The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

UTILIZATION OF RESPIRATORY THERAPIST DRIVEN PROTOCOLS - WEANING VENTILATOR PATIENTS IN SURGICAL INTENSIVE CARE UNITS

JM Graybeal CRTT. GB Russell. MD. E Taylor^{*} RRT. D Olsen^{*} RRT M Weeter^{*} RRT Dept of Anesthesia, Penn State University College of Medicine and ^{*}Respiratory Care Services. University Hospital, Hershey, Pa. 17033

The cost of caring for patients in the intensive care unit has come under close inspection. The expense of and demands placed on highly trained critical care physicians has limited their availability. In an effort to extend their availability in the surgical intensive care unit (SICU), we instituted protocols for weaning, by respiratory therapists, of patients from mechanical ventilators. We evaluated the efficiency and safety of these therapist driven protocols.

Following institutional IRB approval, mechanical ventilation weaning protocols were instituted in our SICU. Protocols were developed for SIMV. T-piece and Pressure Support (PS) weaning methods. Patients were enrolled in the protocols following a written order from the SICU physician. Respiratory therapist evaluation, utilizing established weaning parameters such as inspiratory force, vital capacity, static compliance, spontaneous tidal volume, the tidal volume-respiratory frequency ratio, and spontaneous minute ventilation, determined which weaning protocol was utilized for specific patients. All protocols were conducted by SICU respiratory therapists. A database of weaning protocol use, failure to wean, cause of failure, duration of wean and duration of ventilation prior to wean was maintained. Chi-square analysis was used to evaluate differences between groups, with p < 0.05 determining significance.

There were 151 patients enrolled in the weaning protocols; trauma (38), neurosurgical (26), general surgery (25), vascular surgery (19), sepsis/ARDS (13), renal surgery (10), other (7). 81% of these patients were successfully weaned from mechanical ventilation within 12 hours of enrollment. Of these 151 patients, 111 were weaned by SIMV, 18 by T-piece and 22 by PS. The total failure rate of 3.3% was not different between weaning methods. There was a difference in the time required to wean, between methods (p < 0.001) (Table 1). More PS patients (41%) required > 24 hours to wean than other methods. Patients requiring longer periods of ventilation prior to weaning were weaned more frequently by PS (p < 0.001)(Table 2).

A failure to wean/extubate rate of 3.3% suggests that respiratory therapists, using institutional approved protocols can safely wean patients from mechanical ventilatory support. Use of the PS protocol appears to results in longer duration of weaning than the other protocols. Patients with a longer duration of ventilation prior to weaning utilized the PS protocol more frequently. Institution of respiratory therapist driven weaning protocols is safe and may reduce time requirements of critical care physicians, increasing their availability for other critical care issues.

Table 1 Duration of Wean (# of patients weaned within specific time intervals)

Hours SIMV T-piece PS

4 64 18 6

8 26 - 4

12 2 - 2

>24 15 - 9

Table 2 Duration of Prior Ventilation (# of patients enrolled)

Time SIMV T-piece PS

12 hrs 39 10 1

24 hrs 33 2 2

48 hrs 17 6 2

< 5 days 12 - 5

>5 days 10 - 12

Reference: OF-96-199

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