Ventilator discontinuation protocols.

Mechanical ventilation is a life-saving supportive therapy, but it can also cause lung injury, diaphragmatic dysfunction, and lung infection. Ventilator liberation should be attempted as soon as clinically indicated, to minimize morbidity and mortality. The most effective method of liberation follows a systematic approach that includes a daily assessment of weaning readiness, in conjunction with interruption of sedation infusions and spontaneous breathing trials. Protocols and checklists are decision support tools that help ensure consistent application of key elements of evidence-based practice. A majority of studies of weaning protocols applied by non-physician healthcare providers suggest faster weaning and shorter duration of ventilation and ICU stay, and some suggest reduced failed extubation and ventilator-associated pneumonia rates. Checklists can be used to reinforce application of the protocol, or possibly in lieu of one, particularly in environments where the caregiver-to-patient ratio is high and clinicians are well versed in and dedicated to applying evidence-based care. There is support for integrating best-evidence rules for weaning into the mechanical ventilator so that a substantial portion of the weaning process can be automated, which may be most effective in environments with low caregiver-to-patient ratios or those in which it is challenging to consistently apply evidence-based care. This paper reviews evidence for ventilator liberation protocols and discusses issues of implementation and ongoing monitoring.

Airway clearance applications in the elderly and in patients with neurologic or neuromuscular compromise.

Respiratory compromise is the leading cause of morbidity and mortality in patients with neuromuscular and neurologic disease, and in elderly patients, who have a reduced pulmonary reserve from deterioration of the respiratory system associated with the normal aging process. Although the otherwise healthy older patient is normally asymptomatic, their pulmonary reserve is further compromised during stressful situations such as surgery, pneumonia, or exacerbation of a comorbid condition. The inability to effectively remove retained secretions and prevent aspiration contribute to this compromise. Although no secretion-management therapies are identified as having specific application to the elderly, clinicians must be attentive and understand the needs of the elderly to prevent the development of respiratory compromise. Patients with neuromuscular disease often can not generate an effective cough to mobilize and evacuate secretions. Respiratory muscle training, manual cough assistance, mechanical cough assistance, high-frequency chest wall compression, and intrapulmonary percussive ventilation have each been suggested as having potential benefit in this population. Although strong evidence supporting the benefit of these therapies is lacking, clinicians must be guided as to whether there is a pathophysiologic rationale for applying the therapy, whether adverse effects are associated with the therapy, the cost of therapy, and whether the patient prefers a given therapy.