An Algorithmic Approach to Ventilator Withdrawal at the End of Life

描述（由申请人提供）：终末呼吸机撤机是一个需要对无法维持自主呼吸的患者停止机械辅助支持的过程，通常在ICU进行。呼吸机撤机是为了让病人自然死亡。阿片类药物和/或苯二氮卓类药物作为呼吸机撤机过程的一个组成部分，在撤机前、撤机期间和撤机后给药，以预防或缓解呼吸窘迫，但很少有指南确定给药量或给药时间。阿片类药物和/或苯二氮卓类药物给药不足会使患者面临呼吸窘迫未缓解和可预防痛苦的风险。相反，过度用药可能会加速死亡，这是一个意想不到的后果，也是临床医生关注的问题。呼吸机撤机期间给予的药物有效剂量未知。我们假设，依赖于生物行为仪器来测量和趋势痛苦的呼吸机撤机算法方法将确保患者舒适度，并指导有效的阿片类药物和/或苯二氮卓类药物给药。我们计划使用一项阶梯楔形分组随机对照试验，所有分组提供非结构化常规护理，直到每个分组被随机化以实施算法方法（干预）。这项研究是创新的，因为没有标准化的，以证据为基础的方法指导的客观措施的呼吸窘迫，这一共同的ICU程序。该研究具有广泛的临床意义，可以提供可能减少患者痛苦的知识。

DESCRIPTION (provided by applicant): Terminal ventilator withdrawal is a process that entails the cessation of mechanical ventilatory support with patients who are unable to sustain spontaneous breathing and is commonly performed in the ICU. Ventilator withdrawal is undertaken to allow a natural death. Opioids and/or benzodiazepines are administered before, during, and after as an integral component of the ventilator withdrawal process to prevent or relieve respiratory distress, but there are few guidelines to determine how much to administer or when. Insufficient opioid and/or benzodiazepine administration places the patient at risk for unrelieved respiratory distress and preventable suffering. Conversely, excessive medication administration may hasten death, an unintended consequence, and one that concerns clinicians. The effective doses of medications given during ventilator withdrawal are unknown. We hypothesize that an algorithmic approach to ventilator withdrawal, relying on a biobehavioral instrument to measure and trend distress, will ensure patient comfort, and guide effective opioid and/or benzodiazepine administration. We plan to use a stepped wedge cluster randomized controlled trial with all clusters providing unstructured usual care until each cluster is randomized to implement the algorithmic approach (intervention). The proposed study is innovative because there is no standardized, evidence-based approach guided by an objective measure of respiratory distress to this common ICU procedure. The study has broad clinical significance to provide knowledge that can potentially reduce patient suffering.