The weaning continuum use of Acute Physiology and Chronic

Health Evaluation III, Burns Wean Assessment Program,

Therapeutic Intervention Scoring System, and Wean Index scores
to establish stages of weaning
Suzanne M. Burns, RN, MSN, RRT, CCRN, ACNP-CS; Beverly Ryan, RN, MSN, CCRN, ACNP-CS;
James E. Burns, MD, MBA

Objective: To determine whether four stages of weaning
(acute, prewean, wean, and outcome) could be identified by using
clinical instruments designed to quantify severity of illness, pa-
tient stability, or weaning readiness. The instruments used were
the Acute Physiology and Chronic Health Evaluation (APACHE III),
the Therapeutic Intervention Scoring System (TISS), the Burns
Wean Assessment Program (BWAP), and the Wean Index (WI). The
stages were adapted from those proposed by the American As-
sociation of Critical Care Nurses Third National Study Group’s
Weaning Continuum Model.
Design: Prospective, convenience cohort. This study was part
of a larger study designed to test an outcomes managed approach
to weaning by using an outcomes manager and a clinical path-
way.
Setting: University medical intensive care unit.
Patients: Adult patients requiring mechanical ventilation >3
days admitted to the medical intensive care unit between Novem-
ber 1994 and May 1995.
Interventions: None.
Measurements and Main Results: Scores for the APACHE III,
TISS, BWAP, and WI were collected on 97 patients every other day
until they weaned, were transferred, or died. Outcomes described
for each stage of weaning were dated on the clinical pathway
when achieved. Comments about patient stability and ventilator
progress also were recorded along with a subjective determina-
tion of the stage of weaning. We used decision rules to identify
time intervals for each stage of weaning and outcomes attained
by stage. Finally, APACHE III, TISS, BWAP, and WI scores were
placed in each stage by date for analysis. The APACHE III, TISS,
and BWAP scores were able to differentiate the acute, prewean,
and wean stages but not the outcome stage.
Conclusions: By identifying distinct scores for each stage, we
may be able to better explore appropriate interventions for the
stages as well as predict weaning outcomes. Indices that include
physiologic and respiratory factors can differentiate weaning
stages, but respiratory factors alone cannot. (Crit Care Med 2000;
28:2259 –2267)
KEY WORDS: ventilators; mechanical; severity of illness index;
ventilator weaning; intensive care units; human; clinical proto-
cols; APACHE; monitoring; physiologic; outcome assessment; de-
cision support techniques; models; theoretical; adult

W eaning patients efficiently

from prolonged mechani-
cal ventilation continues
to be a goal of research-
ers, clinicians, and administrators. Long-
term mechanical ventilation is time and
effort intensive, and institutions often ex-
perience financial losses as a result of
long and costly hospital stays. In an effort
to decrease costs and improve outcomes
associated with prolonged ventilation,
numerous weaning indices (1–3), proto-
cols (4 –7), pathways (8, 9), and system
From the University of Virginia Health Systems (Ms.
Burns and Ms. Ryan), University of Virginia, Charlottes-
ville, VA; and the Department of Pediatrics (Dr. Burns),
University of Virginia Health Sciences Center and the
Virginia Department of Health, Charlottesville, VA.
Copyright © 2000 by Lippincott Williams & Wilkins
models of care delivery (e.g., outcomes
management, wean teams, special wean-
ing units) (9 –18) have been designed and
tested. Although most have merit and
have added greatly to our understanding
of the weaning process, we continue to
struggle with questions of when and how
to wean. For example, recent work sug-
gests that bedside testing of the ability to
sustain spontaneous breathing (by using
noninvasive criteria to determine toler-
ance) is a safe and efficient method (6),
yet efforts to predict ability to wean con-
tinue to explore how weaning readiness
might be quantified more reliably. In fact,
even the definition of weaning is at times
unclear, because articles on the topic re-
fer to both the process (gradual liberation
from the ventilator) and the outcome (ex-
tubation) as weaning. In an effort to pro-
vide a framework for discussing and
studying issues related to weaning, the
American Association of Critical Care
Nurses (AACN) Third National Study
Group on Weaning proposed a model of
weaning called the Weaning Continuum
Model in 1994 (19) and recently revised
the model (20). To date, the model has
had limited testing only in a pediatric
population (21).
The purpose of our study was to test
the Weaning Continuum Model stages by
using the Acute Physiology and Chronic
Health Evaluation III score (APACHE III,
APACHE Medical Systems, McLean VA)
(22), the Therapeutic Intervention Scor-
ing System (TISS) (23, 24), the Burns
Wean Assessment Program (BWAP) (25),

Crit Care Med 2000 Vol. 28, No. 7 1

and the Weaning Index (WI) (2). We be-
lieved that identifying threshold scores
for each stage would be extremely valu-
able both for clinical application (e.g.,
when to rest, when to assign to a weaning
protocol) and so that future research in
weaning might use the identified stages
to better evaluate weaning potential and
outcomes. This study was part of a larger
study designed to test the results of an
outcomes managed approach to caring
for the patient who requires prolonged
ventilation by using a multidisciplinary
clinical pathway and an outcomes man-
ager (9). The larger study is described in
the study design section of this article.
The Weaning Continuum Model. The
Weaning Continuum Model (Fig. 1) con-
sists of three weaning stages. The first
stage, the prewean stage, encompasses
that time when active weaning cannot
occur because the event or condition that
necessitated mechanical ventilation has
not resolved and/or other complications
are present. The weaning stage is identi-
fied as that interval when the patient’s
overall condition has stabilized and for-
ward progress in ventilator liberation is
occurring. The outcome stage consists of
spontaneous breathing (with or without
an artificial airway) for 24 hrs, incom-
plete weaning with dependence on partial
ventilatory support, dependence on com-
plete ventilatory support, or death. Be-
cause we believe that the first 48 –72 hrs
of the patient’s admission often is char-
acterized by medical instability and the
need for multiple diagnostic and thera-
Figure 1. Weaning continuum model, a refined
model of weaning in which the stages and for-
ward progression are represented by a stair-step
configuration. The trajectory shown is only one
theoretical possibility. Testing of the model will
be required to determine the actual trajectory of
individual patients. The length of the steps is not
intended to represent the actual duration of each
stage. For clarity, relevant elements of the orig-
inal model (such as factors affecting weaning and
decisions about weaning) have been omitted. Re-
2 Crit Care Med 2000 Vol. 28, No. 7
produced with permission from the American
peutic interventions, we chose to add an
Association of Critical Care Nurses.
additional stage called the “acute stage”
to our clinical pathway. During this
stage, full weaning assessments are diffi-
cult to attain, and some patients are on
muscle relaxants to ensure adequate ven-
tilation. Although we acknowledge that
the prewean stage of the Weaning Con-
tinuum Model incorporates the acute
stage, we felt it was important to separate
the stages in the pathway for this study to
better examine score trends. In addition,
because long-term mechanical ventila-
tion was identified by the Third National
Study Group as the continuation of me-
chanical ventilation beyond 3 days (26,
27), we believe our identification of the
acute stage as separate from the prewean
stage may help define that interval that
separates short-term from long-term me-
chanical ventilation.
Few clinical bedside instruments exist
that are noninvasive yet comprehensive
enough to quantify the stability and se-
verity of illness of critical care patients.
Previous testing of the four tools selected
for use in our study has established their
characteristics in clinical use (2, 3, 9,
22–24, 28, 29). We hypothesized that
weaning progress would parallel patient
stability, and that distinct APACHE III,
TISS, BWAP, and WI scores could be
identified that were associated with the
proposed weaning continuum stages.
Our decision to use the APACHE III,
TISS, BWAP, and WI scores to test the
stages of the weaning continuum was
based on our belief that weaning is a
process that requires clinical decisions
about the patient’s readiness and/or abil- ity
to accomplish the work associated with
weaning. Although a tremendous amount
of work has been accomplished in the
area of weaning, clinicians still struggle
to determine the combination of
mechanical, physiologic, and psychologi-
cal data that best indicate weaning readi-
ness; to date, no single factor or combi-
nation of factors has been identified as
most predictive. Pulmonary-specific indi-
ces have dominated work in weaning pre-
diction, yet few of the pulmonary-specific
indices have been tested over the contin-
uum of weaning. Instead, most have been
tested at the end of the continuum, at
extubation (1, 2). In work by two of us
(S.B., J.B.) (3), the BWAP, a comprehen-
sive 26-factor weaning assessment tool,
performed better than pulmonary-spe- cific
indices over time, suggesting that
weaning readiness is determined by the
attainment of an overall physiologic
and track factors important to weaning
also directs users about how to offset
weaning impediments (25). Central to
the BWAP is a 26-factor bedside work-
sheet used to assess weaning potential
(25). This worksheet is broken down into
12 general categories (hemodynamics,
nutrition, etc.) and 14 respiratory catego-
ries (negative inspiratory pressure, spon-
taneous tidal volume and respiratory
rate, tube size, secretions, etc.). Dividing
the number of factors that are scored as
“yes” (those that meet the established
threshold) by 26 creates a proportionate
score expressed as a percentage. In a pre-
vious study (3), the threshold score of
64% was found to correlate with the abil-
ity to spontaneously breathe for 24 hrs.
Scores ,64% were found to have strong
negative predictive ability (3). In the
study by Burns et al. (3), the BWAP,
tracked every other day until weaning
was accomplished, changed significantly
between prewean and wean stages.
Last, the WI is an integrated index of
strength, endurance, and gas exchange
Crit Care Med 2000 Vol. 28, No. 7
threshold rather than simply
respiratory strength and endurance. In
addition, pre- mature attempts at
weaning may be harmful (30). A
reasonable first step in determining
weaning readiness, then, is to attempt
to identify the proposed stages of
weaning by describing the course of
the weaning continuum using reliable
clinical tools that are sensitive to
changes in physiologic stability over
time. To that end, we selected severity
of illness indices (APACHE III and
TISS), a combined physiologic and
respiratory factors index (BWAP), and a
pure respiratory factor in- dex (WI),
which are described next.
Description of the APACHE III, TISS,
BWAP, and WI. The APACHE III
prognos- tic system (22) is designed
to associate the acute changes in a
patient’s physio- logic state with risk of
death. This com- puterized system uses
diagnosis, acute physiologic and
laboratory abnormalities, age, chronic
health status, admission source,
treatment, resource use, and out- come.
The system has two major compo-
nents: the APACHE III score and the
pre- dictive equations that compare a
patient to an extensive database (22).
Only the APACHE III score was used in
(2). Thresholds for the WI have been ,
4 (successful wean) and .4
(unsuccessful wean). It was recognized
that this index would be extremely
difficult to measure over the continuum
of illness because many of the factors
may not be measured routinely during
the acute or prewean phase. This is
because calculation of the score
depends on measuring standard
variables such as negative inspiratory
pressure and spontaneous tidal volume,
which are unlikely to be attempted
unless the patient is stable. We
believed that it would be valuable to
study this index for a variety of reasons.
In previous studies, traditional
respiratory variables such as negative
inspiratory pressure and positive
expiratory pressure did not prove to
be reliable predictors of weaning
potential (1, 3, 31). Both Burns et al. (3)
and Mor- ganroth et al. (31) found that
individual respiratory factors, even when
integrated with other respiratory factors,
were not as predictive as when combined
this study.
The APACHE III score is a combina-
tion of the patient’s physiologic reserve
points (age plus chronic health score)
and an acute physiology score. The
chronic health score reflects the presence
of one or more of seven comorbid condi-
tions that influence immune status and
short-term mortality risk. The acute
physiology score is a measure of the acute
severity or clinical significance of de-
ranged physiology based on the worst
value for the preceding 24 hrs. The range
of possible APACHE III scores is 0 –299,
with 299 indicating the highest severity
level of illness.
TISS, initially developed at Massachu-
setts General Hospital and introduced in
1974 (23), was updated in 1983 (24). This
system has been used widely to classify
critical care patients. TISS assigns points
(1– 4) to interventions based on an in-
creasing level of complexity or effort. In-
terventions include diagnostic, monitor-
ing, and therapeutic tasks commonly
performed in intensive care. Thus, a wide
range of scores is possible, with higher
TISS points reflecting patient deteriora-
tion and lower points suggesting im-
provement.
The BWAP, a computer application de-
signed to help clinicians assess, evaluate,
with non- pulmonary factors. In addition,
respiratory- specific scores did not change
over time, further suggesting their
inability to pre- dict weaning outcomes.
Because both the BWAP and the WI were
used routinely in our unit, the data were
easy to attain and the ability of the WI
(and thus respiratory- specific variables)
to change during the course of the
weaning continuum could be tested.
3
MATERIALS AND METHODS
Study Design. In this convenience study,
after gaining approval from the institutional
review board, we collected data prospectively
three times per week for 6 months on patients
requiring prolonged ventilation in a 12-bed
medical intensive care unit. The data were
collected in conjunction with data acquired
for a study designed to test the outcomes
associated with an “outcomes managed ap-
proach” to the care of patients requiring pro-
longed mechanical ventilation (defined as pa-
tients requiring ventilation .3 days) (9). In
the larger quasi-experimental study, the out-
comes managed approach, using a multidisci-
plinary clinical pathway and protocols for
weaning and managed by an outcomes man-
ager, was alternated every month for 6 months
with a nonmanaged (control) approach, and
after that, outcomes were managed continu-
ously for an additional 6 months. Variables of
interest in the larger study included duration
of mechanical ventilation, hospital length of
stay, days of mechanical ventilation with and
without a tracheostomy, and outcomes
(weaned, withdrawal, death, or transfer with-
out weaning). All prospective data also were
compared with data from a 1-yr retrospective
chart review. During the nonmanaged pro-
spective portions of the larger study, the out-
comes manager did not actively “manage”
components of care; however, data collection
continued and included the variables of inter-
est for this study.
Data Collection. A consecutive sample of
mechanically ventilated patients who were
$18 yrs old of either gender admitted to the
medical intensive care unit between Novem-
ber 1994 and May 1995 were enrolled. How-
ever, only patient data on those who required
mechanical ventilation for .3 days were ana-
lyzed. All study subjects were followed until
they were discharged, were transferred, or
died. Data collection was truncated at 90 days,
but in this data set all patients had achieved an
outcome by 54 days.
Study Sample. As noted, this study sample
was a subset of a larger study. The larger study
consisted of 409 patients (1 yr of retrospective
data and 1 yr of prospective data). The current
study includes only the 97 patients enrolled in
the initial 6-month prospective data collection
period. The mean age of this study sample was
55.7 6 16.1 yrs, and the female/male distribu-
tion was 48% and 52%, respectively.
Methods. Five outcomes managers col-
lected data every Monday, Wednesday, and Fri-
day for the duration of the study. The data
collectors were familiar with all aspects of the
tools, and data were reviewed daily for accu-
racy by the primary investigator. All scores,
except for the WI, were obtained on each of the
study days (with few exceptions). The WI could
not be evaluated routinely, because patients
were not always clinically stable and negative
inspiratory pressure (which is essential to cal-
4 Crit Care Med 2000 Vol. 28, No. 7
culate the WI) could not be measured safely. Although standard weaning criteria also are
assessed in the BWAP, calculation of the
BWAP score does not require scoring of all the
variables; a “not assessed” category is pro-
vided. When BWAP factors are recorded as
“not assessed” they are counted as “no,” so the
score is lowered. We assumed that being un-
able to assess a factor reflected patient insta-
bility.
Because the original study was designed to
test an outcomes managed approach to wean-
ing patients from mechanical ventilation
using an outcomes manager and a multi-
disciplinary clinical pathway, measurable
outcomes for progression from one stage to
another were identified on the clinical path-
way (Fig. 2) (9). The multidisciplinary team
selected the outcomes for the stages (called
phases on the pathway but referred to in this
paper as stages) during the benchmarking
pathway development of the original study.
During the study, the outcomes were dated
when they were achieved, and clinical com-
ments about patient stability and ventilator
progress were noted on a separate comment
section of the instrument. A subjective deter-
mination of the stage of weaning also was
recorded based on the description of the stages
discussed earlier. APACHE III, TISS, BWAP,
and WI scores were listed by date on a separate
data sheet. Then, decision rules were used to
determine the relationship of the scores to the
stages of weaning. This evaluation was done as
a group (separate from data collection). We
employed the following decision rules:
1. For each study patient, stage-specific out-
comes (Fig. 2, outcome columns), were
clustered by attainment dates (we did not
require that all outcomes be achieved but
rather a majority of them). A range of dates
by stage was identified.
2. Then, the dated subjective stage assign-
ments were clustered for each patient.
These date ranges were compared with rule
1 stage-specific date ranges. If the dates
were not comparable between the two eval-
uation methods, then we reviewed com-
ment section notes that described patient
stability, active therapies, and ventilator
progress in addition to reviewing the chart
until consensus was reached about the
stage dates. Generally, the dates were com-
parable and we easily identified the dates
defining the stages.
3. Once the stage-specific interval dates were
identified, the patient’s APACHE III, TISS,
BWAP, and WI scores were placed in the
appropriate stages by date.
Statistical Analysis. We used the Kruskal
Wallis test to compare stage of weaning inter-
val data. The one-way analysis of variance was
used to test the weaning stages as a group.
Pearson correlation coefficients were used to
compare the four indices. No corrections were
made for multiple comparisons. Alpha was set
at .05.

Crit Care Med 2000 Vol. 28, No. 7 5

Figure 2. Clinical pathway. Care pathway for patients requiring long-term mechanical ventilation. Reproduced with permission from the American
Association of Critical Care Nurses.
Figure 2. Continues.

Crit Care Med 2000 Vol. 28, No. 7 2263

Figure 2. Continues.

2264 Crit Care Med 2000 Vol. 28, No. 7

Table 1. Ventilator days by stage of weaning
Acute (n 5 77) Prewean (n 5 43)
Mean days 5.6 (4.1–7.1)
Median days 3.0
Mean number of days (95% confidence interval for mean).
RESULTS
The study consisted of a total of 97
patients and 839 patient-days. Of the 839
patient-days, 446 (53.2%) were in the acute
stage, 247 (29.4%) were in the pre-
wean stage, 128 (15.3%) were in the wean
stage, and 18 (2.2%) were in the out-
come stage (7 patient-days were unclas-
sified and are not included). Patients av-
eraged 5.6, 6.3, 3.7, and 2.6 days in acute
through weaning outcomes stages, re-
spectively. Fifty-seven percent of the
study sample weaned, 37% died before
weaning occurred, and 6% were trans-
ferred home or to another facility while
ventilated.
Figure 3 shows the APACHE III, TISS,
BWAP, and WI mean scores by stages of
weaning. Score differences were signifi-
cant between acute and prewean and be-
tween prewean and wean for all indices
except the WI. None of the differences
between wean and outcome stages were
significant; the sample size for the out-
come stage is quite small at n 5 8 –
29. The maximum number of patients in
any phase was 77. The difference
between that number and the total of 97
patients in the study is because the
entry stages varied (e.g., not all patients
entered in stage 1). There were 12
instances where patients regressed one
stage (seven were from the prewean back
to acute) and one patient regressed two
stages.
Table 1 shows the mean and median
number of patient days by stage of wean-
ing. Table 2 presents the Pearson bivari-
ate correlation coefficients for the four
indices. There is significant but modest
correlation among the APACHE, BWAP,
and TISS. WI correlations are significant
only with the APACHE III score.
DISCUSSION
The study hypothesis that clinical
tools designed to quantify severity of ill-
ness may identify distinct stages of wean-
ing appears to be supported. The scores,
with the exception of the WI, are inclu-
sive of physiologic variables that improve
as the patient gains stability and
Crit Care Med 2000 Vol. 28, No. 7
Wean (n 5 43) Outcome (n 5 15)
6.3 (4.6–8.1) 3.7 (2.3–4.7) 2.6 (1.4–3.8)
4.0 3.0 2.0
progresses through the weaning stages.
Although the mean APACHE, TISS, and
BWAP scores clearly identify the stages,
selection of inclusive and exclusive scores
is more difficult. The APACHE, TISS, and
BWAP allow distinction between acute,
prewean, and wean stages but do not dis-
tinguish wean from outcome. The WI, a
respiratory-specific variable, does not ap-
pear to identify patient stability or wean-
ing ability. In fact, respiratory variables
alone do not appear to predict weaning
ability, at least in patients ventilated
long-term. In studies by Morganroth et
al. (31) and Burns et al. (3), respiratory-
specific indices did not change over time,
suggesting that their ability to test wean-
ing readiness is weak at best.
The stages of weaning described in the
AACN9s Weaning Continuum Model ap-
pear to be logical and consistent with
clinical practice. This finding was also
supported in a study by Curley and
Fackler (21) on young children identified
as demonstrating an “inconsistent” wean-
ing pattern (where the weaning contin-
uum is characterized by peaks and valleys
rather than a linear predictable pattern).
However, it appears that the acute stage,
as identified in this study, is distinct
enough to be separated from the prewean
stage, at least in adults. To that end, an
acute stage should be represented in the
Weaning Continuum Model.
It is interesting that the APACHE III,
TISS, and BWAP performed well given
that only the BWAP is designed expressly
to assess weaning ability. It appears that
patients who require prolonged mechan-
ical ventilation suffer from a combination
of physiologic factors that impede
progress, and that despite gains in respi-
ratory muscle function, they will not wean
until their overall status supports wean-
ing. The BWAP is a comprehensive
weaning index and incorporates both re-
spiratory and general factors. Both Burns
et al. (3) and Morganroth et al. (31) dem-
onstrated that combined general and re-
spiratory factors are more predictive than
when evaluated separately. Although this
concept inherently makes sense and has
C
linical tools de-
signed to quantify
severity of illness
may identify distinct stages
of weaning.
been expressed before, research contin-
ues to focus on respiratory-specific indi-
cators to the exclusion of others (1, 2).
Despite evidence that respiratory-specific
variables are weak positive predictors (1,
3, 31) and that the values are often not
reproducible (32, 33), studies on their
performance as predictors of weaning
readiness continue (1, 2). Although respi-
ratory variables such as the negative in-
spiratory pressure do tell us something
about respiratory muscle function, they
only tell us about that one specific func-
tion, not the more holistic concept of
weaning readiness.
It is intriguing that there are relatively
few days in the weaning stage (3.7), cer-
tainly fewer than the acute (5.6) and
prewean (6.3) stages of the model (Table
1). In contrast, the literature and discus-
sions related to weaning tend to regard a
large portion of the period of mechanical
ventilation as appropriate for weaning.
Only recently, in studies on weaning pro-
tocols, has the consistent use of thresh-
old criteria for initiating weaning trials
been described (4 –7). Although these
protocol criteria appear logical and easy
to evaluate at bedside, their relationship
to weaning stages is unknown. This is
clinically important because weaning at-
tempts initiated during the acute or
prewean stages either may be futile or
may unduly stress the patient, leading to
fatigue, failure, longer ventilator dura-
tion, and poor outcomes. It may be that
weaning has less to do with what we do
with the ventilator than when we do it.
This has practical implications in terms
of the appropriate use of healthcare re-
sources. For example, it may be prudent
to defer weaning trials until stage-specific
thresholds are reached or at least until
scores likely to be associated with the
weaning stage are achieved.
By identifying distinct scores for each
weaning continuum stage, we may be
able to explore appropriate interventions
for each stage. As noted by MacIntyre
9
Figure 3. Mean index scores by weaning stage. Columns show mean scores. Error bars show 95% confidence interval of mean. Solid diamonds, difference
between adjacent plots is significant at p , .01. “Observations” is the number of separate observations summarized in the plot above, and “patients” is
the number of patients from which those observations are derived. APACHE, Acute Physiology and Chronic Health Evaluation; TISS, Therapeutic
Intervention Scoring System; BWAP, Burns Wean Assessment Program; WI, Wean Index.

Table 2. Pearson bivariate correlation coefficients ness has been suggested by the two stud-
ies noted (3, 31) in long-term mechani-
Correlation cally ventilated patients, as well as in
Comparison Coefficient (r2) Significance short-term mechanically ventilated pa-
tients. Hanneman (34) demonstrated that
APACHE—TISS .239 ,.01 multidimensional predictors (e.g., hemo-
APACHE—WI .084 ,.01 dynamics, vital capacity per kilogram)
APACHE—BWAP .077 ,.01
BWAP—TISS .063 ,.01
were superior to unidimensional predic-
BWAP—WI .036 NS TISS tors in postoperative cardiac surgery pa-
—WI ,.001 NS tients. It is important to resolve this dis-
crepancy between the variables we
APACHE, Acute Physiology and Chronic commonly use to assess weaning readi-
Health Evaluation; TISS, Therapeutic Interven-
ness and the more holistic factors that
tion Scoring System; WI, Wean Index; BWAP,
Burns Wean Assessment Program. have been identified as important to the
process.
Two limitations to this study are
(30), it may be harmful to begin trials of
noted. A greater number of scores for
ventilator liberation prematurely. Studies
each index was obtained in the early
that test respiratory muscle function by stages of the patient’s illness compared
the weaning continuum stages would be
with later stages (Fig. 3 and Table 1).
helpful to validate the inadequacy of re- Patients spent less time in the weaning
spiratory muscle function as the major
and outcome stages than the acute or
predictor of weaning readiness or wean- prewean stages. A study designed to cap-
ing outcome. The argument that respira-
ture equal numbers of scores for each
tory-specific variables do not capture the stage of the weaning continuum model
full picture with regard to weaning readi-
may strengthen our ability to test stage-
specific scores.
An undetected bias may have occurred
in the method used to assign the weaning
stages. Because the various methods used
to make these determinations were al-
most always in agreement, we think this
bias would be minimal.
CONCLUSIONS
The prewean and wean stages de-
scribed in the conceptual model designed
by the AACN9s Third National Study
Group on Weaning were validated by the
distinct APACHE III, TISS, and BWAP
scores identified in this study. However,
the model would more accurately reflect
clinical practice if an acute stage were
represented. The trajectory and length of
the acute stage may be important predic-
tors of outcomes in these patients. Al-
though studies designed to test the pro-
posed weaning stages are needed, they
will be difficult to accomplish because
patients will need to be followed inten-

2266 Crit Care Med 2000 Vol. 28, No. 7

sively and over the course of ventilator
duration. Studies that test the stages of
weaning in different patient populations
and that compare the efficacy of interven-
tions by stage, will be important. Predic-
tive models using stage-specific scores in
combination with other data such as
length of time in the stage may enable
true prediction of outcomes. This study
begins to describe the continuum of
weaning by stages; however, other studies
in a variety of patient populations are
necessary before we can truly understand
the totality of the long-term mechani-
cally ventilated patient’s experience and
apply interventions efficiently and effec-
tively.
REFERENCES
1. Yang KL, Tobin MJ: A prospective study of
indexes predicting the outcome of trials of
weaning from mechanical ventilation.
N Engl J Med 1991; 324:1445–1450
2. Jabour ER, Rabil DM, Truwit JD, et al: Eval-
uation of a new weaning index based on
ventilatory endurance and the efficiency of
gas exchange. Am Rev Respir Dis 1991; 144:
531–537
3. Burns SM, Burns JE, Truwit JD: Comparison
of five clinical weaning indices. Am J Crit
Care 1994; 3:342–352
4. Brochard L, Rauss A, Benitos S, et al: Com-
parison of three methods of gradual with-
drawal from ventilatory support during
weaning form mechanical ventilation. Am J
Respir Crit Care Med 1994; 150:896 –903
5. Esteban A, Fruitos F, Tobin M, et al: A com-
parison of four methods of weaning patients
from mechanical ventilation. N Engl J Med
1995; 332:345–350
6. Ely EW, Baker AM, Dunagan DP, et al: Effect
on the duration of mechanical ventilation of
identifying patients capable of breathing
spontaneously. N Engl J Med 1996; 335:
1854 –1869
7. Kollef MH, Shapiro SD, Silver P, et al: A
randomized, controlled trial of protocol-
directed versus physician directed weaning
from mechanical ventilation. Crit Care Med
1997; 25:567–574
8. Kite-Powell D, Sauban D, Ideno KT, et al:
Crit Care Med 2000 Vol. 28, No. 7
Optimizing outcomes in ventilator-depen-
dent patients: Challenging critical care prac-
tice. Crit Care Nurs Q 1996; 19:77–90
9. Burns SM, Marshall M, Burns JE, et al: De- 22.
sign, testing and results of an outcomes
managed approach to patients requiring pro-
longed ventilation. Am J Crit Care 1998;
7:45–57
10. Burns SM, Carpenter R, Harris R, et al: 23.
Developing a team approach to weaning.
Nursing 1995; 25:32TT-32WW
11. Cohen IL, Bari N, Strosberg MA, et al: Re-
duction of duration and cost of mechanical 24.
ventilation in an intensive care unit by use of
a ventilatory management team. Crit Care
Med 1994; 19:1278 –1284 25.
12. Daly B, Rudy ER, Thompson KS, et al: De-
velopment of a special care unit for chroni-
cally ill patients. Heart Lung 1991; 20:40 –51
13. Daly BI, Phelps C, Rudy EB: A nurse- 26.
managed special care unit. J Nurs Adm 1991;
21:31–38
14. Gracey DR, Gillespie D, Nobrega F, et al:
Financial implications of prolonged ventila- 27.
tor care of Medicare patients under the pro-
spective payment system: A multicenter
study. Chest 198 7:91:424 – 427 28.
15. Elpern EH, Silver MR, Bone RL, et al: The
noninvasive respiratory care unit: Patterns of
use and financial implications. Chest 1991;
99:205–208
16. Indihar FJ: A 10-year report of patients in a 29.
prolonged respiratory care unit. Minn Med
1991; 74:23–27
17. Gracey DR, Viggiano RW, Naessens JM, et
al: Outcomes of patients admitted in a
30.
chronic ventilatory-dependent unit in an
acute care hospital. Mayo Clin Proc 1992;
67:131–136
18. Scheinhorn DJ, Artinian BM, Catlin JL: 31.
Weaning from prolonged mechanical venti-
lation: The experience of a regional weaning
center. Chest 1994; 105:534 –539
19. Knebel AR, Shekleton ME, Burns SM, et al: 32.
Weaning from mechanical ventilation: Con-
cept development. Am J Crit Care 1994;
3:416 – 33.
420
20. Knebel AR, Shekleton ME, Burns SM, et al: 34.
Weaning from mechanical ventilatory sup-
port: Refinement of a model. Am J Crit Care
1998; 7:149 –152
21. Curley M, Fackler JC: Weaning from me-
chanical ventilation: Patterns in young chil-
dren recovering from acute hypoxemic respi-
ratory failure. Am J Crit Care 1998;
7:335–345
Knaus WA, Wagner DP, Draper EA, et al: The
APACHE III prognostic system: Risk predic-
tion of hospital mortality for critically ill
hospitalized adults. Chest 1991; 100:
1619 –1636
Cullen DJ, Civetta JM, Briggs BA, et al: Ther-
apeutic Intervention Scoring System: A
method for quantitative comparison of pa-
tient care. Crit Care Med 1974; 2:57– 80
Keene AR, Cullen DJ: Therapeutic Interven-
tion Scoring System: Update 1983. Critical
Care Med 1983; 11:1–3
Burns SM, Barton D, Fahey S, et al: Weaning
from mechanical ventilation: A method for
assessment and planning. AACN Clin Issues
Crit Care Nurs 1991; 2:372–387
Hanneman SK, Ingersoll GL, Knebel AR, et
al: Weaning from short-term mechanical
ventilation: A review. Am J Crit Care 1994;
3:421– 443
Burns SM, Clochesy JM, Hanneman SK, et al:
Weaning from long-term mechanical venti-
lation. Am J Crit Care 1995; 4:4 –22
Zimmerman JE, Wagner DP, Sun X, et al:
Planning patient services for intermediate
care units: Insights based on care for inten-
sive care unit low-risk monitor admission.
Crit Care Med 1996; 24:1626 –1632
Zimmerman JE, Wagner DP, Draper EA, et
al: Evaluation of Acute Physiology and
Chronic Health Evaluation III predictions of
hospital mortality in an independent data-
base. Crit Care Med 1998; 26:1317–1326
MacIntyre NR: Ventilatory muscles and me-
chanical ventilatory support. Crit Care Med
1997; 25:1106 –1107
Morganroth ML, Morganroth JL, Nett LM, et
al: Criteria for weaning from prolonged me-
chanical ventilation. Arch Intern Med 1984;
144:1012–1016
Yang KL: Reproducibility of weaning param-
eters: A need for standardization. Chest 1992;
102:1829 –1832
Mador MJ: Weaning parameters: Are they
clinically useful? Chest 1992; 102:1642–1643
Goodnough-Hanneman SK: Multidimen-
sional predictors of success or failure with
early weaning from mechanical ventilation
after cardiac surgery. Nurs Res 1994; 43:
4 –10
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