Critically ill adult patients admitted in intensive care units (ICU) require assistance in the form of mechanical ventilation to meet the body’s oxygen demand. However, the discontinuity involved in mechanical ventilation, the process known as weaning often contributes to clinical complications leading to mortality in patients who are weak in breathing. Weaning protocols have been devised and applied in various formats in units. But, there is no concrete information on the advantage offered by the protocolised and nonprotocolised weaning approaches in reducing the patient’s ventilator days and length of stay. Therefore, the main objective of the study is to carry out a literature review to find significant information on the protocols. Databases were searched like Pubmed, Cochrane using the key words like ‘mechanical ventilation, weaning protocol, non-weaning protocol, adult patients in ICU’s, protocolised and non protocolised weaning. Studies included, reviews, randomized control trials in patients with conditions like respiratory, cardiovascular and pulmonary ailments.
It was found that protocolised weaning had superiority over non protocolised weaning.
Significantly, several factors have influenced the success of weaning protocol like nurse/ health care professional’s roles, awareness, confidence, assessment, psychology and the overall inter unit-interactions. Nurse driven sedation practice has influenced the weaning protocol. Computer technology has brought several modifications to weaning protocol. It was revealed that the most of the protocols on weaning are regularly in use and standardized in many units. This led to their gradual up gradation and preference compared to non-protocolised weaning. Non-protcolised weaning found to suffer a huge paucity in the significant contribution to the reduction of ventilation and length of stay. It can be concluded that literature review has furnished better insight on the protocolised weaning in an evidence based practice approach.
Health care strategies aimed at the betterment of mankind involve a lot of support from several corners. Regardless of age and sex, the service executed for a given patient relies mostly on the utility of specific devices that play an influential role. Very often, the severity of a medical ailment determines the care to be provided to the patient. Especially, in intensive care units multiple devices are equipped to render instant help to the patient in emergency condition. This task appears complicated with the aged adult patients who require certain assistance in the form of mechanical ventilation. Patients need mechanical ventilation for several reasons and for variations in time periods which may be hours, weeks, months and years. In fact, mechanical ventilation is recommended when the oxygen demand is not met by the body through natural breathing or when the carbon dioxide (CO2) is not sufficiently eliminated by the body. Several conditions can contribute to an increasing demand of oxygen.
Various conditions can increase the oxygen demand, like aberrations of cardiovascular system, neuromuscular disease, and respiratory system. So this procedure is meant to give sufficient ventillatory assistance to meet the oxygen demand of patient in a harmless fashion. The delivery of ventilation is carried out through airway of artificial nature like a surgically placed tracheostomy tube or an oral or nasal endotracheal tube (Pruitt Bill, 2006). Under some circumstances, the process of mechanical ventilation is discontinued which is known as weaning. This process often leads to adverse consequences like high rat of mortality. The recognition of a patient who is ready to breathe independently without mechanical ventilation is a determining factor in the care.
Therefore, the purpose of the description is to provide a review of mechanical ventilation with and without weaning protocol in adult patients and its effect on length of stay in intensive care units (ICU) (Blackwood et al., 2011).
In detail, in the care of severely ill and injured patients, the use of Mechanical ventilation (MV) is considered as a vital component. But weaning from the process of MV induces a task in intensive care units (ICUs). This is because a small hindrance in weaning can lead to rise in the complication number at a high rate. Although, nursing oriented protocol has made the concept of weaning famous, the process is not used properly. Discrepancies were recognized between the available and utilized time for weaning. They revealed a significant delay between the available and utilized time for weaning. The factor contributing was the role of intensive care nurses in making use of available time for weaning (Hansen et al., 2008).This indicated the role of nurses awareness on weaning protocol and understanding the patients critical conditions.
So, weaning protocol may rely on more number of factors to be considered for the efficient care of adult patients in ICU’s.In a qualitative study involving semi-structured interviews, six important themes were identified that could impact nurses choice on weaning. These are education, confidence, nurse’s experience, clinical reassessment and decision making, and physiological influences. Patients on weaning from mechanical ventilation require a complex nature of care and decisions of critical care (Lavelle & Dowling,2011).
Thus, the dependence on weaning protocol has firm connection not only with patients condition but also on the health care professionals and nurses decision. There was a gradual attention on the utility of mechanical ventilation in a protocol based and non protocol based standards. Efficacy of mechanical ventilation and novel approaches designed without the interference of mechanical could be better assessed through comparisons and contrast studies from several perspectives.
Protocol driven management of ventilated patients in experimental trials have not proven significant in reducing the mechanical ventilation and length of stay in ICU’s when compared with non protocol based local management. This was attributed to the responsibility of staff nurse in several forms of ventilatory practice (Bucknall, Manias & Presneill,2008). It may be inferred that the presence or absence of a given weaning protocol may influence the duration of patients stay in the hospital which n turn is largely dependant on the nurse’s role. However, it is important to note that patients who face difficult situation with weaning protocols need a longer duration of stay which s associated with higher morbidity and mortality. Attempts are still underway to minimize the weaning time to lessen the ventilation duration and the relevant complications. This could be due to the fact that there is a huge variation in protocol composition and execution in several settings by different healthcare professionals (Blackwood et al., 2009 a).
To investigate further, a collaborative study was carried out in various nations like America, Europe and Australia on 1971 severely ill patients. The ICU’s indicated that the patients had head injuries, trauma and following major surgery, breathing difficulties and heart ailments. The investigation was split into 11 studies, where eight had adhere to protocol standards to minimize the support of ventilator and three had depended on programmed computers on a protocol without ventilator support.
The findings indicate that there was a 25 % reduction in time spent in ICU’s and the weaning duration was also lessened by 78% with a length of stay reduction by 10%.
It may again indicate that practice methodology adopted like protocol changes, the eligibility conditions for beginning the weaning, types of implementation like computers or professionals, patients medical conditions and the general weaning practice have led to a minimized patient stay duration in ICU’S(Blackwood et al., 2011b). So, a weaning protocol compared to a non weaning protocol affects ventilator days during ICU length of stay through various factors mentioned above.
The advent of computer technology has brought forward an improvement in mechanical support adaptation to the patient requirements. This is because from the automated weaning studies conducted earlier, it was revealed that computers could assess the variations in ventilation, predict real time real-time physiological changes and facilitate ventilation adaptation to the corresponding changes (Stahl et al., 2009). In contrast, the efficacy of non-protocolized weaning is still not proven completely in their potential to reduce the mechanical ventilation duration. The use of protocolized weaning has achieved a stage that it has become a common practice in many hospitals.
Moreover, a sort of variable practice was observed in ICU’s of surgical/trauma and medical departments. Here, an absence of reliable approach to weaning was observed in medical unit compared to surgical unit that has ventilator management standardised approach (Marelich et al., 2000).The lack of reduction in mechanical ventilation could be due to ICU’s usual practice that involved weaning assessment by critical care nurses who are professionals. Hence, an association clinical outcomes and critical care nurses could play a role in the weaning practice and its implementation as described previously. This may encompass 24 hour medical staff with a 1:1 nurse to patient ratio and an intensivist led rounds twice daily in the hospital (Rose et al., 2008)
Weaning protocol was found to be more influential in reducing the length of stay when there was potential staffing of medical personnel, which also influenced reduced mortality in ICU and hospital (Pronovost et al., 2002).
Similarly, increased patient to doctor ratios have been significantly connected to increased proportions of success of weaning and discharge at home in patients who were on continued mechanical ventilation on non-protocol pattern (Polverino et al., 2010).The instances cited above indicate a standardized high level approaches to weaning in units that having work culture in an organized manner and context that assist trained hospital staff. Under these circumstances, the utility of weaning protocols may get much benefit. This may shed light on the success of already existing weaning protocols currently in use in hospitals and their superiority over non standardized or non protocol based approaches.
Nursing interventions applied for the modulation of weaning protocol and looking for gradual adaption of patients in ICU’s to that approach may reflect a theory known as Adaptation Theory. This theory describes adaptation as the adjustment of living beings / things to environmental conditions. It is a spontaneously occurring process which influences variations, interactions and responses. According to this theory, human adaptation may occur at the level of internal (self ) social (others) and the physical ( biochemical reactions) (Nursing Theories, 2012). For example, a weaning protocol is better influenced by sedation practice which in turn effects the duration of ventilation and length of patients ‘stay nursing driven protocols (Rivera et al., 2008). Here, adjusted experimentation was applied for the use of sedatives and analgesics using an algorithm-based. In a heterogeneous patient group on mechanical ventilation, this strategy may likely to enhance the feasibility of extubation (Rivera et al., 2008).
Sedative agents used for this purpose has reflected their pharmacological properties and importance. In the hospital and intensive care unit, small time periods of ventilation and length of stay were related to administration of sedative agents in moderate doses and analgesics rather than breaks in sedation daily and subsequent weaning assessments (Kress et al., 2000).In contrast, protocols that did not involve sedation led patients to spend more number of days significantly without ventilation than those who received sedation breaks on a daily schedule (Strom, Martinussen & Toft, 2010).
Therefore, it is reasonable to mention that nurse care of adult patients in ICUs may have a firm link with the nursing theory of Adaptation. More probably, the goal of nurses is to predict a change in the care environment that has a patient and his or her health as the main components. The standard weaning protocols that have become usual and common in units have a mandatory change and adaptation oriented nurse care factor, as observed in content described here and also in the literature reviews. So, non-weaning protocols may have a poor significant outcome compared to weaning protocol which is constantly being focused with changes and updates for novel insights.
In view of the above mentioned information, it can be summarized that adult patient’s ventilation duration and length of stay are largely influenced by the use of weaning protocol in intensive care unit. Protocol based weaning has superiority over non protocol based weaning due to the regular standardized application of weaning protocol as an objective criteria for determining weaning readiness and a monitored approach to lessen the support. Likewise, decreased length of stay in ICU’s is due to lessened mechanical ventilation. This could lead to low need for tracheostomy requirements.
Several factors have influenced the weaning protocol in ICU’s during care delivery to adult patients. These may include educational awareness confidence, expertise of nurses, assessment in clinical decision making and psychology.
The staffing of doctors, nurses, nurse /or doctor to patient ratio, continuous availability have also influenced the weaning protocol implementation and duration of stay.
The complexity involved in weaning process is not easily understood which is leading to heterogeneity accompanied by variations. Discrepancies in results do exist and are attributed to adverse events, quality of life, mortality, quality of life etc. (Blackwood et al., 2009). Attempts to evaluate the influence of different patient population on mechanical ventilation duration by focusing on ICU types have become essential. But not all studies are providing the significant results due to the fact that certain units are of mixed type and involve trauma, neurosurgical, surgical and medical units (Blackwood et al., 2011a).
The weaning protocol and its effect on duration is also influenced by population of patients. Non protocol based approaches receive poor appreciation due to the paucity of studies and relevant significant information in care implementation. This made it inferior and become less reliable compared to protocol based approaches. Constant focus on the standard protocol in use has become usual in many units. Hence, the intervention of computer technology has brought forward many changes in the existing weaning protocol in regular use compared to the non-protocol. Well organized and structural formats in weaning protocol applied were efficient in offering the care. Use of sedative agents by nurse driven protocols has contributed to the reduced ventilation and length of stay. This approach reflected adaptation theory of nurses which emphasizes on the living being’s adaptation to changes in the environment.
Overall, database search has yielded significant information for the health care professionals to implement novel changes in an evidence based practice approach.
References
Blackwood, B, Alderdice, F. Burns, K., Cardwel, C., Lavery, G., & Halloran, P. O.(2011a). Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis.BMJ, 342,c7237.
Blackwood, B., Alderdice, F., Burns, K., Cardwel, C., Lavery, G. & Halloran, P. O.(2011b). Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev,7,CD006904.
Blackwood, B., Alderdice, F., Burns, K.E., Cardwell, C.R., Lavery, G.G.,& Halloran P.O.(2009). Protocolized vs. non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients: Cochrane review protocol.J Adv Nurs,65(5), 957-64.
Bucknall, T.K., Manias, E., & Presneill, J.J. (2008). A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Crit Care Med,36(5),1444-50.
Hansen, B.S., Fjaelberg, W.T., Nilsen, O.B., Lossius, H.M., & Søreide, E. (2008). Mechanical ventilation in the ICU–is there a gap between the time available and time used for nurse-led weaning? Scand J Trauma Resusc Emerg Med, 16(17).
Kress, J.P., Pohlman, A.S., Connor, M.F., Hall, J.B.(2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med, 342, 1471-7.
Lavelle, C.,& Dowling, M. (2011). The factors which influence nurses when weaning patients from mechanical ventilation: findings from a qualitative study. Intensive Crit Care Nurs,27(5),244-52.
Marelich, G.P., Murin, S., Battistella, F., Inciardi, J., Vierra, T., Roby, M. (2000). Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest,118,459-67.
Nursing Theories: An Overview.(2012). Web.
Polverino, E., Nava, S., Ferrer, M., Ceriana, P., Clini, E., Spada, E, et al. (2010). Patients’ characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units. Intensive Care Med,36,137-42
Pronovost, P.J., Angus, D.C., Dorman, T., Robinson, K.A., Dremsizov, T.T., Young, T.L. (2002). Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA, 288, 2151-62.
Pruitt, B. (2006). Weaning patients from mechanical ventilation. Nursing, 36 (9), 36-41.
Rose, L., Presneill, J.J., Johnston, L., Cade, J.F. (2008) A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartCare TM/PS. Intensive Care Med,34,1788.
Stahl, C., Dahmen, G., Ziegler, A., & Muhl, E. (2009).Comparisonof automated protocol-based versus non-protocol-based physician-directed weaning from mechanical ventilation. Intensivmedizin und Notfallmedizin,46(6), 441–6.
Strom,T., Martinussen,T., Toft,P.(2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet, 375,475-80.