Debate to weigh strategies and interventions in mechanical ventilator liberation

Liberation from mechanical ventilation represents a daily challenge for physicians practicing in the ICU, as the decision of when to liberate a patient from the ventilator is fraught with grave consequences. Metrics, such as the rapid shallow breathing index (RSBI), and interventions, such as noninvasive support modes postliberation, are areas of controversy. 

Experts in these domains will discuss and debate the clinical evidence of their effectiveness in ventilator liberation during Controversies in Mechanical Ventilator Liberation, on Wednesday, from 8:30 am to 9:30 am, in Room 311 of the convention center. Presenters will help physicians determine the timing and patients best suited for these different strategies.

Daniel Ouellette, MD, MS, FCCP
Daniel Ouellette, MD, MS, FCCP

“Mechanical ventilation is a challenging field because, like in many fields, there are different interventions which are controversial. Some data support their use, whereas other data don’t, and how practitioners navigate their way through these questions is very important,” said Session Chair, Daniel Ouellette, MD, MS, FCCP, Associate Professor of Medicine at Wayne State University School of Medicine and Chief of Pulmonary and Critical Care Medicine at Henry Ford Hospital in Detroit.

The first debate will look at the question of whether noninvasive ventilation following extubation should be done to improve outcomes. Dr. Ouellette will argue in favor of noninvasive ventilation, and Jonathan Casey, MD, Assistant Professor of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center, will argue that noninvasive ventilation following extubation is not effective to improve outcomes.

“What we know is that it’s very important to keep our patients on the ventilator no longer than we have to because with each day that the person is on a ventilator, their risk of mortality increases,” Dr. Ouellette said. “At the same time, we know that those persons who we take off the ventilator whose treatment subsequently fails, especially in the first 48 hours, have a very, very high mortality rate. So, there’s a fine edge between trying to take the patient off a ventilator as early as possible and, yet, trying to avoid the circumstance where the treatment fails, and they have to go back on it.”

While there are some data and evidence that support noninvasive, or mask, ventilation as a postextubation strategy, Dr. Ouellette said there are also data that do not support it.

“I think the question really comes down to proper patient selection because there are some patients who you might predict are going to have a good outcome and others who you would predict are going to have a more challenging course,” he said. “So, I think this debate will focus on how you determine which population your patient belongs to and how to choose which ones should get the noninvasive ventilation vs not.”

In the session’s second debate, a pair of experts will argue whether the RSBI is a useful tool in predicting successful ventilator liberation. Melanie Dalton Garbarino, MBBS, Assistant Professor in the Department of Internal Medicine at the University of Cincinnati, will take the pro side of the argument, while the con side will be presented by Katie Gardner, DO, Clinical Assistant Professor in the Division of Pulmonary Medicine at the University of Tennessee.

“The rapid shallow breathing index, which is a ratio of the respiratory rate to tidal volume, is a metric that has been in use since 1990 when there were some seminal medical studies which demonstrated that it could be an effective metric to determine whether or not patients are ready to come off the mechanical ventilator,” Dr. Ouellette said. “Over the years, most of us have used this metric, but its use over the ensuing 3 decades has become more nuanced, and physicians are beginning to learn that there are other factors that they have to take into account besides the rapid shallow breathing index.”

One side of this debate will focus on the traditional viewpoint that this metric is important and should be used, he said, while the other, more recent perspective is that the RSBI is not as predictive as once thought, and there are other factors that need to be taken into account.

“Like the first debate, this is really addressing the same important and challenging question that we, as pulmonologists and critical care physicians, all regularly face about that fine line between failure and success of extubating,” Dr. Ouellette said.