Key Points
➤ Mechanical ventilation is a life-saving intervention, but it is also
associated with complications. Therefore, it is desirable to liberate
patients from mechanical ventilation as soon as the underlying cause
that led to the mechanical ventilation has sufficiently improved and
the patient is able to sustain spontaneous breathing and adequate
gas exchange.
➤ These clinical practice guidelines provide recommendations regarding
seven management strategies that have been shown to improve
outcomes for acutely hospitalized adults who are mechanically
ventilated >24 hours.
Recommendations
➤ For acutely hospitalized patients ventilated >24 hours, the ATS and
CHEST suggest that the initial SBT be conducted with inspiratory
pressure augmentation (5–8 cm H
2
O) rather than without (T-piece
or CPAP). (Conditional recommendation, moderate certainty in the
evidence)
• Remark: This recommendation relates to how to conduct the initial SBT but
does not inform how to ventilate patients between unsuccessful SBTs.
➤ For acutely hospitalized patients ventilated for >24 hours, the ATS and
CHEST suggest protocols attempting to minimize sedation. (Conditional
recommendation, low certainty in the evidence)
• Remark: There is insufficient evidence to recommend any protocol over another.
➤ For patients at high risk for extubation failure who have been receiving
mechanical ventilation for >24 hours, and who have passed an SBT, the
ATS and CHEST recommend extubation to preventative NIV.
(Strong recommendation, moderate certainty in the evidence)
• Remark: Patients at high risk for failure of extubation may include those patients
with hypercapnia, chronic obstructive pulmonary disease (COPD), congestive
heart failure (CHF), or other serious co-morbidities. Physicians may choose to
avoid extubation to NIV in selected patients for patient-specific factors including
but not limited to the inability to receive ventilation through a mask or similar
interface. Physicians who choose to use NIV should apply such treatment
immediately after extubation to realize the outcome benefits.
