Thread by @iwashyna

#ICUreadings -- we're back!

Senior residents, so 2 articles per day at 2 pm

Effect of Pressure Support vs Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation via @JAMA_current

jamanetwork.com/journals/jama/…

#ICUreadings -- we're back! (2/2)

Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study via @ATSBlueEditor

ncbi.nlm.nih.gov/pubmed/32023081

Gotta love the clarity with which the Jubran paper describe the two methods of weaning, and of respiratory failure. I wish everybody was this clear

Trach collar was faster

Can I admit that I had never read this paper before? It's an embarrassment, I know, but I have many failings

I had always been taught this as if it were an approach to strengthening patients. I don't think it is--I think it is an approach to testing readiness for vent liberation

It feels like this is great data on how to assess readiness for long-term liberation, but I'm still at a loss for what the best approach to strengthening and preparing for liberation those now long-term stuck on a vent

@BernieBissett @NickHartThorax, I'd welcome your teaching

As I read the n's from Figure 3 in the bottom, nearly everybody was in the early failure group, and in the early failure group there was really no difference in which approach was used to help them

(to be clearer, rather than just having a conversation with myself:)

The RCT was really nicely stratified by how long folks took to fail an initial "eligibility" 5 day unassisted test, making sure they weren't already ready to liberate

Early failure went for <12h on that

Ok, on to Rak et al

This is a brilliant set-up "organizational practices derived from the ICU, where the focus is on acute resuscitation rather than on chronic rehabilitation, are unlikely to extend to prolonged mechanical ventilation"

Rak et al:

The main part of weaning this type of patient is not spinning the dials on the ventilator. It’s doing all the other things. It’s stopping the medicines that are hurting them. It’s getting them out of bed. It’s feeding them appropriately. —Physician, high-performing

Rak et al:

At low-performing hospitals, providers tended to work in parallel rather than together.

🔥🔥🔥🔥🔥🔥

Rak et al (2020) AJRCCM:

Although all hospitals had weekly interprofessional team meetings, hospitals differed in how they were used: High-performing hospitals used these to engender discussion among care providers and troubleshoot problems, whereas low-performing hospitals ...

... used these merely for informational exchange without active discussion. High-performing hospitals also consistently brought in frontline clinicians for interdisciplinary team meetings rather than limiting the meetings to management only.

Now Rak et al (2020) break my heart in the #COVID19 era:

"Patients and #families play a key moderating role. Specifically, supportive families and engaged patients enhance relational coordination, leading to care that is more aggressive and more responsive"

(ping @GioraNetzer)

"For example, at high-performing hospitals, family members were frequently used as coaches during episodes of spontaneous breathing, reassuring patients and reducing anxiety. In such instances, patients and families are considered part of the care team, ...

... and their input was used to refine and improve the care plan over the course of a hospitalization."

#ICUreadings summarizing Rak et al (2020) @ATSBlueEditor

Relational coordination enables teams to be SIMULTANEOUSLY more aggressive + responsive in supporting patients recovery from prolonged mechanical ventilation via specific integrated care tasks

ncbi.nlm.nih.gov/pubmed/32023081