Have we really come that far since the days of Negative Pressure Ventilation?

Prolonged Mechanical Ventilation

Weaning Strategies in the ICU

When is MV Prolonged?
 

Numerous Definitions NAMDRC Consensus Statement

>21 consecutive days for >6 h/d (recommendation #1) Estimated 5% of MV patients will require PMV (Pierson et al.) But, nearly 34% of patients intubated for >48 hours will require extended intubations


Patient Type
  

Older Comorbid Conditions Underlying Obstructive Lung Disease

Ventilator Dependence


Systemic  Chronic comorbid conditions  Chronic Hypercapnia  Organ Failure (Renal failure especially can dramatically increase the mortality rate) Mechanics  Increased Work of Breathing  Decreased Respiratory Muscle Capacity  Intrinsic PEEP  Airway Patency (eg. tracheal stenosis) Iatrogenic  Unrecognized withdrawal potential  Inappropriate vent settings  MEDS (Suppress drive and muscle weakness) LongLong-term hospital stay  Infection (VAP, Sepsis/SIRSdecrease O2 uptake) Sepsis/SIRS  Recurrent Aspiration  DVT Psych  Sedation  Depression  Anxiety

Dependence/Failure to Wean


Additional Features
Cardiovascular Function
Ischemia Heart Failure

Metabolic Derangements
Hypophosphatemia Hypocalcemia Hypomagnesemia Hypothyroidism (severe)

Nutrition
Poorprotein catabolism Poor Overfeedingexcess CO2 Overfeeding

Deconditioning

Complications of PMV


Infection
Bacterial Pneumonia Line sepsis C. Diff

        

Volume Overload Laryngeal Edema Pneumothorax Tracheal Bleeding Renal Failure Ileus GI Bleeding DVT Additional Complications if Tracheostomy is necessary

Weaning
 

Start as soon as possible Success depends generally on

1) Strength of Respiratory muscles 2) Load Applied 3) Drive to Breath

Has the problem which led to intubation been resolved? Is there a new problem? Identify those factors contributing to dependence that are potentially reversible (NAMDRC Rec #4) SedativeSedative-based depression of respiratory drive can lead to inappropriately prolonged dependence on MV

Initiate Weaning


When there is:

1. Adequate Oxygenation
A) PaO2/FiO2 >150-200 >150B) Vent Settings: PEEP <8 and FiO2 <0.5

2. 3. 4. 5.

pH >7.25 Hemodynamic stablility Ability to Initiate an Inspiratory Effort Sedation (esp. with resp-depressing respdrugs) has itself been weaned

Predicting Success


A number of criteria have been proposed

 

Vital Capacity Tidal Volume (using a cutoff of 4 mL/Kg)

PPV 0.67, NPV 0.85

  

PaO2/FiO2 Max Insp. Pressure RR/VT (Rapid Shallow Breathing Index)

RSBI


 

First described by Yang and Tobin in 1991 Simply the f/VT Observation that those who fail weaning trials decrease their tidal volumes and increase their rate Threshold <105
PPV: 0.78 and NPV: 0.95

In PMV


Even with these indices predicting weaning success in this population is difficult. Some attempts have been made
 

Success has been correlated with number of comorbid diagnoses as well as length of MV Scheinhorn et al used A-a gradient, gender, and BUN A(recognizing the increased mortality when renal failure was involved) to attempt to score the likelihood of successful weaning. Unfortunately this has shown limited success in repeat studies.

Additionally, the up and coming use of postpost-ICU weaning facilities has improved weaning outcome.

Methods of Weaning


 

Synchronized Intermittent Mandatory Ventilation (SIMV) Pressure Support Ventilation (PSV) SBT
  

No Support CPAP PS

NB: These methods are the same used with acute patients. The important difference is PMV patients generally require a more gradual weaning course

SIMV


Breaths are either spontaneous (+/- pressure support) or (+/mandatory vent-controlled. Mandatory breaths are synchronized ventwith patients own efforts Allows for a gradual decrease in ventilator-provided support and a ventilatorgradual increase in the patients respiratory workload
  

Rate is Reduced Progressively (2 breaths every 1-2 hours) 1Blood gasses are checked Patient is monitored for ability to accept increased work of breathing (HR, RR, Sats, clinical signs)

But, studies have shown that respiratory muscles are unable to rest during the mandatory ventilator breaths (the respiratory center fails to adapt to the intermittent support). Can delay weaning by contributing to the development of respiratory muscle fatigue and therefore can delay extubation

Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish lung failure collaborative group. N Engl J Med 1995; 332:345-350

Pressure Support Ventilation

 

All breaths are spontaneous. But when PS is high relative to patient effort, support is almost fully from MV Enough PS is given with each breath to ensure an adequate VT. Method
 

Gradually decrease the amount of PS (transferring the work to the patient) Once PS approaches 5-6 cmH2O extubation can be 5considered

 

Reduces the work of breathing Can be used in conjunction with SIMV during weaning Reduces the likelihood of reintubation but was shown to be only slightly better than SIMV in duration of weaning

SBT SBTSink or Swim



Applications


Extubation readinessa 90 minute test (though at readiness least one studyEsteban et alsuggested that only study al 30 min may be necessary) Weaning
Length of SBT is increased daily Periods of ventilation are alternated with these trials T-piece Trials  Requires removing patient from vent and providing supplemental humidified O2 to their airway (through a tube that looks like a T.)  These trials can also now be done with the patient still directly connected to the vent which allows closer observation (and all the bells and whistles that the vent provides)

Types of SBTs
1. 2. 3.

No Vent Support Low level of CPAPclosing pressure CPAP Low Level of PSairway resistance PS
No controlled studies have demonstrated superiority of any of these modes. However, in certain patient populations such as those with marginal left ventricular function, a low level of CPAP and the subsequent increase in intrathoracic pressure can help prevent heart failure. But, its removal, may lead to acute heart failure following extubation secondary to increased LV preload and LVEDP

Trial
 

3030-90 minutes Once daily



A number of studies have demonstrated equivalent results between multiple daily tests and once daily tests

Following each SBT evaluate for possible extubation

 

BP, RR, HR, ABG should all be considered Level of sedation

SBTs are superior to both IMV and PS in duration of weaning and likelihood of success after weaning In patients on PMV, daily trials may be required for a longer period of time.

Seminal Study (Esteban et al)



546 Patients


All underwent a 2-hr SBT to evaluate for 2extubation

130 had respiratory distress during the SBT and were not extubated These pts were randomized to 1 of 4 groups
SIMVinitial rate of 10.0 breaths per minute, then SIMV decreased at least twice a day, by 2 to 4 bpm (29) PSVinitially set at 18.0 cm H2O then reduced by 2 to PSV 4 cm H2O at least twice a day (37) Once a day SBT (31) Multiple daily SBTs (33)

Conclusion


A once-daily SBT led to extubation onceabout three times more quickly than IMV and about twice as quickly as PSV. Multiple daily SBTs were equally successful.

Weaning Protocol
 

Improve overall outcome Example:

1. Is patient is a candidate for weaning?
i) PaO2 > 60mmHg ii) FiO2 <0.5 iii) PEEP < 8 cm H2O

2. 3. 4. 5.

Screen for readinessRSB Trial readiness

i) i) i) ii) i) ii) SBT for one minute to calculate RSBI Coughing during suctioning PS, CPAP, or T-piece TUp to 120 minutes Successfully tolerates the SBT from 30-120 minutes 30Shows s/sx of failure

Ensure intact airway reflexes Patient can now be subject to SBTs SBT can be terminated if patient:

Weaning Failure
      

HR >140 bpm or a sustained increase of >20% RR >35 breaths/min for >5 min O2 Sats <90% for >30s HR with a sustained decrease of >20% SBP>180 for > 5 min SBP<90 for > 5 min Clinical features: Anxiety, agitation, diaphoresis


NB: May not be due to weaning failure and should be treated appropriately

Problems with Failure



Failing can put significant stress on the respiratory system Inspiratory effort can increase 4-6 4times following a failed SBT (Jubran et al.)

Who should run the Trial?



Protocols are driven by RT and/or nurses Studies have shown that protocol-driven protocolweaning by these individuals is superior to independent physician-directed weaning physician(Horst et al.) Sending PMV patients to institutions dedicated specifically to weaning improves outcomes (ie, Long-Term Assisted Care Longfacilities)

The Future


Automatic Tube Compensation

 

Compensates for pressure drop across ET tube Delivers the exact amount of pressure to overcome the resistive load of the tube given the flow across the tube measured at that instant (variable pressure support) Studies by Cohen and others have demonstrated that ATC improves weaning outcome compared to PSV and CPAP No studies as of yet have compared ATC vs. T-piece TVentilator adjusts airway pressure in proportion to patients instantaneous effort. This occurs from breath-to-breath and breath-tocontinuously through each inspiration No set tidal volume, pressure, or flow rate. The patients work of breathing remains constant despite changing effort or demand Using knowledge-based algorithms knowledgeDecreased MV duration from 12 to 7.5 days in a recent trial (Lellouche et al.)
 

ProportionalProportional-Assist Ventilation


 

Computer-Driven Protocols Computer 

Used automatic gradual reduction in pressure support Automatic Performance of SBTs

Outcomes in PMV Patients



Population is very diverse

Results are therefore difficult to generalize For example, patients who require PMV postpostoperatively generally do significantly better than patients with COPD

LTAC facilities
Scheinhorn et al.(2007) Large, multicenter trial evaluating outcomes in postpost-ICU PMV patients at 23 LTAC facilities.

Scheinhorn et al (2007)
  

1,419 patients 23 sites from 3/2002-2/2003 3/2002Excluded: End-of-life care; terminal End-ofweaning, or considered incapable of weaning at the time of admission OneOne-Year Mortality: 52%
 

25% died in the weaning hospital 27% died after discharge

 

Survival to Discharge: 67% Cost: $3968/day

References


Cohen JD, Shapiro M, et al. Automatic tube compensation-assissted respiratory rate to tidal volume ratio improves the prediction of weaning outcome. Chest 2002. 122:980-4 Ely EW, Baker AM, Dunagan DP, et al. Effect of the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:18641869 Eskanadar N, Apostolakos M.Weaning from mechanical ventilation.Crit Care Clin(2007) 23:263-274 Esteban A, Alia I, Gordo F. Weaning: what the recent studies have shown us. Clin Pulm Med 1996, 3:91-100 3:91Esteban E, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med 1999; 159:512518 Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995; 6:345350 Horst HM, Muoro D, et al. Decrease in ventilation time with a standardized weaning process. Arch Surg 1998. 133:483-489 Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Resp Crit Care Med 1997; 155: 906 Lellouche F, Mancebo J, Jolliet P, et al. Am J Respir Crit Care Med 2006. 174:894-900 174:894Lemaire F, Teboul J, Cinotti L, et al. Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 1988; 69:171179 Pierson DJ. Long-term mechanical ventilation and weaning. Respir Care 1995; 40: 289-95. Scalise PJ, Vottol JJ. Weaning from long-term mechanical ventilation. Chron Respir Dis 2005. 2: 99-103 Scheinhom DJ, Artinian BM, Catlin JL et al. Weaning from prolonged mechanical ventilation. The experience at a regional weaning center. Chest 1994; 105: 534-39. Scheinhorn DJ, et al. Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest 2007; 131:85