|Year : 2020 | Volume
| Issue : 1 | Page : 15-19
The impact of multidisciplinary huddle in decreasing time to extubation from mechanical ventilation
Rana Al Tabee1, Amal A Al Khalfan2, Khaled A Al Awam2
1 Ph. D. Candidate, Norwich Medical School, University of East Anglia, Norwich, UK
2 Respiratory Therapy Program, Inaya Medical Colleges, Riyadh, Saudi Arabia
|Date of Submission||18-Feb-2020|
|Date of Decision||18-Mar-2020|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||30-Apr-2020|
Rana Al Tabee
Norwich Medical School, University of East Anglia, Norwich
Source of Support: None, Conflict of Interest: None
Weaning from mechanical ventilator support is the optimal goal after the resolution of indications prompting need for this intervention. Failure of patient to pass weaning indicators will lead to prolonged mechanical ventilation duration and potentially more complications. The primary aim of this literature review was to determine if multidisciplinary huddle will effectively decreased time to extubation after passing a spontaneous breathing trial and length of mechanical ventilation. For this literature review, ProQuest, Medline, and PubMed were used to find articles about the influence of multidisciplinary approach on time to extubation. Search was narrowed to article between 2013 and 2018. A total of 20 articles were included, which were found to match inclusion criteria. This literature review searched a total of 20 articles between 2015 and 2018 to determine the influence of multidisciplinary approach on time to extubation. Inclusion criteria for this literature review included studies conducted on patients aged 18 years and above, admitted to intensive care units, and on mechanical ventilation for at least 48 h. Studies on re-intubated patients and patients with a tracheostomy were excluded from this review. Findings indicated that implementation of the multidisciplinary huddle along with ABCDEF bundle was associated with reduction in duration of intubation and time to extubation, but it did not affect the patient's length of hospital stay. The prevention of prolonged duration of mechanical ventilation should be the desired goal for all endotracheally intubated patients. Achievement of this requires a multidisciplinary team huddle to minimize the weaning delay and optimize the patient's outcome.
Keywords: Extubation, mechanical ventilation, multidisciplinary, weaning
|How to cite this article:|
Al Tabee R, Al Khalfan AA, Al Awam KA. The impact of multidisciplinary huddle in decreasing time to extubation from mechanical ventilation. Saudi Crit Care J 2020;4:15-9
|How to cite this URL:|
Al Tabee R, Al Khalfan AA, Al Awam KA. The impact of multidisciplinary huddle in decreasing time to extubation from mechanical ventilation. Saudi Crit Care J [serial online] 2020 [cited 2020 Jun 1];4:15-9. Available from: http://www.sccj-sa.org/text.asp?2020/4/1/15/283640
| Introduction|| |
The process of discontinuation of the mechanical ventilation is not an easy task and requires time, some patients succeed and others fail and return on full ventilatory support for a longer period. Consequently, those who fail are exposed to many complications that might threaten their life. Duration from passing spontaneous breathing trials (SBTs) to extubation can be prolonged due to staffing and communication reasons. This literature review searched a total of 20 articles between 2015 and 2018 to determine the influence of multidisciplinary approach on time to extubation. Inclusion criteria for this literature review included studies conducted on patients aged 18 years and above, admitted to intensive care units (ICUs), and on mechanical ventilation for at least 48 h. Studies on re-intubated patients and patients with a tracheostomy were excluded from this review.
One study indicated that prolonged ventilator support is associated with high ICU mortality (14.2%), hospital mortality (19.1%), prolonged hospital stay after being discharged from the ICU (26.9 vs. 10.3 days), and increased the cost of care. Furthermore, muscular weakness, pressure ulcers, ventilator-associated pneumonia, nosocomial sepsis, candidemia, pulmonary embolism, and delirium were associated with prolonged mechanical ventilation during ICU stay.
Mechanical ventilation is considered a lifesaving intervention; patients who fail SBT and take longer time to breath by their own might have higher risks of morbidity and mortality. Therefore, faster patient liberation from the mechanical ventilator lowers the probability of developing ventilator-associated complications and less time spent in ICU. Weaning is referred to as the process of switching the patient from fully supported breaths to completely spontaneous breaths. Most clinicians refer to a successful weaning trial as extubation without the need for reintubation for 48–72 h.
Weaning procedure involves using a gradual process of applying available weaning modes of ventilation on the ventilator on the patient following no protocol. The weaning process primarily depends on the patient's tolerance of the weaning process. Compared to nonprotocolized weaning, protocolized weaning was associated with a greater reduction in duration of mechanical ventilation by about 26%, reduction in weaning duration by 70%, and ICU length of stay by 11%. Awakening and breathing coordination, delirium assessment and management, early mobility, and family engagement bundle, also known as Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/ Management, Early Exercise/Mobility and Family Empowerment (ABCDEF) bundle, is a multidisciplinary approach that takes in consideration all professions who are involved in the ICU setting and creates a interprofessional and multicomponent strategy aiming to reduce sedation and prolonged mechanical ventilation. The implementation of this approach over the 4-year period resulted in a reduced ICU mortality rate from 64% to 35%. Furthermore, the duration of mechanical ventilation was decreased from a median level of 51 days to 42 days. Therefore, collaboration among different disciplines provides a steady continuum of care to patients.
The extubation procedure is subject to success or failure. In the latter case, the patient may need to be reintubated again. To prevent extubation failure, clinicians should assess the patient's signs and symptoms of extubation failure before attempting the procedure. There are many predictors that might help health-care providers to estimate the extubation failure. These include disease severity, rapid shallow breathing, maximum inspiratory pressure (MIP), maximum expiratory pressure, and cuff leak test, which are collected before the extubation. Moreover, age plays an important role in predicting successful extubation as does Glasgow Coma Scale (GCS). Compared to younger patients, older patients have higher chances to fail extubation. Lower GCS is associated with more prospects to fail extubation.
| Different Weaning Protocols|| |
Multiple weaning techniques have been developed for facilitating successful extubation in the shortest time possible. However, a discussion on when to initiate an SBT relies on clinician's decision based on breathing assessment that is conducted before the extubation trial. However, clinicians can misinterpret some physiological changes that may lead to delayed weaning. Therefore, automated weaning systems have been developed to reduce the amount of time needed to wean a patient by making calculated setting changes in a timely manner.
There are different weaning techniques that were developed over the course of history, including synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), and T-piece. SIMV is a ventilator mode used for discontinuation of full mechanical ventilation support by allowing the patient to take spontaneous breaths in between mechanical breaths that is either aided by pressure support or not. The goal of using the SIMV technique in weaning is to gradually decrease the mandatory mechanical rate from 12 to 4 by attempting to reduce mandatory breathing rate 2 breaths/min, twice a day. PSV is a mode that requires the patient to breath spontaneously while providing a set pressure to support the breath. Outstanding features that make PSV different from SIMV is that the patient takes full control over all breaths delivered, as there is no mechanical rate provided by the ventilator. The use of pressure support in weaning aims to gradually reduce the pressure support level by 2–4 cmH2O twice a day until 8 cmH2O is tolerated. T-piece, on the other hand, is a more aggressive weaning method that involves disconnecting patient from the ventilator and attaching a T-piece to patient's endotracheal tube. The purpose of using T-piece is to perform it eight times a day, starting from 5 min up to 120 min.
In two studies comparing these three weaning methods together to determine which method resulted in a shorter time to extubation. The results showed that about two-thirds of patients passed the extubation after preforming the first T-piece trial and that both T-piece and PSV were superior to the SIMV mode.
SBT is a test that is conducted before extubation that depends on placing the patient on minimum to no ventilator support and assess the test tolerance for at least 30 min. However, evaluation for resolution of the primary cause of respiratory failure is important for better outcomes. There are three major ways to conduct an SBT, either with PSV, SIMV, or T-piece.
| Use of Extubation Protocols|| |
It is important for clinicians to assess for any signs of extubation failure before initiating the extubation process to prevent reintubation. Therefore, predictive weaning parameters were developed to help determine whether the patient is ready to be extubated. Rapid shallow breathing index (RSBI), a well-known parameter for weaning, can be calculated by dividing the patient respiratory rate by spontaneous tidal volume. A high RSBI of ≥105 breath/min/L is associated with unsuccessful extubation.
Another predictive weaning parameter is MIP. However, it should not be used alone to predict whether a patient can pass extubation or not as inspiratory muscle strength is not a sufficient indicator for successful weaning from a mechanical ventilator. An MIP ≥15 cmH2O is associated more with weaning failure.
One of the most important parameters for weaning is airway occlusion pressure (P0.1) which reflects the respiratory drive. P0.1 measures negative airway pressure generated during inspiration in the first 0.1 s in an occluded airway. Values of 4.0–4.2 cmH2O are acceptable predictors for successful extubation.
The arterial partial pressure of oxygen to fractional inspired oxygen ratio (PaO2/FiO2) is used with patients who suffer from acute respiratory distress syndrome or acute lung injury to indicate oxygenation status. Successful extubation is associated with PaO2/FiO2 of 120 >200.
Assessing patient readiness for weaning plays a vital role in the weaning process that cannot be overlooked due to two main reasons. First, to identify patients who are ready to be weaned from mechanical ventilation and breath on their own without any ventilator support. Unneeded mechanical ventilatory support can result in multiple complications, including ventilator-associated pneumonia, muscle weakness, and pressure injuries. The other reason for assessment of readiness is to identify patients who are not ready to be weaned, therefore, preventing any risk of premature weaning complications such as cardiac dysfunction.
Before measuring predictive parameters for weaning, the patient must meet specific criteria to be a candidate for a weaning procedure. These criteria include resolution of the cause of respiratory failure, improved oxygenation by PaO2/FiO2 ratio ≥150 or oxygen saturation (SpO2) ≥90%, arterial pH ≥7.35, hemodynamic stability without myocardial ischemia with systolic blood pressure of ≥90 mmHg but <180 mmHg with or without low doses of vasopressor, and the ability to initiate an inspiratory effort.
Although some patients get extubated after passing the criteria and weaning trials, it does not mean that they will not be subjected to reintubation and back on ventilator again. Ventilated patients can fail extubation for various reasons such as upper airway obstruction, impaired clearance of secretion, respiratory failure, insecure airway, cardiac failure, or neurological impairment. However, a real complication of extubation failure is reintubation and setting back on mechanical ventilation. In fact, in one study, patients who required reintubation had increased the duration of mechanical ventilation, hospital length of stay, and mortality.
Using a standardized weaning protocol has been shown to be beneficial with reduction of mechanical ventilation duration, weaning time, and consequently fewer days spent in ICU.
| The Process And Significance of Abcdef Bundle For Weaning|| |
Even with a massive improvement in the technology of new generation of mechanical ventilation, there are still different angles that are very vital for a successful weaning procedure and to eliminate any reason for patients to be back on the ventilator. Therefore, ABCDEF bundle was created to provide a multidisciplinary approach on how to handle the extubation process, involving physicians, nurses, respiratory therapists, and other health-care providers. This approach aims to improve coordination and collaboration among professions, stop the cycle of oversedation, and prolonged intubation and mechanical ventilation.
| Awakening and Breathing Coordination|| |
To conduct a weaning trial, the patient needs to be awake and able to spontaneously breathing; therefore, spontaneous awakening trial (SAT) accompanied by SBT is the first step in ABCDEF bundle. Using sedation to comfort a mechanically ventilated patient is not an uncommon practice. SAT evaluates whether the patient can survive without sedation and works on a daily reduction of sedation amount. Furthermore, continuous sedation for patients who are mechanically ventilated hinders conducting a physical assessment and consequently, inability to evaluate patient tolerance for the weaning process. According to a randomized control trial conducted by Girard et al., patients who underwent interruption of sedation, SAT, and SBT had more days spent breathing on their own without assistance, reduction in duration of ICU, and hospital stay compared to the patients who received sedation and usual care in addition to SBT. Therefore, combination of SAT and SBT resulted in better tolerance to weaning than SBT alone.
| Delirium Assessment and Management|| |
Delirium is an acute disturbance of the mental ability that results in an impaired perception and cognition. Prolonged ventilatory support increases the chance of developing delirium in the ICU setting. Around 50%–80% of mechanically ventilated patients in the ICU suffer from delirium. Therefore, many assessment methods were developed to help diagnose delirium such as Intensive Care Delirium Screening Checklist and Confusion Assessment Method for the ICU which is usually done by the nurses.
| Enhancement of Early Mobility|| |
Prolonged periods in the ICU and mechanical ventilation are associated with physical and psychological impairment; rehabilitation was suggested as a method of enhancing early mobility and physical activity in the ICU. Furthermore, a study done by McWilliams found that the introduction of a rehabilitation program in the ICU was associated with a significant reduction in the length of ICU stay, days on the ventilator, hospital stay, and in-hospital mortality. However, the physical therapist should coordinate with the other critical care staff to conduct these sessions.
| Family Engagement|| |
Family participation in the plan of care is crucial for satisfying outcomes. They play an important role in the weaning process as well, which reflects on after discharge outcomes. Therefore, they need to be educated about the patient's condition including delirium and its detrimental effect on the patient after being discharged from the hospital.
| The Impact of Multidisciplinary Teams On Weaning From Mechanical Ventilation|| |
Physicians, nurses, respiratory therapists, physical therapists, and more are all essential to implement the ABCDEF bundle. Coordination and communication between these multidiscipline are crucial to conduct the bundle finely. For this multidisciplinary team to function properly, they need a stakeholder to provide leadership and education. One of the challenges that might face the health-care facility to implement this approach is understaffing, which may affect the quality of the care delivered and the patient outcomes.
| The Compliance To Multidisciplinary Protocol Implementation|| |
Introducing the new multidisciplinary protocol is the first step, but education and motivation are important for this protocol to work. Therefore, Balas et al. conducted a study to determine the facilitators and the barriers to ABCDEF bundle adaptation. Balas et al. found that the main influencers for implementing the bundle were the performance of the daily interdisciplinary rounds, involvement of key implementation leader, sustained and divers educational efforts, and bundle's quality. On the contrary, the main obstacles were intervention-related issues due to fear of some adverse effects, for instance, challenges imposed from communication and care coordination, knowledge deficits, workload concerns, and documentation burden.
| Tools To Improve Collaboration To Decrease Weaning Time During Mechanical Ventilation|| |
There are three essential tools to keep the interdisciplinary team collaboration going smoothly and without affecting the health-care service delivery. First, the use of a standardized protocol of care. Due to the lack of controlled clinical practice, the need for standardized guidelines became essential to achieve a successful weaning outcome.
Second, multidisciplinary meetings are a very useful tool to keep all the health team members updated with the patient care plan and to which direction the patient weaning procedure is going. Furthermore, these meetings will help discuss any concurrent issues that affect the delivery of care and establish better communication and information sharing between the health team members.
Finally, the presence of a team leader gives a sense of direction. The team leader provides the support and the encouragement that the team members need to collaborate and participate in the multidisciplinary approach plan. Moreover, the team leader is responsible for conducting training in interprofessional cooperation that will enhance mutual respect among the team members.
| Conclusion|| |
Preventing prolong mechanical ventilation duration should be the desired goal for all endotracheally intubated patients. Therefore, to achieve this goal, an appropriate weaning protocol should be designed to reduce the mechanical ventilation period and ICU length of stay. Moreover, weaning protocol should be initiated as soon as the reason for respiratory failure resolves and that is due to the complications associated with prolonged mechanical ventilation such as ventilator-associated pneumonia, pressure injuries, and tracheal stenosis.
It is important to pay attention to the weaning predictor parameters, which can tell a lot regarding whether the patient can pass extubation or not. Furthermore, the patient who was successfully extubated does not mean that the assessment should be stopped, the patient should be continuously monitored for any signs of extubation failure.
In addition to choosing the appreciate weaning methods, the role of the multidisciplinary approach is undeniable in terms of facilitating weaning and extubation. Therefore, the ABCDEF bundle was developed to help organize and address the issues that need to be focused on in terms of weaning a patient who is on full ventilatory support. One of the proper methods to apply this approach is an early morning AM huddles that will assist in establishing the roles in facilitating weaning and give an insight into where the patient is in the weaning process.
There are no specific defined universal guidelines for weaning, due to the heterogeneity of weaning protocols used by different hospitals result in wild variability of mechanical ventilation duration. Therefore, the development of a reliable extubation protocol is crucial to minimize the weaning delay, and the multidisciplinary approach should be employed to optimize the patient's outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loss SH, de Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al
. The reality of patients requiring prolonged mechanical ventilation: A multicenter study. Rev Bras Ter Intensiva 2015;27:26-35.
Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O'Halloran P. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ 2011;342:c7237.
Blackwood B, Burns KE, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev 2014;11:CD006904.
Boehm LM, Vasilevskis EE, Mion LC. Interprofessional perspectives on ABCDE Bundle implementation: A Focus group study. Dimens Crit Care Nurs 2016;35:339-47.
Black CJ, Kuper M, Bellingan GJ, Batson S, Matejowsky C, Howell DC. A multidisciplinary team approach to weaning from prolonged mechanical ventilation. Br J Hosp Med (Lond) 2012;73:462-6.
Lai CC, Chen CM, Chiang SR, Liu WL, Weng SF, Sung MI, et al
. Establishing predictors for successfully planned endotracheal extubation. Medicine (Baltimore) 2016;95:e4852.
Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: A cochrane systematic review and meta-analysis. Crit Care 2015;19:48.
Alía I, Esteban A. Weaning from mechanical ventilation. Crit Care 2000;4:72-80.
Pellegrini JA, Moraes RB, Maccari JG, de Oliveira RP, Savi A, Ribeiro RA, et al
. Spontaneous breathing trials with T-piece or pressure support ventilation. Respir Care 2016;61:1693-703.
Hess D. Ventilator modes used in weaning. Chest 2001;120:474S-6S.
Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al
. Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-56.
Nemer SN, Barbas CS. Predictive parameters for weaning from mechanical ventilation. J Bras Pneumol 2011;37:669-79.
MacIntyre NR, Cook DJ, Ely EW Jr., Epstein SK, Fink JB, Heffner JE, et al
. Evidence-based guidelines for weaning and discontinuing ventilatory support: A collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120:375S-95S.
Kulkarni AP, Agarwal V. Extubation failure in intensive care unit: Predictors and management. Indian J Crit Care Med 2008;12:1-9.
] [Full text]
Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: Epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit. Crit Care 2011;15:R102.
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al
. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. Lancet 2008;371:126-34.
Marra A, Frimpong K, Ely E. The ABCDEF implementation bundle. Korean J Crit Care Med 2016;31:181-93.
McWilliams D, Weblin J, Atkins G, Bion J, Williams J, Elliott C, et al
. Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project. J Crit Care 2015;30:13-8.
Kram SL, DiBartolo MC, Hinderer K, Jones RA. Implementation of the ABCDE Bundle to improve patient outcomes in the intensive care unit in a rural community hospital. Dimens Crit Care Nurs 2015;34:250-8.
Balas MC, Burke WJ, Gannon D, Cohen MZ, Colburn L, Bevil C, et al
. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU Pain, agitation, and delirium guidelines. Crit Care Med 2013;41:S116-27.