Discontinuous versus continuous weaning in stroke patients

Teismann I., Oelschläger C., Werstler N., Korsukewitz C., Minnerup J., Ringelstein E., Dziewas R.

Zusammenfassung

Background: An increasing number of stroke patients have to be supported by mechanical ventilation in intensive care units (ICU), with a relevant proportion of them requiring gradual withdrawal from a respirator. To date, weaning studies have focused merely on mixed patient groups, COPD patients or patients after cardiac surgery. Therefore, the best weaning strategy for stroke patients remains to be determined. Methods: Here, we designed a prospective randomized controlled study comparing adaptive support ventilation (ASV), a continuous weaning strategy, with biphasic positive airway pressure (BIPAP) in combination with spontaneous breathing trials, a discontinuous technique, in the treatment of stroke patients. The primary endpoint was the duration of the weaning process. Results: Only the 40 (out of 54) patients failing in an initial spontaneous breathing trial (T-piece test) were included into the study; the failure proportion is considerably larger compared to previous studies. Eligible patients were pseudo-randomly assigned to one of the two weaning groups. Both groups did not differ regarding age, gender, and severity of stroke. The results showed that the median weaning duration was 10.7 days (±SD 7.0) in the discontinuous weaning group, and 8 days (±SD 4.5) in the continuous weaning group (p < 0.05). Conclusions: To the best of our knowledge, this is the first clinical study to show that continuous weaning is significantly more effective compared to discontinuous weaning in mechanically ventilated stroke patients. We suppose that the reason for the superiority of continuous weaning using ASV as well as the bad performance of our patients in the 2 h T-piece test is caused by the patients' compliance. Compared to patients on surgical and medical ICUs, neurological patients more often suffer from reduced vigilance, lack of adverse-effects reflexes, dysphagia, and cerebral dysfunction. Therefore, stroke patients may profit from a more gradual withdrawal of weaning.