Premature, Opportune, and Delayed Weaning in Mechanically Ventilated Patients: A Call for Implementation of Weaning Protocols in Low- and Middle-Income Countries
Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria.
Prospective, multicenter observational study.
Five medical ICUs in four public hospitals in Lima, Perú.
Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657).
Measurements and Main Results:
We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (–2.18, p = 0.008) and (–3.49, p < 0.001), ICU-free days (–2.25, p = 0.001) and (–3.72, p < 0.001), and hospital-free days (–2.76, p = 0.044) and (–4.53, p = 0.004), respectively, compared with the opportune weaning group.
Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.
The INTENSIVOS Cohort Study are as follows: Roy G. Brower, Francesca Capanni, Maria A. Caravedo, Jorge Cerna, William Checkley, Eduardo E. Chirinos, Long Davalos, Aldo De Ferrari, Joshua A. Denney, Augusto Dulanto, Phabiola Herrera, Amador A. Jaymez, Nicole Mongilardi, Carmen Paredes, Enrique Paz, Maria Alejandra Pereda, Jose Portugal, Rocio Quispe, Rollin Roldan, and Navid Shams.
Dr. Diaz-Soto and Mr. Morgan analyzed and interpreted the data, and drafted the article. Dr. Davalos collected, analyzed, and interpreted the data, and drafted the article. Drs. Herrera, Roldan, Paz, Jaymez, Chirinos, Portugal, and Quispe collected the data and drafted the article. Dr. Denney helped with the study design, collected the data, and drafted the article. Dr. Brower helped with the study design, interpreted the data, and drafted the article. Dr. Checkley designed and supervised the study, obtained funding, analyzed and interpreted the data, and drafted the article.
This study was supported by a Pathway to Independence Award (R00HL096955) from the National Heart, Lung and Blood Institute, National Institutes of Health.
Dr. Diaz-Soto disclosed that this study was supported by a the National Heart, Lung and Blood Institute, National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.
We received ethics approval and permission to conduct this study in each of the participating institutions: Hospital Nacional Edgardo Rebagliati Martins, Hospital Nacional Guillermo Almenara Irigoyen, Hospital Nacional Arzobispo Loayza, Hospital de Emergencias Casimiro Ulloa. Ethics approvals were obtained from the institutional review boards of A.B. PRISMA and ESSALUD Hospital Nacional Edgardo Rebagliati Martins in Lima, Peru, and the Johns Hopkins School of Medicine, in Baltimore, MD. We obtained a waiver of written informed consent to conduct this observational study.
Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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