Abstract
Background
The impact of comorbidities on patients weaning from invasive ventilation is incompletely understood. We wished to understand the impact of the number and type of comorbidities on patients’ weaning from invasive mechanical ventilation enrolled in the ‘WorldwidE AssessmeNt of Separation of pAtients From ventilatory assistancE (WEAN SAFE) study.
Methods
The study population consisted of patients enrolled in the WEAN SAFE study that commenced the weaning process. We categorized patients by the number of comorbidities (none, 1, 2, or 3 plus), and by specific comorbidity type. The primary outcome was the impact of comorbidities on delayed weaning and failed weaning from invasive MV. Secondary outcomes included the impact of comorbidities on ICU and hospital survival, and decisions to limit life-sustaining interventions.
Results
Of 4523 patients in the study population, 1614 (35.7%) had one comorbidity, 889 (19.7%) had two comorbidities, 432 (9.6%) had three or more comorbidities, while 1562 (34.5%) had no comorbidities. The most frequently occurring comorbid conditions were respiratory (22%) and cardiovascular (11%). Patients with comorbidities were more likely to fail a separation attempt, more likely to receive an extubation attempt, and to require more than 1 extubation attempt. The proportion of patients with failed weaning from invasive MV increased progressively with increasing comorbidities. Neuromuscular comorbidities were associated with increased weaning duration. Weaning failure was increased with respiratory, hepatic, renal, neuromuscular, and immune dysfunction comorbidities. Hospital mortality rates increased progressively from 16% with no comorbidity to 34% with ≥ 3 comorbidities. Each specific comorbidity was independently associated with increased hospital mortality. The presence of comorbidities was associated with decisions to limit life sustaining interventions.
Conclusions
Most patients weaning from invasive ventilation have comorbidities, which are associated with higher weaning failure risk and worse outcomes. The adverse impact of comorbidities on the weaning outcomes and of the process are not explained by a less aggressive approach to weaning.
Key Points
- Prevalence of Comorbidities in Weaning Patients: Among 4,523 patients analyzed, 65.5% had at least one comorbidity, with respiratory (22%) and cardiovascular (11%) diseases being the most common.
- Increased Risk of Weaning Failure: The likelihood of weaning failure progressively increased with the number of comorbidities, from 12% in patients without comorbidities to 22% in those with three or more.
- Delayed Weaning and Sedation Practices: Contrary to expectations, patients with comorbidities were not delayed in weaning initiation and were less likely to receive deep sedation, indicating proactive management by clinicians.
- Neuromuscular Comorbidities Prolong Weaning Duration: Patients with neuromuscular conditions had significantly longer weaning times, emphasizing the role of muscle strength in ventilator liberation.
- Respiratory, Renal, and Hepatic Comorbidities Worsen Weaning Outcomes: These conditions were independently associated with higher rates of weaning failure and prolonged ventilation dependence.
- Hospital and ICU Mortality Rates Escalate with Comorbidities: ICU mortality rose from 10% (no comorbidities) to 20% (≥3 comorbidities), while hospital mortality increased from 16% to 34%.
- Association with End-of-Life Decisions: Patients with multiple comorbidities were more likely to have limitations placed on life-sustaining treatments, reflecting clinical concerns over prognosis.
- Variability in Weaning Approaches: Despite poorer outcomes, patients with comorbidities underwent similar numbers of weaning trials and extubation attempts compared to those without comorbidities.
- Potential Implications for Weaning Protocols: The findings suggest a need for individualized weaning protocols that integrate risk assessment based on comorbidity profiles.
- Future Research and Clinical Strategies: Further studies should explore targeted interventions to improve weaning success rates among high-risk patient populations with multiple comorbidities.
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