Successful Implementation of a Nurse-Led Daily Spontaneous Awakening Trial Within a Modified Extubation Protocol: A...

Background Successful liberation from mechanical ventilation (MV) requires a systematic assessment of readiness for extubation. The 2015 Japanese Society of Intensive Care Medicine guidelines recommend daily spontaneous awakening trials (SATs) paired with spontaneous breathing trials (SBTs) and standardized risk stratification for post-extubation failure. We implemented a modified extubation protocol incorporating a nurse-led daily SAT and an enhanced risk assessment framework. This study aimed to evaluate the feasibility and safety of this implementation compared with the existing protocol (EP). Methods In this retrospective before-and-after study, we compared outcomes in patients managed with the EP (March 2017 to February 2020) and those managed with the modified protocol (MP) (March 2021 to February 2024) at the Advanced Emergency and Critical Care Center of Shinshu University Hospital, Matsumoto, Japan. We included adult patients who received MV for ≥48 hours and underwent protocolized extubation. The primary outcomes were the duration of MV, re-intubation rate, and post-extubation respiratory failure (PERF). Statistical analysis included inverse probability of treatment weighting (IPTW) to adjust for baseline differences. Results We analyzed 158 and 122 patients in the EP and MP groups, respectively. After IPTW adjustment, there were no significant differences in the duration of MV (median 6.0 vs. 6.0 days, p = 1.0), re-intubation rate (3.8% vs. 3.5%, p = 0.94), or PERF rate (12.7% vs. 10.1%, p = 0.54). The MP group had a significantly higher rate of prophylactic high-flow nasal cannula (HFNC) use (6.2% vs. 21.0%, p < 0.001). Conclusions In this exploratory study, the MP did not show statistically significant differences in re-intubation rates or PERF compared to the EP. However, the MP, incorporating nurse-led daily SATs and systematic risk stratification, was associated with a significantly higher use of prophylactic HFNC. The study was underpowered to confirm equivalence, and these findings should be interpreted as hypothesis-generating.