EFFECT ON THE DURATION OF MECHANICAL VENTILATION OF IDENTIFYING PATIENTS CAPABLE OF BREATHING SPONTANEOUSLY

Background Prompt recognition of the reversal of respiratory failure m ay permit earlier discontinuation of mechanical ventilation, without h arm to the patient. Methods We conducted a randomized, controlled tria l in 300 adult patients receiving mechanical ventilation in medical an d coronary intensive care units. In the intervention group, patients u nderwent daily screening of respiratory function by physicians, respir atory therapists, and nurses to identify those possibly capable of bre athing spontaneously; successful tests were followed by two-hour trial s of spontaneous breathing in those who met the criteria. Physicians w ere notified when their patients successfully completed the trials of spontaneous breathing. The control subjects had daily screening but no other interventions. In both groups, all clinical decisions, includin g the decision to discontinue mechanical ventilation, were made by the attending physicians. Results Although the 149 patients randomly assi gned to the intervention group had more severe disease, they received mechanical ventilation for a median of 4.5 days, as compared with 6 da ys in the 151 patients in the control group (P=0.003). The median inte rval between the time a patient met the screening criteria and the dis continuation of mechanical ventilation was one day in the intervention group and three days in the control group (P<0.001). Complications - removal of the breathing tube by the patient, reintubation, tracheosto my, and mechanical ventilation for more than 21 days - occurred in 20 percent of the intervention group and 41 percent of the control group (P=0.001). The number of days of intensive care and hospital care was similar in the two groups. Total costs for the intensive care unit wer e lower in the intervention group (median, $15,740, vs. $20,890 in the controls; P=0.03); hospital costs were lower, though not significantl y so (median, $26,229 and $29,048, respectively; P=0.3). Conclusions D aily screening of the respiratory function of adults receiving mechani cal ventilation, followed by trials of spontaneous breathing in approp riate patients and notification of their physicians when the trials we re successful, can reduce the duration of mechanical ventilation and t he cost of intensive care and is associated with fewer complications t han usual care.