Improved extubation rates and earlier liberation from mechanical ventilation with implementation of a daily spontaneous-breathing trial protocol.

BACKGROUND: Daily spontaneous-breathing trials (SBTs) are promulgated as the best method for assessing readiness for discontinuation of mechanical ventilation. SBT protocols have also been shown to improve outcomes as opposed to wild-type implementation of daily SBT recommendations. Here we determine whether implementation of a mandatory, protocol-driven daily SBT on all ventilated patients in the ICU improves extubation rates and accelerates liberation from mechanical ventilation.

STUDY DESIGN: A daily 30-minute SBT protocol was introduced into an academic surgical ICU in July 2005 and followed through September 2006. Decisions about next steps (continued mechanical support versus liberation) after each trial were recorded. Owing to the low liberation rate, physicians began (in January 2006) recording the reasons for continuing mechanical ventilation after a passing SBT. Differences in patient outcomes were compared for the first and last 8 weeks of the study period, corresponding to similar times in the academic and calendar years.

RESULTS: Four hundred eighty-eight patients experienced 547 mechanical ventilation episodes from July 2005 to September 2006. A total of 2,835 safety evaluations for SBTs were completed. Rate of extubations of passing patients after the first 8 weeks of implementation (n = 73 patients) was 27% (35 extubations of 131 passed trials). This rate improved in the last 8 weeks to 42% (42 of 101) (p < 0.02) (n = 57 patients). Reintubation rate was similar at 6% for the first 8 weeks and 8% for the final 8 weeks (p = 0.65), including self-extubations.

CONCLUSIONS: Implementation of a daily SBT protocol resulted in improvement of extubation rates during the year of implementation without a change in the reintubation rate. Requesting that physicians enumerate reasons for continuing mechanical ventilation in the face of a passing breathing trial was associated with a sustained improvement in extubation rate.