Study Evaluates Approaches for Weaning Patients With Tracheostomy From Long-Term Ventilator Support
EMBARGOED FOR EARLY RELEASE: 12:55 P.M. (CT) TUESDAY, JANUARY 22, 2013
Media Advisory: To contact Amal Jubran, M.D., call Maureen Dyman at 708-202-5627 or email Maureen.Dyman@va.gov.
CHICAGO – Among patients with a tracheostomy requiring prolonged mechanical ventilation and treated at a single long-term care facility, unassisted breathing using an oxygen delivery device connected to a tracheostomy collar, compared with using a method known as pressure support, resulted in earlier weaning (gradually decreasing dependence on assisted ventilation), although there was no difference between the methods in patient survival at 6 and 12 months, according to a JAMA study published online. The study is being released early to coincide with its presentation at the Society of Critical Care Medicine’s 42nd Critical Care Congress.
“Patients requiring prolonged mechanical ventilation, defined as more than 21 days, account for more than 13 percent of ventilated patients and 37 percent of intensive care unit (ICU) costs. Because of changes in U.S. reimbursement practices, these patients are usually transferred to centers that specialize in weaning, also known as long-term acute care hospitals (LTACHs). The number of LTACHs increased from 192 to 408 between 1997 and 2006, and costs increased by 267 percent, reaching $1.3 billion in 2006,” according to background information in the article. The number of ICU patients transferred to LTACHs for weaning from prolonged ventilation is expected to increase substantially. “The most effective method of weaning such patients has not been investigated.”
Amal Jubran, M.D., of the Edward Hines Jr. Veterans Affairs Hospital, Hines, IL., and colleagues conducted a study to compare the length of time required for weaning from prolonged ventilation with pressure support vs. unassisted breathing through an oxygen-delivery device connected to a tracheostomy collar (holds the tracheostomy tube in place). Pressure support is mechanical ventilatory assistance in which the ventilator provides support for each breath using a preset amount of pressure. Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH (RML Specialty Hospital, Hinsdale, IL.) for weaning from prolonged ventilation. Of 500 patients who underwent a 5-day screening procedure, 316 did not tolerate the procedure and were randomly assigned to receive weaning with pressure support (n = 155) or a tracheostomy collar (n = 161). Survival at 6- and 12-month time points was also determined.
Of 316 patients, 4 were withdrawn and not included in analysis. Of 152 patients in the pressure-support group, 68 (44.7 percent) were weaned; 22 (14.5 percent) died. Of 160 patients in the tracheostomy collar group, 85 (53.1 percent) were weaned; 16 (10.0 percent) died. Among the entire group of randomized patients, median (midpoint) weaning time was shorter with tracheostomy collar use than with pressure support: 15 days vs. 19 days. Among patients who completed the study (n = 194), median weaning time was shorter with tracheostomy collar use than with pressure support: 13 days vs. 19 days.
The researchers also found there was no significant difference in mortality between the pressure-support group vs. the tracheostomy collar group at 6 months (55.92 percent vs. 51.25 percent) and 12 months (66.45 percent vs. 60.00 percent). Frequency of adverse events (new episode of pneumonia, arrhythmias, pneumothorax) was similar in the 2 groups.
“This study has 3 major findings. First, tracheostomy collar use resulted in earlier weaning than did pressure support in patients who required prolonged mechanical ventilation. Second, the influence of weaning method on rate of successful weaning was related to time taken to fail the screening procedure: weaning was faster with tracheostomy collar use than with pressure support in the late-failure group but not in the early-failure group. Third, mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 and 12 months,” the authors write.
(doi:10.1001/jama.2013.159; Available pre-embargo to the media at http://media.jamanetwork.com)
Editor’s Note: This work was supported by funding from the National Institute of Nursing Research. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Tobin declares receipt of royalties from McGraw-Hill for 2 books published on critical care medicine. The other authors report no disclosures.
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