Tracheostomy collar yields faster long-term ventilation weaning

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.

SAN JUAN, P.R. – Patients on prolonged ventilation who had previously failed a 5-day breathing challenge were weaned more rapidly off ventilators when a tracheostomy collar rather than pressure support was used, Dr. Amal Jubran reported.

Among 312 patients on prolonged ventilation (more than 21 days) transferred to a long-term acute care hospital, the median weaning time with unassisted breathing through tracheostomy collars was 4 days shorter than when pressure support was used as the weaning method, said Dr. Jubran of the division of pulmonary and critical care medicine at the Edward Hines Jr. VA Hospital in Hines, Ill.

"The method of ventilator weaning significantly improves the outcome of patients who require prolonged ventilation ... at a long-term care facility," she said at the annual congress of the Society of Critical Care Medicine.

The study findings were published simultaneously online in JAMA. There, the authors suggested that the more rapid weaning achieved with the use of the tracheostomy collar could be because the collar allows clinicians to directly observe whether patients are capable of breathing spontaneously (JAMA 2013 [doi:10.1001/jama.2013.159]).

"During a tracheostomy collar challenge, the amount of respiratory effort is determined solely by the patient. As such, observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities. In contrast, a clinician’s ability to judge weanability during pressure support is clouded because the patient is receiving ventilator assistance," the investigators wrote.

Clinicians may be more willing to wean patients who do better than expected on a trachesotomy challenge than they would patients who are on only low levels of pressure support, the authors suggested.

Weaning failures randomized

They based their conclusions on a decade-long randomized trial of patients with tracheotomies on prolonged ventilation who were transferred to a single center for weaning.

A total of 500 patients had a 5-day screening process during which they were given humidified oxygen through a tracheostomy collar and observed for signs of respiratory distress. Patients with no signs of distress during the challenge were considered to be weaned from ventilation and were excluded from the study, and the remaining 316 were randomly assigned to weaning with either a tracheostomy collar or pressure support. Patients in each study arm were stratified into one of four underlying disease categories, and to either early- or late-failure groups, based on the time it took for the breathing trial to fail (0 to less than 12 hours for early failures, 12-120 hours for late failures).

Ultimately, a total of 312 patients were included in the analysis.

Of the 160 patients in the tracheostomy collar group, 15 were deemed to be unweanable, 15 withdrew for various reasons, 16 died, and 10 were transferred to an acute care hospital. Of the remaining 104 patients in this arm, 85 (53.1% of the total group) were successfully weaned.

Of the 152 patients in the pressure support group, 21 were judged to be unweanable, 12 withdrew, 7 were transferred to an acute care hospital, and 22 died. Of the remaining 90 patients, 68 (45% of the total) were successfully weaned.

The median weaning time for patients on the collar was 15 (interquartile range [IQR], 8-25 days), compared with 19 days (IQR, 12-31 days) for patients on pressure support.

In an analysis adjusted for baseline clinical covariates, the hazard ratio (HR) favoring tracheostomy collar weaning was 1.43. Among patients in the late-failure subgroup, tracheostomy offered significantly more rapid weaning than did pressure support (HR, 3.33). There was no significant difference between the methods in time to weaning among patients who were deemed to be early screening failures, however. There were also no significant differences between weaning protocols in either 6- or 12-month mortality rates.

Dr. Jubran and colleagues acknowledged that their study was limited by the inability to fully mask treatment type from investigators (although investigators analyzing the data were blinded to protocol assignment), and by the use of single-center data, potentially limiting generalizability.

The study was supported by funding from the National Institute of Nursing Research. Dr. Jubran reported having no relevant financial disclosures.