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Meta-Analysis
. 2014 Nov 6;2014(11):CD006904.
doi: 10.1002/14651858.CD006904.pub3.

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients

Bronagh Blackwood  1 , Karen E A Burns, Chris R Cardwell, Peter O'Halloran
Affiliations
Meta-Analysis

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients

Bronagh Blackwood et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a review last published in Issue 5, 2010, of The Cochrane Library. Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent.

Objectives: The first objective of this review was to compare the total duration of mechanical ventilation of critically ill adults who were weaned using protocols versus usual (non-protocolized) practice.The second objective was to ascertain differences between protocolized and non-protocolized weaning in outcomes measuring weaning duration, harm (adverse events) and resource use (intensive care unit (ICU) and hospital length of stay, cost).The third objective was to explore, using subgroup analyses, variations in outcomes by type of ICU, type of protocol and approach to delivering the protocol (professional-led or computer-driven).

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE (1950 to January 2014), EMBASE (1988 to January 2014), CINAHL (1937 to January 2014), LILACS (1982 to January 2014), ISI Web of Science and ISI Conference Proceedings (1970 to February 2014), and reference lists of articles. We did not apply language restrictions. The original search was performed in January 2010 and updated in January 2014.

Selection criteria: We included randomized controlled trials (RCTs) and quasi-RCTs of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults.

Data collection and analysis: Two authors independently assessed trial quality and extracted data. We performed a priori subgroup and sensitivity analyses. We contacted study authors for additional information.

Main results: We included 17 trials (with 2434 patients) in this updated review. The original review included 11 trials. The total geometric mean duration of mechanical ventilation in the protocolized weaning group was on average reduced by 26% compared with the usual care group (N = 14 trials, 95% confidence interval (CI) 13% to 37%, P = 0.0002). Reductions were most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. Weaning duration was reduced by 70% (N = 8 trials, 95% CI 27% to 88%, P = 0.009); and ICU length of stay by 11% (N = 9 trials, 95% CI 3% to 19%, P = 0.01). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2) = 67%, P < 0.0001) and weaning duration (I(2) = 97%, P < 0.00001), which could not be explained by subgroup analyses based on type of unit or type of approach.

Authors' conclusions: There is evidence of reduced duration of mechanical ventilation, weaning duration and ICU length of stay with use of standardized weaning protocols. Reductions are most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. However, significant heterogeneity among studies indicates caution in generalizing results. Some study authors suggest that organizational context may influence outcomes, however these factors were not considered in all included studies and could not be evaluated. Future trials should consider an evaluation of the process of intervention delivery to distinguish between intervention and implementation effects. There is an important need for further development and research in the neurosurgical population.

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Conflict of interest statement

Bronagh Blackwood: none known.

Karen EA Burns: holds a CAD 5000 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 not included in this Cochrane review. (The WEAN Study is an investigator‐initiated trial comparing SmartCare™ and protocolized weaning, for which the co‐principal investigator (Dr Burns) 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).

Chris R Cardwell: none known.

Peter O'Halloran: none known.

Figures

1
1
Updated study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.3 Total duration of mechanical ventilation by type of protocol [log hours].
5
5
Forest plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.9 Weaning duration by type of approach [log hours].
6
6
Funnel plot of comparison: 1 Primary analysis: protocolized versus non‐protocolized weaning, outcome: 1.2 Total duration of MV by type of approach [log hours].
1.1
1.1. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 1 Total duration of MV by type of unit.
1.2
1.2. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 2 Total duration of MV by type of approach.
1.3
1.3. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 3 Total duration of MV by type of protocol [log hours].
1.4
1.4. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 4 Mortality.
1.5
1.5. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 5 Reintubation.
1.6
1.6. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 6 Self extubation.
1.7
1.7. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 7 Tracheostomy.
1.8
1.8. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 8 Weaning duration by type of ICU.
1.9
1.9. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 9 Weaning duration by type of approach.
1.10
1.10. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 10 Weaning duration by type of protocol [log hours].
1.11
1.11. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 11 ICU length of stay.
1.12
1.12. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 12 Hospital length of stay.
1.13
1.13. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 13 ICU costs.
1.14
1.14. Analysis
Comparison 1 Primary analysis: protocolized versus non‐protocolized weaning, Outcome 14 Hospital costs.
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 1 Total duration of MV.
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis: protocolized versus non‐protocolized weaning excluding high risk of bias studies, Outcome 2 Weaning duration.
3.1
3.1. Analysis
Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 1 Total duration of MV.
3.2
3.2. Analysis
Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 2 Weaning duration.
3.3
3.3. Analysis
Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 3 ICU length of stay.
3.4
3.4. Analysis
Comparison 3 Sensitivity analysis: protocolized versus non‐protocolized weaning, unlogged data, Outcome 4 Hospital length of stay.
See this image and copyright information in PMC

Update of

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