Breathing and Awakening Trials Cut Ventilator Complications

Daniel M. Keller, PhD

October 15, 2014

PHILADELPHIA — For patients on a ventilator, daily spontaneous awakening and breathing trials leads to less time on assisted breathing, fewer adverse effects, and fewer days in the intensive care unit and in the hospital, a new study shows.

The Centers for Disease Control and Prevention (CDC) last year replaced its ventilator-associated pneumonia definitions with descriptions of ventilator-associated events because it was hard to determine exactly what was pneumonia.

Still, no one knew if ventilator-associated events were preventable, and so the CDC Prevention Epicenters Wake Up and Breathe Collaborative was born.

"Our objective really was to try to answer that question. Are ventilator-associated events preventable?" Deverick Anderson, MD, from Duke University Medical Center in Durham, North Carolina, asked in his presentation here at IDWeek 2014, where the study was selected as a Society for Healthcare Epidemiology of America featured abstract.

To answer the question, researchers tested the hypothesis that decreasing sedation through daily coordinated spontaneous awakening and breathing trials would prevent events and shorten the time that patients are on ventilators. They used an opt-out protocol led by nurses and respiratory therapists in 12 adult medical, surgical, and cardiac intensive care units (ICUs) in seven hospitals. Eight other units involved surveillance only.

Wake Up and Breathe is a multicenter learning collaborative that uses an all-teach, all-learn model. Each unit had a designated registered nurse, respiratory therapist, and physician champion for the program.

Dr Anderson said the program also involved an improvement advisor to coordinate and motivate the collaborative monthly written reports to the ICUs, monthly collaborative phone calls, and monthly feedback of local and comparative awakening and breathing rates and outcomes.

A flow chart showed the protocol and defined what constituted a success or failure. The study involved 3425 consecutive episodes and 22,991 days in collaborative units and 1739 episodes in surveillance-only units.

"We saw a total of 293 ventilator-associated conditions, including 100 infection-related ventilator-associated complications and 50 pneumonias," Dr Anderson reported.

Spontaneous awakening performance rates started at 30% at the beginning of the collaborative, and rose to about 70% at the end (cumulative odds ratio [OR], 20; P < .001). Spontaneous breathing rates also rose, albeit more modestly, from 55% to 65% (cumulative OR, 3.2; < .001). Spontaneous breathing trials with sedatives went from just over 50% to almost 100% (cumulative OR, 107; P < .001).

The researchers found statistically significant decreases in events, ventilator days, infection-related complications, and mean ICU and hospital days per patient. There was no change in the rate of pneumonias or deaths per 100 episodes, but because fewer events occurred, the lack of changes resulted from a lowering of both the numerator and denominator.

Table. Outcomes of the Wake Up and Breathe Collaborative

Outcome Decrease Relative Risk 95% Confidence Interval P Value
Ventilator-associated events (%) 37.0 0.63 0.42–0.97 .040
Mean ventilator days 2.4 0.71 0.65–0.78 <.001
Ventilator-associated events per 1000 days 0.0 1.09 0.72–1.64 .730
Infection-related complications (%) 65.0 0.35 0.17–0.71 .010
Pneumonias per 100 episodes 0.0 0.51 0.19–1.31 .180
Mean ICU days per patient 3.0 0.78 0.71–0.85 <.001
Hospital days per patient 6.3 0.75 0.68–0.82 <.001
Deaths per 100 episodes 0.0 1.10 0.81–1.41 .650

 

The rate of self-extubations rose from about 1.5 per 100 episodes to about 4.5 per 100 episodes (cumulative OR, 2.1; = .03), but there was no change in the rate of re-intubations (OR, 1.0; P = .86). Dr Anderson noted these data are consistent with the use of previous protocols.

Limitations of the study are that it was not randomized, in that units volunteered to participate, it was open-label, and there were no control subjects.

Dr Anderson concluded that the collaborative was successful in achieving increased rates of awakening and breathing trials, and that the intervention was successful in decreasing the duration of ventilation by more than 2 days, events by 37%, ICU stays by 3 days, and hospital stays by 6 days.

Sean Berenholtz, MD, from Johns Hopkins University School of Medicine, told Medscape Medical News that the field has evolved over the past 5 years "in a very good way, as increasing pressures for public reporting and improving quality continued and emphasis was placed on reducing ventilator-associated pneumonia." Common strategies included the development of evidence-based bundles, such as the collaborative employed.

Increasing focus is not just on ventilator-associated pneumonia, but on reducing short-term and long-term complications associated with mechanical ventilation, "which could be devastating for patients and their families, with the lifelong disability that can occur from mechanical ventilation and prolonged ICU stays," explained Dr Berenholtz, who was not involved in the study. Some of the near-term complications are adverse events, but long-term cognitive and physical complications can be debilitating.

Dr Anderson has disclosed no relevant financial relationships. Dr Berenholtz reports that he receives grant and contract funding from the National Institutes of Health and the Agency for Healthcare Research and Quality for multistate collaborative projects, focusing on improving care for mechanically ventilated patients.

IDWeek 2014: Abstract 1236. Presented October 10, 2014.

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