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. 2014 Feb 13;2014(2):CD008639.
doi: 10.1002/14651858.CD008639.pub2.

Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults

Karen E A Burns  1 , Francois Lellouche, Martin R Lessard, Jan O Friedrich
Affiliations

Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults

Karen E A Burns et al. Cochrane Database Syst Rev. .

Abstract

Background: Automated systems use closed-loop control to enable ventilators to perform basic and advanced functions while supporting respiration. Selected automated systems can now not only measure selected respiratory variables and adapt ventilator output to individual patient needs by operationalizing predetermined algorithms but also automate the conduct of spontaneous breathing trials (SBTs).

Objectives: To summarize the evidence comparing automated weaning and SBT systems to non-automated mechanical ventilation strategies on time to mechanical ventilation discontinuation in adult postoperative patients. In secondary objectives we ascertained differences between automated weaning and SBT systems and non-automated mechanical ventilation discontinuation strategies on clinical outcomes (time to successful extubation, time to first SBT and first successful SBT, mortality, total duration of ventilation, intensive care unit (ICU) and hospital lengths of stay, use of non-invasive ventilation (NIV) following extubation, and adverse events).

Search methods: We searched CENTRAL (The Cochrane Library 2013, Issue 5); MEDLINE (OvidSP) (1966 to May 2013); EMBASE (OvidSP) (1988 to May 2013); CINAHL (EBSCOhost) (1982 to May 2013), Evidence Based Medicine Reviews and Ovid Health Star (1999 to May 2013), conference proceedings, trial registration websites, and contacted authors and content experts to identify potentially eligible trials.

Selection criteria: Randomized and quasi-randomized trials comparing automated weaning and SBT systems to non-automated mechanical ventilation discontinuation strategies in intubated adults in the postoperative setting.

Data collection and analysis: Two review authors independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses were planned to assess the impact of the type of (i) clinician primarily involved in implementing the automated weaning and SBT systems, (ii) intensive care unit (ICU), and (iii) non-automated discontinuation (control) strategy utilized on selected outcomes.

Main results: We identified one randomized controlled trial of high quality, involving 300 patients , comparing SmartCare™ to a written protocol. In this trial, SmartCare™ had no effect on discontinuation time. While SmartCare™ significantly reduced the time to the first SBT (mean difference (MD) -0.34 days, 95% CI -0.60 to -0.08; P = 0.01) it did not reduce the time to the first successful SBT (MD -0.25 days, 95% CI -0.55 to 0.05; P = 0.10) and other clinically important outcomes. SmartCare™ did not demonstrate beneficial effects on most clinically important outcomes including time to successful extubation, total duration of mechanical ventilation, ICU and hospital lengths of stay, and the requirement for tracheostomy. Moreover, SmartCare™ did not favourably impact reintubation, mortality, self-extubation, and the proportion of patients undergoing protracted mechanical ventilation, with a small numbers of events in this single trial.

Authors' conclusions: There is a paucity of evidence from randomized controlled trials to support or refute use of automated weaning and SBT systems in discontinuing invasive mechanical ventilation in adult postoperative patients. In a single large trial of high methodologic quality, while the use of SmartCare™ to adjust ventilator settings and conduct SBTs shortened the time to undergoing the first SBT, it did not reduce the time to the first successful SBT or the rate of tracheostomy compared to a written protocol implemented by physicians. SmartCare™ did not demonstrate beneficial effects on clinically important outcomes including time to mechanical ventilation discontinuation, time to successful discontinuation, total duration of mechanical ventilation, and ICU and hospital lengths of stay. Additional well-designed, adequately powered randomized controlled trials are needed to clarify the role for SmartCare™ on important outcomes in patients who predominantly require short term ventilation and in specific postoperative patient populations.

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Conflict of interest statement

Drs Burns and Lellouche hold a $5000 CDN travel bursary from Draeger Medical Inc (Canada) for the purpose of conducting site visits to participating centres in the WEAN Study. The WEAN Study is an investigator‐initiated trial comparing SmartCare™ and protocolized weaning for which the co‐principal investigators (Drs Burns and Lellouche) obtained peer‐review funding to implement. Draeger Medical Inc provided ventilators and ventilator upgrades for the WEAN Study and a central randomization system using electronic mail correspondence (Draeger Medical, Germany). Draeger Medical was not involved in any aspects of the study design and oversight, data management or data analysis.

Drs Burns, Lellouche and Lessard have self‐identified as investigators of trials that apply the intervention in question. However, the methods used in conducting this review do not allow bias in the selection, data extraction or risk of bias assessment of any included or excluded studies from these authors.

Drs Friedrich and Nisenbaum have no conflicts of interest to declare.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Discontinuation time (randomization to extubation), Outcome 1 Discontinuation time (randomization to extubation).
2.1
2.1. Analysis
Comparison 2 Time to successful extubation, Outcome 1 Time to successful extubation.
3.1
3.1. Analysis
Comparison 3 Time to first spontaneous breathing trial, Outcome 1 Time to first spontaneous breathing trial.
4.1
4.1. Analysis
Comparison 4 Time to first successful spontaneous breathing trial, Outcome 1 Time to first successful spontaneous breathing trial.
5.1
5.1. Analysis
Comparison 5 Most protracted measure of mortality, Outcome 1 Most protracted measure of mortality.
6.1
6.1. Analysis
Comparison 6 Total duration of mechanical ventilation, Outcome 1 Total duration of mechanical ventilation.
7.1
7.1. Analysis
Comparison 7 Intensive care unit length of stay, Outcome 1 Intensive care unit length of stay.
8.1
8.1. Analysis
Comparison 8 Use of non‐invasive ventilation following extubation, Outcome 1 Use of noninvasive ventilation following extubation.
9.1
9.1. Analysis
Comparison 9 Adverse event: reintubation, Outcome 1 Adverse event: reintubation.
10.1
10.1. Analysis
Comparison 10 Prolonged mechanical ventilation (> 14 days), Outcome 1 Prolonged mechanical ventilation (> 14 days).
11.1
11.1. Analysis
Comparison 11 Prolonged mechanical ventilation (> 21 days), Outcome 1 Prolonged mechanical ventilation (> 21 days).
12.1
12.1. Analysis
Comparison 12 Adverse event: tracheostomy, Outcome 1 Adverse event: tracheostomy.
13.1
13.1. Analysis
Comparison 13 Adverse event: self‐extubation, Outcome 1 Adverse event: self‐extubation.
14.1
14.1. Analysis
Comparison 14 Hospital length of stay, Outcome 1 Hospital length of stay.
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Update of

  • doi: 10.1002/14651858.CD008639

References

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