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receiving mechanical ventilation can be achieved. For example, in a randomized controlled trial173 of a nursing-implemented sedation protocol for 321 patients receiving mechanical ventilation, the use of the protocol was associated with a 50% reduction in the duration of mechanical ventilation and 2-day and 3-day reductions in the median ICU and lengths of hospital stay, respectively (all p values 0.01). More recently, Kress et al174 published the results of a randomized controlled trial of 128 patients showing that a daily spontaneous awakening trial was associated with 2 days fewer spent receiving mechanical ventilation (p 0.004) and a 3-day shorter ICU stay (p 0.02). The data do not support endorsing any one ventilator discontinuation protocol, and the choice of a specific protocol is best left to the individual institution. In designing these protocols, consideration should be given to other recommendations in this document as well as to the specific patient populations. For instance, medical patients with severe lung injury might benefit from one type of management strategy (see recommendations 2 to 5), whereas surgical patients recovering from anesthesia might benefit from another strategy (see recommendation 7). In the context of emerging data about the benefits of NPPV159,160 and the substantial roles of HCPs in providing this treatment, there should be efforts made to develop HCP-driven protocols for this modality. While each institution must customize the protocols to local practice, there are important general concepts that may ease the process of implementation and enhance success. First, protocols should not be used to replace clinical judgment, but rather to complement it. Protocols are meant as guides and can serve as the general default management decision unless the managing clinician can justify a departure from the protocol.
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