Editorial
The magic formula of weaning: The doctors’ holy grail
A fórmula mágica de desmame: o santo graal dos médicos
M. Vitacca
Respiratory Unit and Weaning Center, Fondazione Salvatore Maugeri, IRCCS, Lumezzane (BS), Italy
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Vitacca" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Vitacca" "email" => array:1 [ 0 => "michele.vitacca@fsm.it" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Respiratory Unit and Weaning Center, Fondazione Salvatore Maugeri, IRCCS, Lumezzane (BS), Italy" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A fórmula mágica de desmame: o <span class="elsevierStyleItalic">santo graal</span> dos médicos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the last 10 years, availability of beds in intensive care units (ICUs) and new technologies coupled with improved levels of care have highlighted a new population of patients defined as <span class="elsevierStyleItalic">survivors from catastrophic illness</span>. These patients often require long drawn out weaning procedures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> About 80% of patients with acute respiratory failure (ARF) under mechanical ventilation (MV) admitted to an ICU resume spontaneous breathing (SB) quite easily after few days of MV.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The patients discussed here represent less than 10% of ICU admissions but account for a disproportionate burden on health financial resources.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To this end, new strategies and protocols for weaning from MV are urgently needed in daily health care.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The weaning process is a delicate phase in the medical history of a patient who has survived an acute episode of ARF and spent a period of time under MV. In fact, during this period, there are a lot of issues that are currently somewhat underestimated in daily medical practice: occupation of beds, healthcare costs, burden to the families and to patients themselves.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although these occurrences are quite common and critical, there are no clear guidelines on the minimal criteria required for assessing the correct weaning time for different diseases or on the need for screening criteria prior to SB test (SBT).</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is also crucial to identify the patients who could be considered as likely to respond successfully to the weaning process: <span class="elsevierStyleItalic">Weaning from Mechanical Ventilation is rarely performed early, often too late</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Physicians often fail to recognize patients who may be suitable for extubation. Studies about patients who are extubated either accidentally or by themselves demonstrate that 23% of patients receiving full MV and 69% of patients who have begun weaning do not require reintubation.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> On the other hand, 5–20% of patients who are successfully weaned and possibly extubated need subsequent tracheal reintubation within the next 48–72<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">For all these reasons, in current clinical practice, there is a complete anarchy in terms of the correct time of extubation, types of MV needed, how these techniques are used, poor tolerance criteria for SBT, personnel involved in the weaning process, different approaches according to different diseases and clear-cut definition of weaning failure.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Investigation of the influence of different ventilatory supports on predicting breathing pattern variability for extubation outcomes in ICU patients is one of the most common topics in weaning research groups.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A lot of different parameters have been studied to find <span class="elsevierStyleItalic">the magic formula</span> for ready-for-weaning or -extubating patients and to discover the best way of ventilation so as to prove the superiority of one over another. Also a lot of automatic and intelligent systems have been tested to predict failure or success in weaning or extubation. Among these, a variety of strategies to facilitate the separation or the release of the patient from MV, T-tube trials, continuous positive airway pressure (CPAP), pressure-support ventilation (PSV), synchronized intermittent mandatory ventilation (SIMV) and proportional assist ventilation (PAV) have been proposed.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–11</span></a> It has been previously demonstrated that weaning should be considered at early stages in patients under MV. It has been shown that the majority of patients can be successfully weaned at the first attempt and for this majority SBT is the major diagnostic test to determine if they can be successfully extubated. The initial SBT should last 30<span class="elsevierStyleHsp" style=""></span>min and consist of either T-tube breathing or low levels of PSV with or without 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O positive end expiratory pressure (PEEP); SIMV should be avoided as a weaning modality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the current issue of the Journal,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">12</span></a> Gnanapandithan et al. have added further information that will improve our knowledge about the desirable “<span class="elsevierStyleItalic">Holy Grail</span>” for successful weaning. These authors have shown that weaning by gradual reduction of pressure support (PS) without initial SBT is associated with higher success rates, quicker weaning, and a shorter ICU stay vs. once a day PS-supported SBTs.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We also know that one of the major limitations for weaning-dedicated protocols is the impossibility of making generalizations about different diseases and conditions: different diseases have different physio-pathological approaches and need different weaning protocols (WP).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A protocol for starting weaning or whether to decide the extubation time is mandatory. However, there is less evidence about the need for a strict protocol on how weaning is carried out in terms of modality and the time to be dedicated to each stage of weaning.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is necessary to have WP to provide feedback for young doctors, for ICUs with a high turnover, in Operative Units with a rapid turn-over in expertise, for better integration of the different professionals who make up a weaning team and for more effective documenting of the clinical activity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Whatever the explanation, it is important for us to highlight that in the weaning process, the method employed is probably less important than confidence and familiarity with the technique adopted, and that the same ventilatory approach may result in different outcomes depending on the underlying diseases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The way to conduct weaning and patient's underlying conditions – rather than ventilator modality <span class="elsevierStyleItalic">per se</span> – may influence weaning outcomes as days of MV and percentage of success but will have no effect on survival. Also the potential role of NIV and synergic effect of cough assistance devices during weaning needs further clarification.</p><p id="par0070" class="elsevierStylePara elsevierViewall">There are too many aspects that still have to be investigated. Therefore, the specific need for availability of clear WP is stressed and recommended. Future studies should define:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(i)</span><p id="par0075" class="elsevierStylePara elsevierViewall">minimal criteria required for assessing the correct weaning time in view of diseases,</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(ii)</span><p id="par0080" class="elsevierStylePara elsevierViewall">the need for a screening test prior to SBT,</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(iii)</span><p id="par0085" class="elsevierStylePara elsevierViewall">identification of patients with successful SBT but who failed extubation,</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(iv)</span><p id="par0090" class="elsevierStylePara elsevierViewall">the role of CPAP/PEEP in COPD patients undergoing SBT,</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(v)</span><p id="par0095" class="elsevierStylePara elsevierViewall">the required duration of SBT in patients who failed the initial trial, and</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(vi)</span><p id="par0100" class="elsevierStylePara elsevierViewall">specific aspects of WP that resulted in improved weaning outcome.</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">We do not know if the magic formula of weaning will be ever <span class="elsevierStyleItalic">revealed</span> to doctors. Nevertheless, we are confident that this issue will remain the <span class="elsevierStyleItalic">Holy Grail</span> of continued research efforts. The quest for the Grail, by all of us involved in weaning, is a search for that indescribable uniqueness, <span class="elsevierStyleItalic">philosophical stone</span>. The ultimate quest for the highest knowledge can only be gained by courage and perseverance.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic ventilator facilities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Nava" 1 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 8 | 13 |
| 2024 October | 39 | 31 | 70 |
| 2024 September | 46 | 24 | 70 |
| 2024 August | 64 | 34 | 98 |
| 2024 July | 45 | 38 | 83 |
| 2024 June | 45 | 37 | 82 |
| 2024 May | 46 | 39 | 85 |
| 2024 April | 49 | 34 | 83 |
| 2024 March | 39 | 28 | 67 |
| 2024 February | 39 | 23 | 62 |
| 2024 January | 33 | 26 | 59 |
| 2023 December | 60 | 25 | 85 |
| 2023 November | 33 | 32 | 65 |
| 2023 October | 24 | 38 | 62 |
| 2023 September | 28 | 35 | 63 |
| 2023 August | 32 | 13 | 45 |
| 2023 July | 32 | 30 | 62 |
| 2023 June | 18 | 20 | 38 |
| 2023 May | 33 | 21 | 54 |
| 2023 April | 24 | 19 | 43 |
| 2023 March | 43 | 21 | 64 |
| 2023 February | 23 | 25 | 48 |
| 2023 January | 23 | 15 | 38 |
| 2022 December | 28 | 24 | 52 |
| 2022 November | 47 | 33 | 80 |
| 2022 October | 47 | 31 | 78 |
| 2022 September | 41 | 41 | 82 |
| 2022 August | 39 | 45 | 84 |
| 2022 July | 40 | 44 | 84 |
| 2022 June | 29 | 34 | 63 |
| 2022 May | 39 | 46 | 85 |
| 2022 April | 35 | 45 | 80 |
| 2022 March | 37 | 43 | 80 |
| 2022 February | 28 | 29 | 57 |
| 2022 January | 35 | 35 | 70 |
| 2021 December | 34 | 42 | 76 |
| 2021 November | 29 | 34 | 63 |
| 2021 October | 35 | 39 | 74 |
| 2021 September | 25 | 26 | 51 |
| 2021 August | 21 | 28 | 49 |
| 2021 July | 40 | 26 | 66 |
| 2021 June | 15 | 25 | 40 |
| 2021 May | 22 | 33 | 55 |
| 2021 April | 59 | 25 | 84 |
| 2021 March | 40 | 37 | 77 |
| 2021 February | 62 | 20 | 82 |
| 2021 January | 31 | 17 | 48 |
| 2020 December | 25 | 14 | 39 |
| 2020 November | 33 | 23 | 56 |
| 2020 October | 32 | 11 | 43 |
| 2020 September | 62 | 23 | 85 |
| 2020 August | 51 | 19 | 70 |
| 2020 July | 86 | 18 | 104 |
| 2020 June | 65 | 16 | 81 |
| 2020 May | 83 | 19 | 102 |
| 2020 April | 57 | 10 | 67 |
| 2020 March | 56 | 13 | 69 |
| 2020 February | 54 | 15 | 69 |
| 2020 January | 68 | 19 | 87 |
| 2019 December | 72 | 20 | 92 |
| 2019 November | 66 | 9 | 75 |
| 2019 October | 62 | 17 | 79 |
| 2019 September | 68 | 15 | 83 |
| 2019 August | 129 | 22 | 151 |
| 2019 July | 131 | 18 | 149 |
| 2019 June | 124 | 10 | 134 |
| 2019 May | 120 | 19 | 139 |
| 2019 April | 108 | 21 | 129 |
| 2019 March | 251 | 12 | 263 |
| 2019 February | 188 | 10 | 198 |
| 2019 January | 155 | 19 | 174 |
| 2018 December | 89 | 5 | 94 |
| 2018 November | 27 | 0 | 27 |
| 2018 October | 48 | 10 | 58 |
| 2018 September | 32 | 8 | 40 |
| 2018 August | 40 | 21 | 61 |
| 2018 July | 44 | 23 | 67 |
| 2018 June | 39 | 20 | 59 |
| 2018 May | 49 | 17 | 66 |
| 2018 April | 65 | 21 | 86 |
| 2018 March | 52 | 13 | 65 |
| 2018 February | 27 | 6 | 33 |
| 2018 January | 25 | 20 | 45 |
| 2017 December | 48 | 16 | 64 |
| 2017 November | 32 | 20 | 52 |
| 2017 October | 25 | 12 | 37 |
| 2017 September | 36 | 19 | 55 |
| 2017 August | 35 | 16 | 51 |
| 2017 July | 20 | 14 | 34 |
| 2017 June | 49 | 19 | 68 |
| 2017 May | 39 | 19 | 58 |
| 2017 April | 10 | 9 | 19 |
| 2017 March | 11 | 74 | 85 |
| 2017 February | 12 | 14 | 26 |
| 2017 January | 13 | 7 | 20 |
| 2016 December | 31 | 14 | 45 |
| 2016 November | 22 | 10 | 32 |
| 2016 October | 24 | 13 | 37 |
| 2016 September | 16 | 5 | 21 |
| 2016 August | 21 | 5 | 26 |
| 2016 July | 12 | 5 | 17 |
| 2016 June | 6 | 3 | 9 |
| 2016 April | 10 | 1 | 11 |
| 2016 March | 25 | 16 | 41 |
| 2016 February | 26 | 16 | 42 |
| 2016 January | 25 | 15 | 40 |
| 2015 December | 28 | 6 | 34 |
| 2015 November | 22 | 13 | 35 |
| 2015 October | 16 | 3 | 19 |
| 2015 September | 24 | 11 | 35 |
| 2015 August | 21 | 8 | 29 |
| 2015 July | 34 | 4 | 38 |
| 2015 June | 33 | 5 | 38 |
| 2015 May | 27 | 7 | 34 |
| 2015 April | 50 | 10 | 60 |
| 2015 March | 41 | 4 | 45 |
| 2015 February | 30 | 5 | 35 |
| 2015 January | 31 | 11 | 42 |
| 2014 December | 39 | 6 | 45 |
| 2014 November | 29 | 7 | 36 |
| 2014 October | 30 | 10 | 40 |
| 2014 September | 40 | 8 | 48 |
| 2014 August | 32 | 10 | 42 |
| 2014 July | 46 | 7 | 53 |
| 2014 June | 28 | 4 | 32 |
| 2014 May | 37 | 8 | 45 |
| 2014 April | 33 | 6 | 39 |
| 2014 March | 37 | 9 | 46 |
| 2014 February | 37 | 9 | 46 |
| 2014 January | 49 | 7 | 56 |
| 2013 December | 51 | 8 | 59 |
| 2013 November | 38 | 12 | 50 |
| 2013 October | 34 | 9 | 43 |
| 2013 September | 37 | 14 | 51 |
| 2013 August | 44 | 17 | 61 |
| 2013 July | 48 | 20 | 68 |
| 2013 June | 18 | 8 | 26 |
| 2013 May | 33 | 13 | 46 |
| 2013 April | 55 | 26 | 81 |
| 2013 March | 51 | 8 | 59 |
| 2013 February | 55 | 22 | 77 |
| 2013 January | 48 | 21 | 69 |
| 2012 December | 30 | 18 | 48 |
| 2012 November | 36 | 19 | 55 |
| 2012 October | 12 | 10 | 22 |
| 2012 September | 12 | 8 | 20 |
| 2012 January | 298 | 0 | 298 |
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