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Meta-Analysis
. 2014 Sep 9;2014(9):CD008638.
doi: 10.1002/14651858.CD008638.pub2.

Automated weaning and SBT systems versus non-automated weaning strategies for weaning time in invasively ventilated critically ill adults

Karen E A Burns  1 , Francois Lellouche, Rosane Nisenbaum, Martin R Lessard, Jan O Friedrich
Affiliations
Meta-Analysis

Automated weaning and SBT systems versus non-automated weaning strategies for weaning time in invasively ventilated critically ill 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. SmartCare™ is a unique automated weaning system that measures selected respiratory variables, adapts ventilator output to individual patient needs by operationalizing predetermined algorithms and automatically conducts spontaneous breathing trials (SBTs) when predetermined thresholds are met.

Objectives: The primary objective of this review was to compare weaning time (time from randomization to extubation as defined by study authors) between invasively ventilated critically ill adults weaned by automated weaning and SBT systems versus non-automated weaning strategies.As secondary objectives, we ascertained differences between effects of alternative weaning strategies on clinical outcomes (time to successful extubation, time to first SBT and first successful SBT, mortality, ventilator-associated pneumonia, total duration of ventilation, lengths of intensive care unit (ICU) and hospital stay, use of non-invasive ventilation (NIV), adverse events and clinician acceptance).The third objective of our review was to use subgroup analyses to explore variations in weaning time, length of ICU stay, mortality, ventilator-associated pneumonia, use of NIV and reintubation according to (1) the type of clinician primarily involved in implementing the automated weaning and SBT strategy, (2) the ICU (as a reflection of the population involved) and (3) the non-automated (control) weaning strategy utilized.We conducted a sensitivity analysis to evaluate variations in weaning time based on (4) the methodological quality (low or unclear versus high risk of bias) of the included studies.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 5; MEDLINE (1966 to 31 May 2013); EMBASE (1988 to 31 May 2013); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 May 2013), Evidence-Based Medicine Reviews and Ovid HealthSTAR (1999 to 31 May 2013), as well as conference proceedings and trial registration websites; we also contacted study authors and content experts to identify potentially eligible trials.

Selection criteria: Randomized and quasi-randomized trials comparing automated weaning and SBT systems versus non-automated weaning strategies in intubated adults.

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 on selected outcomes of the following: (1) the type of clinician primarily involved in implementing automated weaning and SBT systems, (2) the ICU (as a reflection of the population involved) and (3) the non-automated (control) weaning strategy utilized.

Main results: We pooled summary estimates from 10 trials evaluating SmartCare™ involving 654 participants. Overall, eight trials were judged to be at low or unclear risk of bias, and two trials were judged to be at high risk of bias. Compared with non-automated strategies, SmartCare™ decreased weaning time (mean difference (MD) -2.68 days, 95% confidence interval (CI) -3.99 to -1.37; P value < 0.0001, seven trials, 495 participants, moderate-quality evidence), time to successful extubation (MD -0.99 days, 95% CI -1.89 to -0.09; P value 0.03, seven trials, 516 participants, low-quality evidence), length of ICU stay (MD -5.70 days, 95% CI -10.54 to -0.85; P value 0.02, six trials, 499 participants, moderate-quality evidence) and proportions of participants receiving ventilation for longer than seven and 21 days (risk ratio (RR) 0.44, 95% CI 0.23 to 0.85; P value 0.01 and RR 0.39, 95% CI 0.18 to 0.86; P value 0.02). SmartCare™ reduced the total duration of ventilation (MD -1.68 days, 95% CI -3.33 to -0.03; P value 0.05, seven trials, 521 participants, low-quality evidence) and the number of participants receiving ventilation for longer than 14 days (RR 0.61, 95% CI 0.37 to 1.00; P value 0.05); however the estimated effects were imprecise. SmartCare™ had no effect on time to first successful SBT, mortality or adverse events, specifically reintubation. Subgroup analysis suggested that trials with protocolized (versus non-protocolized) control weaning strategies reported significantly shorter ICU stays. Sensitivity analysis excluded two trials with high risk of bias and supported a trend toward significant reductions in weaning time favouring SmartCare™.

Authors' conclusions: Compared with non-automated weaning strategies, weaning with SmartCare™ significantly decreased weaning time, time to successful extubation, ICU stay and proportions of patients receiving ventilation for longer than seven days and 21 days. It also showed a favourable trend toward fewer patients receiving ventilation for longer than 14 days; however the estimated effect was imprecise. Summary estimates from our review suggest that these benefits may be achieved without increasing the risk of adverse events, especially reintubation; however, the quality of the evidence ranged from low to moderate, and evidence was derived from 10 small randomized controlled trials.

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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 funding from peer‐review, non‐industry sources for implementation. 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 study design and oversight, data management or data analysis.

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

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 SmartCare™ versus non‐automated weaning, Outcome 1 Weaning time (randomization to extubation) based on type of control arm.
2.1
2.1. Analysis
Comparison 2 SmartCare™ versus non‐automated weaning, Outcome 1 Weaning time (randomization to extubation) based on clinician type.
3.1
3.1. Analysis
Comparison 3 SmartCare™ versus non‐automated weaning, Outcome 1 Weaning time (randomization to extubation) based on ICU type.
4.1
4.1. Analysis
Comparison 4 SmartCare™ versus non‐automated weaning, Outcome 1 Time to successful extubation.
5.1
5.1. Analysis
Comparison 5 SmartCare™ versus non‐automated weaning, Outcome 1 Time to first spontaneous breathing trial.
6.1
6.1. Analysis
Comparison 6 SmartCare™ versus non‐automated weaning, Outcome 1 Time to first successful spontaneous breathing trial.
7.1
7.1. Analysis
Comparison 7 SmartCare™ versus non‐automated weaning, Outcome 1 Most protracted measure of mortality (based on type of control arm).
8.1
8.1. Analysis
Comparison 8 SmartCare™ versus non‐automated weaning, Outcome 1 Most protracted measure of mortality (based on clinician type).
9.1
9.1. Analysis
Comparison 9 SmartCare™ versus non‐automated weaning, Outcome 1 Most protracted measure of mortality (based on ICU type).
10.1
10.1. Analysis
Comparison 10 SmartCare™ versus non‐automated weaning, Outcome 1 ICU mortality.
11.1
11.1. Analysis
Comparison 11 SmartCare™ versus non‐automated weaning, Outcome 1 Hospital mortality.
12.1
12.1. Analysis
Comparison 12 SmartCare™ versus non‐automated weaning, Outcome 1 Ventilator‐associated pneumonia (based on clinician type).
14.1
14.1. Analysis
Comparison 14 SmartCare™ versus non‐automated weaning, Outcome 1 Length of intensive care unit stay (based on type of control arm).
14.2
14.2. Analysis
Comparison 14 SmartCare™ versus non‐automated weaning, Outcome 2 Total duration of mechanical ventilation.
15.1
15.1. Analysis
Comparison 15 SmartCare™ versus non‐automated weaning, Outcome 1 Length of intensive care unit stay (based on clinician type).
16.1
16.1. Analysis
Comparison 16 SmartCare™ versus non‐automated weaning, Outcome 1 Use of noninvasive ventilation following extubation (based on type of control arm).
17.1
17.1. Analysis
Comparison 17 SmartCare™ versus non‐automated weaning, Outcome 1 Use of non‐invasive ventilation following extubation (based on clinician type).
18.1
18.1. Analysis
Comparison 18 SmartCare™ versus non‐automated weaning, Outcome 1 Adverse event: reintubation (based on type of control arm).
19.1
19.1. Analysis
Comparison 19 SmartCare™ versus non‐automated weaning, Outcome 1 Adverse event: reintubation (based on clinician type).
20.1
20.1. Analysis
Comparison 20 SmartCare™ versus non‐automated weaning, Outcome 1 Adverse event: self‐extubation.
21.1
21.1. Analysis
Comparison 21 SmartCare™ versus non‐automated weaning, Outcome 1 Adverse event: tracheostomy.
22.1
22.1. Analysis
Comparison 22 SmartCare™ versus non‐automated weaning, Outcome 1 Adverse event: pneumothorax.
23.1
23.1. Analysis
Comparison 23 SmartCare™ versus non‐automated weaning, Outcome 1 Prolonged mechanical ventilation (> 7 days).
24.1
24.1. Analysis
Comparison 24 SmartCare™ versus non‐automated weaning, Outcome 1 Prolonged mechanical ventilation (> 14 days).
25.1
25.1. Analysis
Comparison 25 SmartCare™ versus non‐automated weaning, Outcome 1 Prolonged mechanical ventilation (> 21 days).
26.1
26.1. Analysis
Comparison 26 SmartCare™ versus non‐automated weaning, Outcome 1 Length of hospital stay.
27.1
27.1. Analysis
Comparison 27 Sensitivity analysis: SmartCare™ versus non‐automated weaning, Outcome 1 Weaning time (randomization to extubation) based on type of control arm.
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References

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