasons , an increased central venous pressure , positive pressure ventilation , and the supine position must be regarded as predisposing factors that increase the incidence of sinusitis . We conclude that the conditions of critically ill patients predispose to the development of sinusitis .  Nasotracheal intubation is to be regarded as an additional risk , and therefore oral intubation should be preferred Introduction The aim of the present study was to investigate the effects of the stress response on plasma insulin , cortisol , glucose , and urinary vanilm and elic acid during weaning and after extubation , using pressure support ( PS ) , continuous positive airway pressure ( CPAP ) and T-piece modes . Methods Sixty patients were r and omly divided into three groups ( n = 20 ) . The PS group received FiO2 ≤ 0.4 , PS ≤ 10 cmH2O , and positive end expiratory pressure ≤ 5 cmH2O for 2 hours . The CPAP group was given FiO2 ≤ 0.4 and CPAP 5 ≤ cmH2O for 2 hours . The T-piece group ( group T ) received 4 l/min oxygen via a T-piece for 2 hours . After 1 hour and 2 hours in their respective weaning modes , blood and urine sample s were taken for insulin , cortisol , glucose and vanilm and elic acid measurements . Forty-eight hours after extubation , blood and urine sample s were again taken . Results Plasma insulin was greater in group T than in the PS and CPAP groups ( P < 0.01 and P < 0.01 ) . The plasma cortisol concentration was greater in group T than in group PS during weaning ( P < 0.05 ) and after extubation ( P < 0.05 ) . Blood glucose concentrations were greater in group T than in the other groups ( both P < 0.01 ) both during weaning and post extubation . Urine vanilm and elic acid was greater in group T than in the other groups during weaning and after extubation ( both P < 0.001 ) . Conclusion Weaning via the T-piece caused a greater stress response than the PS and CPAP modes BACKGROUND The rapid shallow breathing index ( RSBI ) is the most widely used index within intensive care units as a predictor of the outcome of weaning , but differences in measurement techniques have generated doubts about its predictive value . OBJECTIVE To investigate the influence of low levels of pressure support ( PS ) on the RSBI value of ill patients . METHOD Prospect i ve study including 30 patients on mechanical ventilation ( MV ) for 72 hours or more , ready for extubation . Prior to extubation , the  RSBI was measured with the patient connected to the ventilator ( DragerTM Evita XL ) and receiving pressure support ventilation ( PSV ) and 5 cmH2O of positive end expiratory pressure or PEEP ( RSBI_MIN ) and then disconnected from the VM and connected to a Wright spirometer in which respiratory rate and exhaled tidal volume  were recorded for 1 min ( RSBI_ESP ) . Patients were divided into groups according to the outcome : successful extubation group ( SG ) and failed extubation group ( FG ) . RESULTS Of the 30 patients , 11 ( 37 % ) failed the extubation process . In the within-group comparison ( RSBI_MIN versus RSBI_ESP ) , the values for RSBI_MIN were lower in both groups : SG ( 34.79±4.67 and 60.95±24.64 ) and FG ( 38.64±12.31 and 80.09±20.71 ; p<0.05 ) . In the between-group comparison , there was no difference in RSBI_MIN ( 34.79±14.67 and 38.64±12.31 ) , however RSBI_ESP was higher in patients with extubation failure : SG ( 60.95±24.64 ) and FG ( 80.09±20.71 ; p<0.05 ) . CONCLUSIONS In critically ill patients on MV for more than 72h , low levels of PS overestimate the RSBI , and the index needs to be measured with the patient breathing spontaneously without the aid of pressure support Purpose To compare cardiovascular and respiratory responses to different spontaneous breathing trials ( SBT ) in difficult-to-wean patients using T-piece and pressure support ventilation ( PSV ) with or without positive end-expiratory pressure ( PEEP ) .  Methods Prospect i ve physiological study . Fourteen patients who were monitored with a Swan-Ganz catheter and had failed a previous T-piece trial were studied . Three SBTs were performed in r and om order in all patients : PSV with PEEP ( PSV-PEEP ) , PSV without PEEP ( PSV-ZEEP ) , and T-piece . PSV level was 7 cmH2O , and PEEP was 5 cmH2O . Inspiratory muscle effort was calculated , and hemodynamic parameters were measured using st and ard methods . Results [ median ( and interquartile range)]Most patients succeeded in the PSV-PEEP ( 11/14 ) and PSV-ZEEP ( 8/14 ) trials , but all failed the T-piece trial . Patient effort was significantly higher during T-piece than during PSV with or without PEEP  [ esophageal pressure-time product was 292 ( 238–512 ) , 128 ( 58–299 ) , and 148 ( 100–465 ) cmH2O·s/min , respectively , p < 0.05 ] . Left ventricular heart failure was observed in 11 of the 14 patients during the T-piece trial . Pulmonary artery occlusion pressure and respiratory rate were significantly higher during T-piece than with PSV-PEEP [ 21 ( 18–24 ) mmHg versus 17 ( 14–22 ) mmHg , p < 0.05 and 27 ( 21–35 ) breaths/min versus 19 ( 16–29 ) breaths/min , p < 0.05 respectively ] . Tidal volume was significantly lower during the T-piece trial . Conclusion In this selected population of difficult-to-wean patients  , PSV and PSV plus PEEP markedly modified the breathing pattern , inspiratory muscle effort , and cardiovascular response as compared to the T-piece . Caregivers should be aware of these differences in SBT as they may play an important role in weaning decision-making STUDY OBJECTIVES ( 1 ) To determine the effect of a single ventilator management protocol ( VMP ) used in medical and surgical ICUs on the duration of mechanical ventilation . ( 2 ) To determine the effect of a VMP on the incidence of ventilator-associated pneumonia ( VAP ) . DESIGN Prospect i ve , r and omized , controlled study . SETTING : University medical center . PATIENTS Three hundred eighty-five patients receiving mechanical ventilation between June 1997 and May 1998 . INTERVENTIONS A respiratory care practitioner- and registered nurse-driven VMP . RESULTS Intervention and control groups were comparable with respect to age , sex , severity of illness and injury , and duration of respiratory failure at the time of r and omization . The duration of mechanical ventilation for patients was decreased from a median of 124 h for the control group to 68 h in the VMP group ( p = 0.0001 ) . Thirty-one total instances of VAP were noted . Twelve patients in the surgical control group had VAP , compared with 5 in the surgical VMP group ( p = 0.061 ) . The impact of the  VMP  on VAP frequency was less for medical patients . Mortality and ventilator discontinuation failure rates were similar between control and VMP groups . CONCLUSIONS A VMP design ed for multidisciplinary use was effective in reducing duration of mechanical ventilatory support without any adverse effects on patient outcome . The VMP was also associated with a decrease in incidence of VAP in trauma patients . These results , in conjunction with prior studies , suggest that VMPs are highly effective means of improving care , even in university ICUs Purpose An International Consensus Conference proposed classifying weaning into simple , difficult , and prolonged weaning . However , the usefulness of this classification in a respiratory intensive care unit ( ICU ) is unknown . The aims of the study were : ( 1 ) to compare the clinical characteristics and outcomes of patients from the three weaning groups in a respiratory ICU ; and ( 2 ) to assess predictors for prolonged weaning and survival . Methods We prospect ively studied 181 mechanically ventilated patients ( 131 , 72 % with chronic respiratory disorders ) in whom weaning had been initiated , divided into  simple ( 78 , 43 % ) ,  difficult  ( 70 , 39 % ) , and  prolonged  ( 33 , 18 % ) weaning . We compared the characteristics and outcomes among the three groups and determined the factors associated with prolonged weaning and survival in multivariate analysis . Results Patients with simple and difficult weaning had similar characteristics and outcomes . A higher proportion of patients with prolonged weaning had chronic obstructive pulmonary disease  , and these patients also had more complications , a longer stay and lower survival . Increased heart rate ( ≥105 min−1 , p < 0.001 ) and PaCO2 ( ≥54 mmHg , p = 0.001 ) during the spontaneous breathing trial independently predicted prolonged weaning . In addition , the need for reintubation ( p < 0.001 ) and hypercapnia during the spontaneous breathing trial ( p = 0.003 ) independently predicted a decreased 90-day survival . Conclusion Because of the similar characteristics and outcomes , the differentiation between simple and difficult weaning had no relevant clinical consequences in a respiratory ICU . Patients with prolonged weaning had the worst outcomes . For the overall population , hypercapnia at the end of spontaneous breathing predicts prolonged weaning and a worse survival , and clinicians should implement measures aim ed at improving weaning outcome BACKGROUND Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely . Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie , daily interruption of sedatives-with spontaneous breathing trials ( SBTs ) . METHODS In four tertiary-care hospitals , we r and omly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT  ( intervention group ; n=168 )  or with sedation per usual care plus a daily SBT ( control group ; n=168 ) . The primary endpoint was time breathing without assistance . Data were analysed by intention to treat . This study is registered with Clinical Trials.gov , number NCT00097630 . FINDINGS One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up . Seven patients in the control group discontinued their assigned protocol , and two of these patients were lost to follow-up . Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group ( 14.7 days vs 11.6 days ; mean difference 3.1 days , 95 % CI 0.7 to 5.6 ; p=0.02 ) and were discharged from intensive care ( median time in intensive care 9.1 days vs 12.9 days ; p=0.01 ) and the hospital earlier ( median time in the hospital 14.9 days vs 19.2 days ; p=0.04 ) . More patients in the intervention group self-extubated than in the control group ( 16 patients vs six patients ; 6.0 % difference , 95 % CI 0.6 % to 11.8 % ; p=0.03 ) , but the number of patients who required reintubation after self-extubation was similar ( five patients vs three patients ; 1.2 % difference , 95 % CI -5.2 % to 2.5 % ; p=0.47 ) , as were total reintubation rates ( 13.8%vs 12.5 % ; 1.3 % difference , 95 % CI -8.6 % to 6.1 % ; p=0.73 ) . At any instant during the year after enrolment , patients in the intervention group were less likely to die than were patients in the control group ( HR 0.68 , 95 % CI 0.50 to 0.92 ; p=0.01 ) . For every seven patients treated with the intervention , one life was saved ( number needed to treat was 7.4 , 95 % CI 4.2 to 35.5 ) . INTERPRETATION Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials ( ie , interruption of sedatives ) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current st and ard approaches and should become routine practice BACKGROUND AND OBJECTIVES To compare the attainment of the rapid shallow breathing index ( IRRS ) in modalities PSV 10 cmH2O and PEEP 5 cmH2O ( PSV10 ) , CPAP 5 cmH2O ( CPAP5 ) and spontaneous breathing ( SB ) , correlating them with success on failure in the withdrawal of mechanical ventilation ( MV ) . METHODS Prospect i ve study including 54 patients in MV > 48 hours , su bmi tted to the IRRS in three ventilatory modalities : PSV10 , CPAP5 and SB at the moments before and after T-tube spontaneous breathing . The patients were removed from MV when IRRS was < 105 . RESULTS There was n't statistically significant difference between IRRS values at the moments before and after T-tube SB . There was statistically significant difference IRRS value between the modalities CPAP5 and PSV10 ( p = 0.008 ) , and between the modalities SB and PSV10 ( p = 0.01 ) at the moment before T-Tube SB and of IRRS value , gotten between CPAP5 and PSV10 ( p = 0.01 ) at the moment after T-tube SB . CONCLUSIONS From this sample , it can be observed that IRRS values are overestimated when gotten in modality PSV10 . It was also evidence d that there is no need of a 30 min T-tube SB before extubation , when the weaning is performed with the technique of gradual reduction of PSV . This study suggested that IRRS is able to predict weaning success ; however it is not able to determine failure when it was < 105 . It is recommended that IRRS must be analyzed in association with other predictive weaning parameters Objective Evidence that PS may facilitate weaning from mechanical ventilation ( MV ) , although not confirmed by r and omized trials , prompted us to investigate whether patients could be weaned with PS after failing a T-tube trial . Design and setting This was a prospect i ve , non-r and omized study in two French intensive care units . Patients and participants One hundred eighteen patients were enrolled and underwent a T-tube trial , after which 87 were extubated . Thirty-one underwent a further trial with PS , after which 21 were extubated . Interventions All patients under MV > 24 h meeting the criteria for a weaning test underwent a 30-min T-tube trial . If this was successful , they were immediately extubated . Otherwise , a 30-min trial with + 7 cm H2O PS was initiated with an individualized pressurization slope and trigger adjustment . If all weaning criteria were met , the patients were extubated ; otherwise , MV was reinstated . Measurements and Results The extubation failure rate at 48 h did not differ significantly between the groups : 11/87 ( 13 % ) versus 4/21 ( 19 % ) , P=0.39 . The groups were comparable with regard to endotracheal tube diameter , MV duration , the use of non-invasive ventilation ( NIV ) after extubation , initial severity score , age and underlying pathology , except for COPD . A significantly higher percentage of patients with COPD was extubated after the trial with PS ( 8/21–38 % ) than after a single T-tube trial ( 11/87–13 % ) ( P=0.003 ) . Conclusions Of the patients , 21/118 ( 18 % ) could be extubated after a trial with PS , despite having failed a T-tube trial . The reintubation rate was not increased . This protocol may particularly benefit patients who are most difficult to wean , notably those with COPD OBJECTIVE To compare a practice of protocol -directed weaning from mechanical ventilation implemented by nurses and respiratory therapists with traditional physician-directed weaning . DESIGN R and omized , controlled trial . SETTING Medical and surgical intensive care units in two university-affiliated teaching hospitals . PATIENTS Patients requiring mechanical ventilation ( n = 357 ) . INTERVENTIONS Patients were r and omly assigned to receive either protocol -directed ( n = 179 ) or physician-directed ( n = 178 ) weaning from mechanical ventilation . MEASUREMENTS AND MAIN RESULTS The primary outcome measure was the duration of mechanical ventilation from tracheal intubation until discontinuation of mechanical ventilation . Other outcome measures included need for reintubation , length of hospital stay , hospital mortality rate , and hospital costs . The median duration of mechanical ventilation was 35 hrs for the protocol -directed group ( first quartile 15 hrs ; third quartile 114 hrs ) compared with 44 hrs for the physician-directed group ( first quartile 21 hrs ; third quartile 209 hrs ) . Kaplan-Meier analysis demonstrated that patients r and omized to protocol -directed weaning had significantly shorter duration s of mechanical ventilation compared with patients r and omized to physician-directed weaning ( chi 2 = 3.62 , p = .057 , log-rank test ; chi 2 = 5.12 , p = .024 , Wilcoxon test ) . Cox proportional-hazards regression analysis , adjusting for other covariates , showed that the rate of successful weaning was significantly greater for patients receiving protocol -directed weaning compared with patients receiving physician-directed weaning ( risk ratio 1.31 ; 95 % confidence interval 1.15 to 1.50 ; p = .039 ) . The hospital mortality rates for the two treatment groups were similar ( protocol -directed 22.3 % vs. physician-directed 23.6 % ; p = .779 ) . Hospital cost savings for patients in the protocol -directed group were $ 42,960 compared with hospital costs for patients in the physician-directed group . CONCLUSION Protocol -guided weaning of mechanical ventilation , as performed by nurses and respiratory therapists , is safe and led to extubation more rapidly than physician-directed weaning The duration of spontaneous breathing trials before extubation has been set at 2 h in research studies , but the optimal duration is not known . We conducted a prospect i ve , multicenter study involving 526 ventilator-supported patients considered ready for weaning , to compare clinical outcomes for trials of spontaneous breathing with target duration s of 30 and 120 min . Of the 270 and 256 patients in the 30- and 120-min trial groups , respectively , 237 ( 87.8 % ) and 216 ( 84.8 % ) , respectively , completed the trial without distress and were extubated ( p = 0.32 ) ; 32 ( 13.5 % ) and 29 ( 13.4 % ) , respectively , of these patients required reintubation within 48 h. The percentage of patients who remained extubated for 48 h after a spontaneous breathing trial did not differ in the 30- and 120-min trial groups ( 75.9 % versus 73.0 % , respectively , p = 0.43 ) . The 30- and 120-min trial groups had similar within-unit mortality rates ( 13 and 9 % , respectively ) and in-hospital mortality rates ( 19 and 18 % , respectively ) . Reintubation was required in 61 ( 13.5 % ) patients , and these patients had a higher mortality ( 20 of 61 , 32.8 % ) than did patients who tolerated extubation ( 18 of 392 , 4.6 % ) ( p < 0.001 ) . Neither measurements of respiratory frequency , heart rate , systolic blood pressure , and oxygen saturation during the trial , nor other functional measurements before the trial discriminated between patients who required reintubation from those who tolerated extubation . In conclusion , after a first trial of spontaneous breathing , successful extubation was achieved equally effectively with trials targeted to last 30 and 120 min Background : Automatic tube compensation ( ATC ) is a new option to compensate for the pressure drop across the endotracheal or tracheostomy tube ( ETT ) , especially during ventilator‐assisted spontaneous breathing . While several benefits of this mode have so far been documented , ATC has not yet been used to predict whether the ETT could be safely removed at the end of weaning , from mechanical ventilation Abstract Abstract Objective . To investigate the possibility of successful extubation performing a spontaneous breathing trial ( SBT ) in pressure support ventilation ( PSV ) with target duration s of 30 and 120 min . Design and setting . Prospect i ve and r and omized study in two medical-surgical adult intensive care units . Patients and participants . 98 adult patients supported by mechanical ventilation for at least 48 h and considered ready for a weaning trial . Interventions . An SBT conducted in PSV with 7 cmH2O and patients r and omly assigned to two groups with target duration s of 30- and 120-min . Measurements and results . In the 30-min group 43 patients ( 93 % ) tolerated the SBT and were extubated while 4 ( 9 % ) needed reintubation within 48 h ; in the 120-min group 46 patients ( 88 % ) successfully completed the trial and were extubated while 2 ( 4 % ) were reintubated . ICU mortality in the groups with short and long periods was 6 % and 4 % , and in-hospital mortality 20 % and 17 % , respectively . Those successful in the 30- and 120-min groups had similar length of ICU stay ( 6 and 7 days , respectively ) and in-hospital length of stay ( 20 and 25 days , respectively ) . Compared to the successfully extubated , the reintubated patients had significantly higher length of ICU stay and mortality ( 17 vs. 6 days and 33 vs. 3.6 % , respectively ) . Conclusions . An SBT with PSV of 7 cmH2O lasting 30 min is equally effective in recognizing the successfully extubated patients as a 120-min trial Several modalities of ventilatory support have been proposed to gradually withdraw patients from mechanical ventilation , but their respective effects on the outcome of weaning from mechanical ventilation are not known . We conducted a r and omized trial in three intensive care units in mechanically ventilated patients who met st and ard weaning criteria . Those who could not sustain 2 h of spontaneous breathing were r and omly assigned to be weaned with T-piece trials , with synchronized intermittent m and atory ventilation ( SIMV ) , or with pressure support ventilation ( PSV ) . Specific criteria for performing tracheal extubation were defined for each modality . The number of patients who could not be separated from the ventilator at 21 d ( i.e. , who failed to wean ) was compared between the groups . Patients in whom tracheal intubation was required in a 48-h period following extubation were also classified as failures . Among 456 mechanically ventilated patients who met weaning criteria , 109 entered into the study ( 35 with T piece , 43 with SIMV , and 31 with PSV )  . The three groups were comparable in terms of etiology of disease or characteristics at entry in the study . When all causes for weaning failure were considered , a lower number of failures was found with PSV than with the other two modes , with the difference just reaching the level of significance ( 23 % for PSV , 43 % for T piece , 42 % for SIMV ; p = 0.05 ) . After excluding patients whose weaning was terminated for complications unrelated to the weaning process , the difference became highly significant ( 8 % for PSV versus 33 % and 39 % , p < 0.025 ) . ( ABSTRACT TRUNCATED AT 250 WORDS We design ed a prospect i ve multicenter r and omized controlled study in three long-term weaning units ( LWU ) to evaluate which protocol , inspiratory pressure support ventilation ( PSV ) or spontaneous breathing trials ( SB ) , is more effective in weaning patients with chronic obstructive pulmonary disease ( COPD ) requiring mechanical ventilation for more than 15 d. Fifty-two of 75 patients , failing an initial T-piece trial at admission , were r and omly assigned to PSV or SB ( 26 in both groups ) . No significant difference was found in weaning success rate ( 73 % versus 77 % in the PSV and SB group , respectively ) , mortality rate ( 11.5 % versus 7.6 % ) , duration of ventilatory assistance ( 181 + /- 161 versus 130 + /- 106 h ) , LWU ( 33 + /- 12 versus 35 + /- 19 d ) , or total hospital stay . The results of these defined protocol s were retrospectively compared with an " uncontrolled clinical practice " in weaning historical control patients . The overall 30-d weaning success rate was significantly greater ( 87 % versus 70 % ) and the time spent under mechanical ventilation by survived and weaned patients was shorter in the patients in the study than in historical control patients ( 103 + /- 144 versus 170 + /- 127 h ) . The LWU and hospital stays were also significantly shorter ( 27 + /- 12 versus 38 + /- 18 and 38 + /- 17 versus 47 + /- 18 d ) . Spontaneous breathing trials and decreasing levels of PSV are equally effective in difficult-to-wean patients with COPD . The application of a well-defined protocol , independent of the mode used , may result in better outcomes than uncontrolled clinical practice The objective of this study was to compare the effects of continuous positive airway pressure ( CPAP ) , pressure support ventilation ( PS ) , and T-piece on the pressure-time product ( PTP ) during weaning from mechanical ventilation . The PTP is an estimate of the metabolic work or oxygen consumption of the respiratory muscles . We studied 10 intubated patients recovering from acute respiratory failure of various etiologies . A modified continuous flow ( flow-by ) CPAP of 0 and 5 cm H2O ( CPAP-0 and CPAP-5 , respectively ) , PS of 5 cm H2O ( PS-5 ) , and T-piece were applied in r and om order for 30 min each . In the last 5 min of the 30-min periods , we measured the esophageal pressure and transdiaphragmatic pressure-time products -- PTP(es ) and PTP(di ) , cm H2O.s/min , respectively-multiplied by respiratory frequency . Breathing pattern , total lung resistance ( RL ) , quasi-static lung compliance ( CL ) , intrinsic positive end-expiratory pressure ( PEEPi ) , end-expiratory transpulmonary pressure ( Ptpexp ) , arterial blood gases , blood pressure , and heart rate were also measured . In comparison to T-piece , CPAP-5 decreased PTP(es ) 40 % ( p less than 0.01 ) and PTP(di ) 43 % ( p less than 0.02 ) , whereas PS-5 decreased PTP(es ) 34 % ( p less than 0.01 ) and PTP(di ) 38 % ( p less than 0.05 ) . The decrease in PTP(es ) with CPAP-5 was associated with a significant reduction in RL , and to a less extent in PEEPi relative to airway pressure . The contribution of the decrease in PEEPi to the reduction in PTP(es ) amounted to 36 % . With PS-5 , respiratory system mechanics and PEEPi were not significantly different compared with T-piece . With CPAP-0 , PTP tended to be lower than with T-piece . ( ABSTRACT TRUNCATED AT 250 WORDS Certain groups of mechanically ventilated patients with acute respiratory failure are difficult to wean from prolonged ventilation despite advanced respiratory support techniques . The common modes for providing support during weaning are intermittent m and atory ventilation ( IMV ) , and spontaneous ventilatory trial ( SVT ) techniques ; such as continuous positive airway pressure ( CPAP ) and T-piece . Weaning is often initiated with IMV , and a series of SVTs are introduced as the patient tolerates decreasing rates of IMV . However , there is some concern that this strategy of weaning may not be optimal for patient comfort , and muscle reconditioning [ 1 ] OBJECTIVE To develop and vali date a new Simplified Acute Physiology Score , the SAPS II , from a large sample of surgical and medical patients , and to provide a method to convert the score to a probability of hospital mortality . DESIGN AND SETTING The SAPS II and the probability of hospital mortality were developed and vali date d using data from consecutive admissions to 137 adult medical and /or surgical intensive care units in 12 countries . PATIENTS The 13,152 patients were r and omly divided into developmental ( 65 % ) and validation ( 35 % ) sample s. Patients younger than 18 years , burn patients , coronary care patients , and cardiac surgery patients were excluded . OUTCOME MEASURE Vital status at hospital discharge . RESULTS The SAPS II includes only 17 variables : 12 physiology variables , age , type of admission ( scheduled surgical , unscheduled surgical , or medical ) , and three underlying disease variables ( acquired immunodeficiency syndrome , metastatic cancer , and hematologic malignancy ) . Goodness-of-fit tests indicated that the model performed well in the developmental sample and vali date d well in an independent sample of patients ( P = .883 and P = .104 in the developmental and validation sample s , respectively ) . The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample . CONCLUSION The SAPS II , based on a large international sample of patients , provides an estimate of the risk of death without having to specify a primary diagnosis . This is a starting point for future evaluation of the efficiency of intensive care units One hundred seventy-four patients ( 179 admissions ) were prospect ively evaluated for the subsequent occurrence of  upper gastrointestinal ( " stress " ) bleeding after admission to a medical/respiratory intensive care unit . Evidence for either overt or occult gastrointestinal bleeding developed in 25 ( 14 percent ) . The group of bleeders had a higher mortality ( 64 percent versus 9 percent ) , duration of intensive care unit stay ( median 14.2 versus 4.2 days ) , number of patients requiring mechanical ventilatory support ( 84 percent versus 26 percent ) , and duration of such support for those who required it ( median 9.5 versus 4.2 days ) than the group who did not bleed . In three patients , death was related to bleeding . Upon patients ' admission to the intensive care unit , diagnoses of an acute respiratory illness ( but not specifically chronic obstructive pulmonary disease ) , a malignancy , or sepsis were more common among those who subsequently bled . Of factors tested , a coagulopathy and the need for mechanical ventilation were most strongly associated with the risk of bleeding . Other factors did not add to the risk once these two were taken into account . Among patients receiving mechanical ventilation  , the risk of overt bleeding was particularly low for those who required such support for less than five days ( only 3 percent ) . It is concluded that ( 1 ) significant upper gastrointestinal bleeding occurring after medical intensive care unit admission is an uncommon event , and ( 2 ) prolonged mechanical ventilation and /or the presence of a coagulopathy are the most potent risk factors . Medical patients with either of the latter conditions are most likely to benefit from prophylaxis regimens against " stress"-induced upper gastrointestinal bleeding CONTEXT The outcome of patients receiving mechanical ventilation for particular indications has been studied , but the outcome in a large number of unselected , heterogeneous patients has not been reported . OBJECTIVE To determine the survival of patients receiving mechanical ventilation  and the relative importance of factors influencing survival . DESIGN , SETTING , AND SUBJECTS Prospect i ve cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1 , 1998 , and March 31 , 1998 . Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days . MAIN OUTCOME MEASURE All-cause mortality during intensive care unit stay . RESULTS Of the 15 757 patients admitted , a total of 5183 ( 33 % ) received mechanical ventilation  for a mean ( SD ) duration of 5.9 ( 7.2 ) days . The mean ( SD ) length of stay in the intensive care unit was 11.2 ( 13.7 ) days . Overall mortality rate in the intensive care unit was 30.7 % ( 1590 patients ) for the entire population , 52 % ( 120 ) in patients who received ventilation because of acute respiratory distress syndrome , and 22 % ( 115 ) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease . Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69 % . The main conditions independently associated with increased mortality were ( 1 ) factors present at the start of mechanical ventilation ( odds ratio [ OR ] , 2.98 ; 95 % confidence interval [ CI ] , 2.44 - 3.63 ; P<.001 for coma ) , ( 2 ) factors related to patient management ( OR , 3.67 ; 95 % CI , 2.02 - 6.66 ; P<.001 for plateau airway pressure > 35 cm H(2)O ) , and ( 3 ) developments occurring over the course of mechanical ventilation ( OR , 8.71 ; 95 % CI , 5.44 - 13.94 ; P<.001 for ratio of PaO(2 ) to fraction of inspired oxygen < 100 ) . CONCLUSION Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation , but also on the development of complications and patient management in the intensive care unit Objective To determine the factors associated with  ventilator-associated pneumonia recurrence  in patients alive after 8 days of treatment for a first episode . Design A 16-month , prospect i ve , observational cohort study of patients diagnosed with a first ventilator-associated pneumonia episode . Predictors of recurrence were assessed by logistic regression analysis . Setting Two intensive care units in a university hospital . Patients Bronchoscopy was performed in 124 patients with clinical ly or radiologically suspected ventilator-associated pneumonia . Ventilator-associated pneumonia was confirmed by the presence of at least two of the following criteria : ≥2 % of cells with intracellular bacteria found on direct examination of bronchoalveolar lavage fluid , protected specimen brush sample culture ≥103 colony-forming units/mL , or bronchoalveolar lavage culture ≥104 colony-forming units/mL. Ventilator-associated pneumonia recurrence was confirmed using the same microbiological criteria . Antibiotic treatment for ventilator-associated pneumonia lasted 14 days . Measurements and Main Results Clinical , radiologic , and biological data at intensive care unit admission , on the day of bronchoscopy ( D1 ) and on D8 , and outcome variables were prospect ively recorded . Ventilator-associated pneumonia recurred in 28 patients ( all of them still on mechanical ventilation on D8 ) , 21 ± 9 days after the first episode ( 82 % after D14 ) . Factors significantly associated with recurrence were : acute respiratory failure as initial reason for mechanical ventilation , D1 radiologic score > 7 , D8 radiologic score > 8 , adult respiratory distress syndrome on D8 , mechanical ventilation persistence on D8 , D8 temperature > 38 ° C , and D8 temperature > D1 temperature , but not disease-severity scores at inclusion and D8 , or first-episode pathogen(s ) . Multivariate analysis identified D1 radiologic score > 7 ( odds ratio = 3.9 ; 95 % confidence interval , 1.3–11.6 ) , D8 temperature > 38 ° C ( odds ratio = 4.4 ; 95 % confidence interval , 1.4–13.4 ) , and adult respiratory distress syndrome on D8 ( odds ratio = 14.6 ; 95 % confidence interval , 1.5–143.5 ) as predictors of recurrence . Conclusions Factors of ventilator-associated pneumonia recurrence evaluated on D8 of a 14-day course of antibiotics are linked to the severity of lung injury and persistence of fever , but not to first-episode pathogen(s ) We measured in rats the effects of 48 h of mechanical ventilation on the weight , contractile properties , and enzymatic profile of the diaphragm , the soleus and the extensor digitorium longus ( EDL ) muscles . Eighteen animals were r and omly divided into a mechanically ventilated ( MV , n = 9 ) group or a control ( C , n = 9 ) group . During the 48 h of mechanical ventilation , animals in the MV group were anesthetized with sodium thiopental and enterally fed with a gastric catheter . Group C animals were neither anesthetized nor mechanically ventilated during the 48-h experimental period , and they had access to food and water ad libitum . Muscular contractile properties were measured in vitro by analysis of force-frequency curves and twitch characteristics . The weights of the three muscles were significantly reduced in the MV group compared with those in the C group . This was accompanied in the diaphragm by a reduction in the normalized force generated for all the frequencies of stimulation , except 20 Hz , whereas twitch characteristics were not modified . The forces generated by the soleus and EDL were not significantly reduced in the MV group compared with those in the C group . Diaphragm , soleus , and EDL citrate synthase and lactate dehydrogenase activities were not significantly different in the two groups . We conclude that mechanical ventilation for 48 h in rats produces a selective force reduction in the diaphragm OBJECTIVE To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation . DESIGN Prospect i ve cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital . The failed extubation group consisted of all patients reintubated within 72 h or within 7 days ( if continuous ICU care had been required ) of extubation . All others were considered to be successfully extubated . Study end points included hospital death vs survival , the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation , the likelihood of requiring > or = 7 or > or = 14 days of ICU care after extubation , and the need for transfer to either a long-term care or rehabilitation facility among the survivors . RESULTS Of 289 intubated patients , 247 ( 85 % ) were successfully extubated , and 42 ( 15 % ) required reintubation for failed extubation ( time to reintubation 1.5+/-0.2 days ) . Reintubation for extubation failure result ed in 12 additional days of mechanical ventilation . When compared with successfully extubated patients , reintubated patients were more likely to die in the hospital ( 43 % vs 12 % ; p<0.0001 ) , spend more time in the ICU ( 21.2+/-2.8 days vs 4.5+/-0.6 days ; p<0.001 ) and in the hospital ( 30.5+/-3.3 days vs 16.3+/-1.2 days ; p<0.001 ) after extubation , and require transfer to a long-term care or rehabilitation facility ( 38 % vs 21 % ; p<0.05 ) . Using multiple logistic regression , extubation failure was an independent predictor for death and the need for transfer to a long-term care facility . Compared with those successfully extubated , patients who failed extubation were seven times ( p<0.0001 ) more likely to die , 31 times ( p<0.0001 ) more likely to spend > or = 14 days in the ICU after extubation , and six times ( p<0.001 ) more likely to need transfer to a long-term care or rehabilitation facility if they survived . CONCLUSION After adjusting for severity of illness and comorbid conditions , extubation failure had a significant independent association with increased risk for death , prolonged ICU stay , and transfer to a long-term care or rehabilitation facility . Extubation failure may serve as an additional independent marker of severity of illness . Alternatively , poor outcomes may be etiologically related to extubation failure . If the latter proves to be the case , identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practice s may reduce mortality , duration of ICU stay , and need for transfer to a long-term care facility Objective : Pneumothorax is present as a frequent complication in acute respiratory distress syndrome ( ARDS ) .  Persistent air leak ( PAL ) prolongs pneumothorax in 2 % of cases of ARDS , increasing the rate of mortality by 26 % . Pleurodesis using autologous blood ( PAB ) is an effective method in cases of oncological pulmonary surgery . The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax . Design : The study was a case-control , prospect i ve , nonr and omized one comparing 2 groups subjected to artificial pairing ( 1:1 ) IMPORTANCE Patients requiring prolonged mechanical ventilation ( > 21 days ) are commonly weaned at long-term acute care hospitals ( LTACHs ) . The most effective method of weaning such patients has not been investigated . OBJECTIVE To compare weaning duration with pressure support vs unassisted breathing through a tracheostomy collar in patients transferred to an LTACH for weaning from prolonged ventilation . DESIGN , SETTING , AND PARTICIPANTS Between 2000 and 2010 , a r and omized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation . Of 500 patients who underwent a 5-day screening procedure , 316 did not tolerate the procedure and were r and omly assigned to receive weaning with pressure support ( n = 155 ) or a tracheostomy collar ( n = 161 ) . Survival at 6- and 12-month time points was also determined . MAIN OUTCOME MEASURE Primary outcome was weaning duration . Secondary outcome was survival at 6 and 12 months after enrollment . RESULTS Of 316 patients , 4 were withdrawn and not included in analysis . Of 152 patients in the pressure-support group , 68 ( 44.7 % ) were weaned ; 22 ( 14.5 % ) died . Of 160 patients in the tracheostomy collar group , 85 ( 53.1 % ) were weaned ; 16 ( 10.0 % ) died . Median weaning time was shorter with tracheostomy collar use ( 15 days ; interquartile range [ IQR ] , 8 - 25 ) than with pressure support ( 19 days ; IQR , 12 - 31 ) , P = .004 . The hazard ratio ( HR ) for successful weaning rate was higher with tracheostomy collar use than with pressure support ( HR , 1.43 ; 95 % CI , 1.03 - 1.98 ; P = .033 ) after adjusting for baseline clinical covariates . Use of the tracheostomy collar achieved faster weaning than did pressure support among patients who did not tolerate the screening procedure between 12 and 120 hours ( HR , 3.33 ; 95 % CI , 1.44 - 7.70 ; P = .005 ) , whereas weaning time was equivalent with the 2 methods in patients who did not tolerate the screening procedure within 0 to 12 hours . Mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 months ( 55.92 % vs 51.25 % ; 4.67 % difference , 95 % CI , -6.4 % to 15.7 % ) and at 12 months ( 66.45 % vs 60.00 % ; 6.45 % difference , 95 % CI , -4.2 % to 17.1 % ) . CONCLUSION AND RELEVANCE Among patients requiring prolonged mechanical ventilation and treated at a single long-term care facility , unassisted breathing through a tracheostomy , compared with pressure support , result ed in shorter median weaning time , although weaning mode had no effect on survival at 6 and 12 months . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01541462
BACKGROUND Mechanical ventilation is important in caring for patients with critical illness .
Clinical complications , increased mortality , and high costs of health care are associated with prolonged ventilatory support or premature discontinuation of mechanical ventilation .
Weaning refers to the process of gradually or abruptly withdrawing mechanical ventilation .
The weaning process begins after partial or complete resolution of the underlying pathophysiology precipitating respiratory failure and ends with weaning success ( successful extubation in intubated patients or permanent withdrawal of ventilatory support in tracheostomized patients ) .
OBJECTIVES To evaluate the effectiveness and safety of two strategies , a T-tube and pressure support ventilation , for weaning adult patients with respiratory failure that required invasive mechanical ventilation for at least 24 hours , measuring weaning success and other clinical ly important outcomes .