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Meta-Analysis
. 2014 Jun 10;2014(6):CD009235.
doi: 10.1002/14651858.CD009235.pub3.

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children

Louise Rose  1 , Marcus J Schultz, Chris R Cardwell, Philippe Jouvet, Danny F McAuley, Bronagh Blackwood
Affiliations
Meta-Analysis

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children

Louise Rose et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Automated closed loop systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. This review was originally published in 2013 with an update published in 2014.

Objectives: The primary objective for this review was to compare the total duration of weaning from mechanical ventilation, defined as the time from study randomization to successful extubation (as defined by study authors), for critically ill ventilated patients managed with an automated weaning system versus no automated weaning system (usual care).Secondary objectives for this review were to determine differences in the duration of ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), mortality, and adverse events related to early or delayed extubation with the use of automated weaning systems compared to weaning in the absence of an automated weaning system.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (OvidSP) (1948 to September 2013); EMBASE (OvidSP) (1980 to September 2013); CINAHL (EBSCOhost) (1982 to September 2013); and the Latin American and Caribbean Health Sciences Literature (LILACS). Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. The original search was run in August 2011, with database auto-alerts up to August 2012.

Selection criteria: We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an ICU.

Data collection and analysis: Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria.

Main results: We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I(2) = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk.

Authors' conclusions: Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

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Conflict of interest statement

Bronagh Blackwood, Chris R Cardwell, Danny F McAuley: none known.

Louise Rose has completed an RCT comparing automated weaning using SmartCare/PS™ with usual care that was included in this systematic review. Dr Rose received no funding from Draeger Medical for this study. SmartCare/PS software, and associated technical upgrades for two ventilators, were provided free of charge to the Intensive Care Unit of The Royal Melbourne Hospital by Draeger Medical, Australia.

Marcus J Schultz received a research fund of EUR 12,000 for a study on weaning with ASV by Hamilton Medical, Switzerland. Hamilton Medical provided Professor Schultz's hospital research group with EUR 12,000 for performing a study of weaning with ASV in cardiac surgical patients. The money was used to buy equipment, a computer, statistician time, and to cover costs involved with the presentation of the results at a scientific meeting and publication of an article.

Philippe Jouvet has completed an RCT comparing automated weaning using SmartCare/PS™ with usual care, included in this systematic review. Dr Jouvet did not receive any funding from Draeger for this study though, for the purposes of the study, Draeger Medical provided one ventilator. Dr Jouvet received two grants as support from Hamilton Medical for two clinical studies, including a prospective trial on automation of weaning with ASV in children (NCT01095406) and a clinical study on criteria for mechanical ventilation adjustments in children. These two studies were not eligible for inclusion in the systematic review. Dr Jouvet also conducted a clinical trial on weaning with NAVA in infants (NCT00603174) that was not eligible for inclusion in the systematic review. Dr Jouvet did not receive any funding from Maquet for this study though, for the purposes of the study, Maquet provided one ventilator.

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.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Primary analysis: automated closed loop system versus non‐automated system, outcome: 1.2 Total weaning duration by automated system (log hours).
5
5
Forest plot of comparison: 1 Primary analysis: automated closed loop system versus non‐automated system, outcome: 1.5 Ventilation duration by study population (log hours).
6
6
Funnel plot of comparison: 1 Primary analysis: automated closed loop system versus non‐automated system, outcome: 1.2 Total weaning duration by automated system (log hours).
1.1
1.1. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 1 Total weaning duration by study population.
1.2
1.2. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 2 Total weaning duration by automated system.
1.3
1.3. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 3 Total weaning duration by non‐automated strategy (control arm).
1.4
1.4. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 4 Randomization to first extubation.
1.5
1.5. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 5 Ventilation duration by study population.
1.6
1.6. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 6 Ventilation duration of by automated system.
1.7
1.7. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 7 Ventilation duration of by non‐automated strategy (control arm).
1.8
1.8. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 8 Intubation to randomization.
1.9
1.9. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 9 Secondary outcome 5.1: mortality.
1.10
1.10. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 10 Hospital length of stay.
1.11
1.11. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 11 ICU length of stay by ICU population.
1.12
1.12. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 12 ICU length of stay by automated system.
1.13
1.13. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 13 Reintubation.
1.14
1.14. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 14 Self‐extubation.
1.15
1.15. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 15 Non invasive ventilation.
1.16
1.16. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 16 Prolonged mechanical ventilation.
1.17
1.17. Analysis
Comparison 1 Primary analysis: automated closed loop system versus non‐automated system, Outcome 17 Tracheostomy.
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 1 Weaning duration by ICU population.
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 2 Weaning duration by automated system [hours].
2.3
2.3. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 3 Weaning duration by non‐automated strategy (control arm).
2.4
2.4. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 4 Randomization to first extubation.
2.5
2.5. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 5 Ventilation duration.
2.6
2.6. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 6 Intubation to randomization.
2.7
2.7. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 7 Hospital length of stay.
2.8
2.8. Analysis
Comparison 2 Sensitivity analysis: automated closed loop system versus non‐automated system, un‐logged data duration of weaning, Outcome 8 ICU length of stay.
3.1
3.1. Analysis
Comparison 3 Sensitivity analysis: automated closed loop system versus non‐automated system excluding high risk of bias studies, Outcome 1 Weaning duration.
See this image and copyright information in PMC

Update of

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