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FAARC. Reprinted with permission from Chest (Chest 2001;120(6)375–395). © American College of Chest Physicians. Copies can be ordered from the American College of Chest Physicians, at 1-800-343-2227 or 1-847-498- 1400. www.chestjournal.org. Correspondence: Neil R MacIntyre MD FAARC, Respiratory Care Services, Duke University Medical Center, Box 3911, Durham NC 27710. E-mail: neil.macintyre@duke.edu. RESPIRATORY CARE • JANUARY 2002 VOL 47 NO 1 69 tients need prompt discontinuation and which need continued ventilatory support. Third, ventilator management strategies for stable/recovering patients who still require some level of ventilatory support need to be employed. These strategies need to minimize both complications and resource consumption. Fourth, extended management plans (including tracheotomy and long-term ventilator facilities) need to be considered for the long-term ventilator-dependent patient. To address many of these issues, the Agency for Healthcare Policy and Research (AHCPR) charged the McMaster University Evidence Based Practice Center to do a comprehensive evidence-based review of many of the issues involved in ventilator weaning/discontinuation. Led by Deborah Cook MD, an exhaustive review of several thousand articles in the world literature resulted in a comprehensive assessment of the state of the literature in 1999.4 At the same time, the American College of Chest Physicians (ACCP), the Society for Critical Care Medicine (SCCM), and the American Association for Respiratory Care (AARC) formed a task force to produce evidencebased clinical practice guidelines for managing the ventilator-dependent patient during the discontinuation process. The charge of this task force was to utilize the McMaster AHCPR report as well as their own literature review to address the following 5 issues: (1) the pathophysiology of ventilator dependence; (2) the criteria for identifying patients who are capable of ventilator discontinuation; (3) ventilator management strategies to maximize discontinuation potential; (4) the role of tracheotomy; and (5) the role of long-term facilities. Review/writing teams were formed for each of these issues. From these evidence-based reviews, a series of recommendations were developed by the task force, which are the basis of this report. Each recommendation is followed by a review of the supporting evidence, including an assessment of the strength of the evidence (Table 1). As there were many areas in which evidence was weak or absent, the expert opinion of the task force was relied on to “fill in the gaps.” Consensus was reached, first, by team discussions and, later, through the repeated cycling of the draft through all members of the task force. Both the McMaster AHCPR group and the task force recognized the needs for the future. These include more randomized controlled trials to look at a number of issues. Among the more important questions that need answering are the following: (1) Which criteria are the best indicators of reversal of respiratory failure in the screening process? (2) What factors are involved in ventilator dependence and which measurement techniques are most useful in determining ultimate success in the discontinuation process? (3) In balancing discontinuation aggressiveness against the risks of premature discontinuation, what is a reasonable reintubation rate in patients recently removed from ventilatory support? (4) What is the value of trying to reduce levels of partial ventilator support in stable/recovering patients who have failed a discontinuation assessment? (5) What role do tracheotomies have in facilitating the discontinuation process? (6) What is the role of the long-term facility, and when should patients be transferred to such facilities? Pathophysiology of Ventilator Dependence Introduction Patients require mechanical ventilatory support when the ventilatory and/or gas exchange capabilities of their respiratory system fail. This failure can be the result of processes both within the lung as well as in other organ systems, most notably the central nervous and the cardiovascular systems. Although patients may be dependent on ventilatory support for brief periods of
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