DOES A WEANING PROTOCOL FACILITATE LIBERATION FROM MECHANICAL VENTILATION IN TRACHEOSTOMIZED BRAIN-INJURED PATIENTS?

INTRODUCTION. Although a life-saving intervention, mechanical ventilation is apt to unwanted side-effects and complications and should be interrupted as soon as possible. In acutely brain-injured patients, delaying weaning and liberation from mechanical ventilation increase the rate of ventilator-associated pneumonia, septic complications, and mortality. In neurologic and neurosurgical intubated patients, a systematic assessment of the patient’s potential to be weaned off the ventilator has been demonstrated to reduce the risk of re- intubation following extubation failure, compared to the sole physician’s clinical judgment. OBJECTIVES. We undertook this multicentre randomized controlled trial to evaluate whether a systematic approach to weaning is superior to the physician’s judgment in pre- venting weaning failure occurring within 48 h, in neurologic patients undergoing mechanical ventilation through a tracheotomic cuffed tube. METHODS. Seventy-six neurosurgical and neurologic tracheotomized patients receiving mechanical ventilation were randomized to receive either protocolized weaning protocol (intervention group, IG) or a liberal weaning process according to the attending physicians’ clinical judgment (control group, CG). Although in this last group the decision was left entirely to the discretion of the physicians, all the information collected and recorded for the IG were also available. The criteria for protocol failure were defined a priori. Patients were considered successfully weaned if they were not reconnected to the ventilator in the following 48 h. RESULTS. We included 38 patients in both groups. The average age of the patients enrolled was 54 ± 15 in IG, and 43 ± 17 in CG (p = 0.001), while the ratio between female and male was 11/27, and 17/21, respectively. The SAPII score at ICU admission was 41 ± 12 for IG, and 36 ± 17 for CG (p = 0.082). On study enrolment, the GCS was 9 ± 1 and 9 ± 2, for IG and CG, respectively (p = 0.14). There was no significant difference with respect to weaning failure (7/38 in IG, 9/38 in CG); the days spent on mechanical ventilation were also no different between the two groups (17 ± 9 and 16 ± 8 days, for IG and CG, p = 0.66, respectively); the overall length of hospital stay was 22 ± 8 days in IG and 23 ± 9 days in CG (p = 0.64). CONCLUSIONS. In tracheotomized brain-injured patients receiving mechanical ventilation arranging physiologic and clinical data in a systematic fashion by means of a written flow chart does not offer any advantage, as opposed to the sole clinical judgement.