Use of a tracheostomy collar is more effective than a technique that reduces positive airway pressure delivered to the lungs in helping patients regain the ability to breathe on their own after more than 21 days on a ventilator, according to a study.
The research — funded by the National Institute of Nursing Research, part of the National Institutes of Health — compared two common methods for weaning such patients from a ventilator. One is to use a tracheostomy collar, which is placed over a breathing tube in a tracheotomy incision in the throat and through which humidified oxygen is given. The other is to reduce the pressure support supplied via the ventilator.
The study found tracheostomy collars significantly outperformed the pressure support method in helping patients breathe on their own again. Researchers examined data on patients in long-term acute care hospitals, where such patients increasingly are being sent from ICUs. The study found the median weaning time among the 194 study participants in an LTACH was six days shorter with tracheostomy collar use.
"By contributing the evidence base for weaning from machine-assisted breathing, this study will help improve the quality of life for patients on ventilators by helping them regain their ability to breathe on their own more quickly," NINR Director Patricia Grady, RN, PhD, FAAN, said in a news release.
"Clinicians also benefit from patient-centered data — which nursing science studies such as this are providing — to develop the most effective guidelines for common procedures such as weaning."
Use of LTACHs for weaning increased 267% between 1997 and 2006. Yet the relative efficacy of these two weaning methods within the LTACH setting has received little or no scrutiny, according to the news release.
The study was led by Amal Jubran, MD, from Edward Hines Jr. Veterans Affairs Hospital in Hines, Ill., RML Specialty Hospital in Hinsdale, Ill., and Loyola University of Chicago Stritch School of Medicine in Maywood, Ill. Jubran and colleagues used a five-day unassisted breathing screening procedure to select participants from among 500 patients enrolled for the study. They selected and randomized 312 patients, with 194 completing the study (118 died or withdrew, but were included in the analysis).
Participants were divided into an early-failure group (0 to 12 hours) or a late-failure group (12 to 120 hours) based on the time they took to fail the screening procedure. They then were randomly assigned to pressure support or a tracheostomy collar for weaning. Successful weaning for both groups was defined as the ability to sustain five days of unassisted breathing.
"The results of the study show that the method of ventilator weaning can significantly improve the outcome of study patients who require prolonged mechanical ventilation at an LTACH facility," Jubran said in the news release.
The researchers found a difference in weaning rates based on the time a patient had taken to fail the screening procedure, with the late-failure group weaning 2.2 times faster with the tracheostomy collar than with pressure support. There was no significant difference in weaning rates between the two techniques for the early-failure group.
"Severity of illness may have had a greater influence on weaning outcome for this group than did weaning method," Jubran noted.
The researchers discovered several clinical variables associated with the time required for successful weaning, in addition to weaning technique: age, ventilator duration before randomizing, the ratio of how fast and deep a patient could breathe and the strength of a patient?s ability to inhale.
The data also indicated that some patients could have been weaned at the ICU, avoiding the need for transfer to the LTACH, since more than 32% of the 500 enrollees passed the five-day unassisted breathing challenge.
The study is scheduled for publication in the Journal of the American Medical Association. The study abstract is available at http://jama.jamanetwork.com/article.aspx?articleid=1558054.
The mission of the NINR is to support basic and clinical research that develops the knowledge to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and enhance end-of-life and palliative care. For more information, visit http://www.ninr.nih.gov.
