CHEST Guidelines-Liberation From Mechanical Ventilation in Critically Ill Adults - An Official American College of Chest Physicians or American Thoracic Society Clinical Practice Guideline

Liberation From Mechanical Ventilation in Critically Ill Adults - An Official American College of Chest Physicians or American Thoracic Society Clinical Practice Guideline

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The American College of Chest Physicians and the American Thoracic Society released guidelines to help clinicians manage the liberation of critically ill adults from mechanical ventilation. The document addresses three main questions concerning the use of Spontaneous Breathing Trials (SBT), sedation minimization protocols, and the role of Noninvasive Ventilation (NIV) after extubation.

1. <strong>Spontaneous Breathing Trials (SBT)</strong>: For hospitalized patients ventilated over 24 hours, the guideline suggests that the initial SBT should include inspiratory pressure augmentation (5-8 cm H2O), rather than using T-piece or CPAP. This is based on moderate-quality evidence which indicates that using pressure support during SBT increases the likelihood of successful extubation.

2. <strong>Sedation Minimization Protocols</strong>: For patients ventilated for more than 24 hours, the guideline suggests employing protocols to minimize sedation. While the evidence quality here is low, the potential benefits of reduced ICU stay and ventilation duration outweigh possible burdens from sedation minimization.

3. <strong>Noninvasive Ventilation (NIV) Post-Extubation</strong>: A strong recommendation is made for the use of preventative NIV post-extubation in patients at high risk of extubation failure, such as those with hypercapnia or COPD, who have been ventilated for more than 24 hours. Moderate-quality evidence indicates this approach improves extubation success rates and reduces ICU stay.

These guidelines reflect a balance of benefits and burdens and form a basis for clinical decision-making without imposing standard care. While a systematic review and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach informed these guidelines, they may be revised with new evidence. The guideline encourages individualized patient care, acknowledging that unique clinical circumstances might necessitate different approaches.

Keywords

mechanical ventilation

Spontaneous Breathing Trials

sedation minimization

Noninvasive Ventilation

extubation

critically ill adults

clinical guidelines

ICU stay

pressure support

individualized patient care