Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation.
BACKGROUND
An update of evidence-based guidelines concerning liberation from mechanical ventilation is needed as new evidence has become available. The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have collaborated to provide recommendations to clinicians concerning liberation from the ventilator.


METHODS
Comprehensive evidence syntheses, including meta-analyses, were performed to summarize all available evidence relevant to the guideline panel's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, and the results were summarized in evidence profiles. The evidence syntheses were discussed and recommendations developed and approved by a multidisciplinary committee of experts in mechanical ventilation.


RESULTS
Recommendations for three population, intervention, comparator, outcome (PICO) questions concerning ventilator liberation are presented in this document. The guideline panel considered the balance of desirable (benefits) and undesirable (burdens, adverse effects, costs) consequences, quality of evidence, feasibility, and acceptability of various interventions with respect to the selected questions. Conditional (weak) recommendations were made to use inspiratory pressure augmentation in the initial spontaneous breathing trial (SBT) and to use protocols to minimize sedation for patients ventilated for more than 24 h. A strong recommendation was made to use preventive noninvasive ventilation (NIV) for high-risk patients ventilated for more than 24 h immediately after extubation to improve selected outcomes. The recommendations were limited by the quality of the available evidence.


CONCLUSIONS
The guideline panel provided recommendations for inspiratory pressure augmentation during an initial SBT, protocols minimizing sedation, and preventative NIV, in relation to ventilator liberation.
Henry Ford Health System, Detroit, MI. Electronic address: douelle1@hfhs.org.
Daniel R
DR
Ouellette
CHEST, Glenview, IL.
Sheena
S
Patel
University of Pittsburgh, Pittsburgh, PA.
Timothy D
TD
Girard
University of Kentucky, Lexington, KY.
Peter E
PE
Morris
Division of Pulmonary, Critical Care & Occupational Medicine, University of Iowa, Iowa City, IA.
Gregory A
GA
Schmidt
Froedtert and Medical College of Wisconsin, Milwaukee, WI.
Jonathon D
JD
Truwit
McMaster University, Hamilton, ON, Canada.
Waleed
W
Alhazzani
University of Virginia Health System, Charlottesville, VA.
Suzanne M
SM
Burns
Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA.
Scott K
SK
Epstein
Unidad de Cuidados Intensivos, University Hospital of Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain.
Andres
A
Esteban
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
Eddy
E
Fan
Department of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, CibeRes (CB06/06/0028), University of Barcelona, Barcelona, Spain.
Miguel
M
Ferrer
Maine Medical Center, Portland, ME.
Gilles L
GL
Fraser
Departments of Medicine and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
Michelle Ng
MN
Gong
Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
Catherine L
CL
Hough
Division of Respirology, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, New York, NY.
Sangeeta
S
Mehta
Medical College of Wisconsin, Milwaukee, WI.
Rahul
R
Nanchal
Department of Therapy Services, University of Chicago Medical Center, Chicago, IL.
Amy J
AJ
Pawlik
Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
William D
WD
Schweickert
Virginia Commonwealth University, Richmond, VA.
Curtis N
CN
Sessler
Department of Anaesthesia and Intensive Care Medicine, University of Southern Denmark, Odense, Denmark.
Thomas
T
Strøm
Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
John P
JP
Kress
D000328:Adult; D000368:Aged; D060666:Airway Extubation / Q000379:methods; D016292:Procedural Sedation / Q000379:methods; D003422:Critical Care / Q000379:methods / Q000592:standards; D016638:Critical Illness / Q000628:therapy*; D055416:Evidence-Based Emergency Medicine / Q000379:methods; D006801:Humans; D063087:Noninvasive Ventilation / Q000379:methods; D012121:Respiration, Artificial / Q000379:methods*; D014481:United States; D015300:Ventilator Weaning / Q000379:methods
evidence-based medicine; guidelines; mechanical ventilation