de intensivist

Teaser : Ontwenning van beademing is een belangrijke mijlpaal in de zorg voor IC-patiënten. Deze nationale survey onder 69 IC's onderzocht praktijkvariatie in ontwenning van beademing in Nederland. De aanpak van Trial Spontaan Ademen, post-extubatie ondersteuning en falende ontwenning worden in detail beschreven.

Background: Weaning patients from invasive mechanical ventilation (IMV) is one of the major goals in care for critically ill patients. Despite its importance there is a lack of consensus on identification of weaning-eligible patients. Diffusion and implementation of guideline recommendations appear to vary among critical care professionals (1). Moreover the COVID-19 pandemic and numerous relevant publications have renewed focus on optimizing weaning. The aim of this nationwide survey study was to evaluate current weaning practice and its variation in the Netherlands.

Methods: We conducted a cross-sectional survey among ICU physicians and ventilation practitioners in all ICU-facilitated hospitals in the Netherlands. The survey design was based on rigorous survey methodology (2) and was endorsed by the Dutch Association of Intensive Care (NVIC).  It encompassed five major components of weaning practice: switch from control to support ventilation, the spontaneous breathing trial (SBT), post-extubation support, tracheostomy, and failure-to-wean. In this abstract we focus on results on protocol availability, SBT, post-extubation support and weaning failure assessment.

Results: Sixty-nine out of 71 ICUs were represented by 63 intensivists and 6 ventilation practitioners. Sixty-four (92.8%) hospitals had a protocol available for weaning for mechanical ventilation, 61 (88.4%) for the SBT, and 32 (46.4%) for post-extubation respiratory support. Twenty-five percent reported to always perform an SBT prior to extubation. The T-piece SBT is used by 50% of ICUs. The SBT duration most commonly reported was 30 minutes (80%), followed by <30 minutes (28%), 60 minutes (25%) and >90 minutes (2%)(Figure 1).

Conventional oxygen therapy (COT) is most frequently used in the post-extubation phase in general, and in obese patients (Table 1). Non-invasive ventilation (NIV) is applied most frequently as post-extubation support in patients intubated for COPD (29%) and heart failure (19%). The most common indication for post-extubation support with NIV and high-flow nasal oxygen (HFNO) is to treat post-extubation failure (15 and 45%, respectively). NIV and HFNO is less frequently used to facilitate early extubation (5% and  31%). In patients failing weaning attempts delirium screening and tapering sedatives are the most frequently performed strategies (85%), followed by cardiac (63%) and pulmonary ultrasound (62%).

Discussion: Our nationwide survey highlights practice variation during weaning across Dutch ICUs. SBT duration and methodology varies substantially. HFNO and NIV are most commonly used for therapeutic purposes and much less to facilitate early extubation. The observed practice variation and deviation from guideline recommendations, may serve as guidance for future guideline content and implementation strategies to optimize weaning care.