Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature

To answer the following question: In difficult-to-wean patients, which of the three commonly used techniques of weaning (T-piece, synchronized intermittent mandatory ventilation, or pressure support ventilation) leads to the highest proportion of successfully weaned patients and the shortest weaning time? Data Sources: Computerized literature searches in MEDLINE (1975-1996), Cinahl (1982-1996), and Healthplan (1985-1996), exploding all Mesh headings pertaining to Mechanical Ventilation and Weaning. Searches were restricted to the English language, adults, and humans. Personal files were hand searched, and references of selected articles were reviewed. Study Selection: a) Population: Patients requiring a gradual weaning process from the ventilator (either requiring prolonged initial ventilation of >72 hrs or a failed trial of spontaneous breathing after >24 hrs of ventilation); b) interventions: At least two of the following three modes of weaning from mechanical ventilation must have been compared: T-piece, synchronized intermittent mandatory ventilation, or pressure support ventilation; c) Outcomes: At least one of the following: weaning time (time from initiation of weaning to extubation) or successful weaning rate (successfully off the ventilator for >48 hrs); and d) Study design: Controlled trial. Data Extraction: Two reviewers independently reviewed the articles and graded them according to their methodologic rigor, Data on the success of weaning and the time to wean were summarized for each study. Data Synthesis: The search strategy identified 667 potentially relevant studies; of these, 228 had weaning as their primary focus, and of these, 48 addressed modes of ventilation during weaning. Only 16 of these 48 studies had one of the specified outcomes, and only ten of these were controlled trials, Of the ten trials, only four fulfilled all our selection criteria. The results of the trials were conflicting, and there was heterogeneity among studies that precluded meaningful pooling of the results. Conclusions: There are few trials designed to determine the most effective mode of ventilation for weaning, and more work is required in this area, From the trials reviewed, we could not identify a superior weaning technique among the three most popular modes, T-piece, pressure support ventilation, or synchronized intermittent mandatory ventilation, However, it appears that synchronized intermittent mandatory ventilation may lead to a longer duration of the weaning process than either T-piece or pressure support ventilation. Finally, the manner in which the mode of weaning is applied may have a greater effect on the likelihood of weaning than the mode itself.