Withdrawal of Mechanical Ventilation in the ICU

IF 2.7

CHEST critical care Pub Date : 2025-12-01 Epub Date: 2025-08-23 DOI:10.1016/j.chstcc.2025.100204

Corey R. Fehnel MD, MPH , Zara Cooper MD, MPH , Margaret Campbell RN, PhD , Daniel Habtemariam MSc, MPH , Thomas G. Travison PhD , Daniel Forsman MD , Richard M. Schwartzstein MD , Douglas B. White MD, MAS , Susan L. Mitchell MD, MPH

{"title":"Withdrawal of Mechanical Ventilation in the ICU","authors":"Corey R. Fehnel MD, MPH , Zara Cooper MD, MPH , Margaret Campbell RN, PhD , Daniel Habtemariam MSc, MPH , Thomas G. Travison PhD , Daniel Forsman MD , Richard M. Schwartzstein MD , Douglas B. White MD, MAS , Susan L. Mitchell MD, MPH","doi":"10.1016/j.chstcc.2025.100204","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>More than 1 in 5 Americans die in ICUs, 50% of whom undergo palliative withdrawal of mechanical ventilation (WMV). Little is known about their experiences or best practices to minimize any suffering they may experience.</div></div><div><h3>Research Question</h3><div>How frequent is distress among patients undergoing withdrawal of mechanical ventilation, and what are the risk factors for distress?</div></div><div><h3>Study Design and Methods</h3><div>The Observational Study of Withdrawal of Mechanical Ventilation is a prospective cohort study conducted from January 2021 through July 2022 in 12 ICUs at 2 academic medical centers among mechanically ventilated, intubated patients transitioning to comfort-focused care via WMV. The cumulative incidence of experiencing distressful episodes resulting from either observed respiratory distress (respiratory distress observation score of > 3 or self-reported dyspnea rated ≥ 5), pain (visual analog scale or clinical pain observation tool score of ≥ 3), or agitation (Richmond Agitation-Sedation Scale score of ≥ +2) from the time of WMV initiation until death (or up to 3 hours after WMV) were calculated. Multivariable Poisson regression identified factors associated with the number of distressful episodes, adjusting for time at risk, generating adjusted incidence risk ratios (aIRRs) with 95% CIs.</div></div><div><h3>Results</h3><div>Among 153 participants, the cumulative incidence of at least 1 distressful episode after WMV was 91% (individual symptoms were: respiratory distress, 90%; pain, 56%; and agitation, 5%), with 41% of patients having > 3 episodes. In multivariable analysis, receiving opiates within 1 hour before WMV (anticipatory dosing) was associated with a lower risk of distressful episodes (aIRR, 0.74; 95% CI, 0.55-0.99). Factors associated with higher risk of distressful episodes included: ICU stays of > 10 days (aIRR, 1.85; 95% CI, 1.20-2.88), lower levels of consciousness (lower Glasgow coma scale score; aIRR, 1.72; 95% CI, 1.06-2.78), and distressful episodes before WMV (aIRR, 1.63; 95% CI, 1.21-2.18).</div></div><div><h3>Interpretation</h3><div>Our results show that nearly all ICU patients undergoing palliative WMV at the end of life demonstrated distressful symptoms or signs. Anticipatory dosing with opiates before WMV may help to mitigate their distress.</div></div>","PeriodicalId":93934,"journal":{"name":"CHEST critical care","volume":"3 4","pages":"Article 100204"},"PeriodicalIF":2.7000,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"CHEST critical care","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S2949788425000772","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2025/8/23 0:00:00","PubModel":"Epub","JCR":"","JCRName":"","Score":null,"Total":0}

引用次数: 0

Abstract

Background

More than 1 in 5 Americans die in ICUs, 50% of whom undergo palliative withdrawal of mechanical ventilation (WMV). Little is known about their experiences or best practices to minimize any suffering they may experience.

Research Question

How frequent is distress among patients undergoing withdrawal of mechanical ventilation, and what are the risk factors for distress?

Study Design and Methods

The Observational Study of Withdrawal of Mechanical Ventilation is a prospective cohort study conducted from January 2021 through July 2022 in 12 ICUs at 2 academic medical centers among mechanically ventilated, intubated patients transitioning to comfort-focused care via WMV. The cumulative incidence of experiencing distressful episodes resulting from either observed respiratory distress (respiratory distress observation score of > 3 or self-reported dyspnea rated ≥ 5), pain (visual analog scale or clinical pain observation tool score of ≥ 3), or agitation (Richmond Agitation-Sedation Scale score of ≥ +2) from the time of WMV initiation until death (or up to 3 hours after WMV) were calculated. Multivariable Poisson regression identified factors associated with the number of distressful episodes, adjusting for time at risk, generating adjusted incidence risk ratios (aIRRs) with 95% CIs.

Results

Among 153 participants, the cumulative incidence of at least 1 distressful episode after WMV was 91% (individual symptoms were: respiratory distress, 90%; pain, 56%; and agitation, 5%), with 41% of patients having > 3 episodes. In multivariable analysis, receiving opiates within 1 hour before WMV (anticipatory dosing) was associated with a lower risk of distressful episodes (aIRR, 0.74; 95% CI, 0.55-0.99). Factors associated with higher risk of distressful episodes included: ICU stays of > 10 days (aIRR, 1.85; 95% CI, 1.20-2.88), lower levels of consciousness (lower Glasgow coma scale score; aIRR, 1.72; 95% CI, 1.06-2.78), and distressful episodes before WMV (aIRR, 1.63; 95% CI, 1.21-2.18).

Interpretation

Our results show that nearly all ICU patients undergoing palliative WMV at the end of life demonstrated distressful symptoms or signs. Anticipatory dosing with opiates before WMV may help to mitigate their distress.

查看原文本刊更多论文

ICU中机械通气的停用

背景：超过五分之一的美国人死于重症监护室，其中50%的人接受了姑息性机械通气停药（WMV）。人们对他们的经历或减少他们可能遭受的痛苦的最佳做法知之甚少。研究问题：停止机械通气患者发生窘迫的频率有多高？发生窘迫的危险因素有哪些？研究设计和方法机械通气停药观察性研究是一项前瞻性队列研究，于2021年1月至2022年7月在2个学术医疗中心的12个icu中进行，研究对象是通过WMV过渡到以舒适为重点的机械通气插管患者。计算由观察到的呼吸窘迫（呼吸窘迫观察评分为>； 3或自我报告的呼吸困难评分≥5）、疼痛（视觉模拟量表或临床疼痛观察工具评分≥3）或躁动（Richmond躁动-镇静量表评分≥+2）从WMV开始至死亡（或WMV后3小时）引起的痛苦发作的累积发生率。多变量泊松回归确定了与痛苦发作次数相关的因素，调整了风险时间，得出了95% ci的调整发生率风险比（airr）。结果153名参与者中，WMV后至少1次痛苦发作的累积发生率为91%（个体症状为：呼吸窘迫，90%；疼痛，56%；躁动，5%），41%的患者有3次发作。在多变量分析中，在WMV（预期给药）前1小时内接受阿片类药物与较低的痛苦发作风险相关（aIRR, 0.74; 95% CI, 0.55-0.99）。与痛苦发作高风险相关的因素包括：ICU住院10天（aIRR, 1.85; 95% CI, 1.20-2.88），意识水平较低（格拉斯哥昏迷评分较低；aIRR, 1.72; 95% CI, 1.96 -2.78）， WMV前的痛苦发作（aIRR, 1.63; 95% CI, 1.21-2.18）。我们的研究结果显示，几乎所有接受姑息性WMV的ICU患者在生命结束时都表现出痛苦的症状或体征。在WMV之前预先服用阿片类药物可能有助于减轻他们的痛苦。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

CHEST critical care Critical Care and Intensive Care Medicine, Pulmonary and Respiratory Medicine

自引率

0.00%

发文量