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Difficult WeaningDifficult Weaning
Dr. Tarek Sabry HelmyDr. Tarek Sabry Helmy
(INTENSIVIST)(INTENSIVIST)
Fujairah HospitalFujairah Hospital
UAEUAE
Objectives:
1) Definition of weaning , difficult weaning , weaning
success, weaning failure and prolonged weaning .
2) The Causes and Pathophysiology of difficult
weaning.
3) The usual process of initial weaning from the
ventilator and weaning protocol.
4) Management of difficult and prolonged weaning.
5) Recommendations .
Definition Of Weaning
- Gradual reduction of ventilatory support from pts. whose
condition is improving.
- 80% of patients requiring temporary mechanical ventilation do
not require a slow withdrawal process and can be
disconnected within hours or days of initial support.
- 20 % of all initial weaning attempts in mechanically ventilated
ICU patients failed.
- Prolongation of mechanical ventilation is associated with
weaning failure.
Schematic Representation of the Different Stages Occurring in a
Mechanically Ventilated Patient
Definition of the different stages, from initiation to mechanical ventilation to weaning
Stages Definitions
Treatment of ARF Period of care and resolution of the disorder that caused respiratory failure and
prompted mechanical ventilation
Suspicion The point at which the clinician suspects the patient may be ready to begin the
weaning process
Assessing readiness to wean Daily testing of physiological measures of readiness for weaning (NIF, fR/VT)
to determine probability of weaning success
Spontaneous breathing trial Assessment of the patient’s ability to breathe spontaneously
Extubation Removal of the endotracheal tube
Reintubation Replacement of the endotracheal tube for patients who are unable to sustain
spontaneous ventilation
Definitions of Weaning Success and Failure
Weaning success is defined as
Extubation and the absence of ventilatory support 48 hs following
the extubation.
Weaning in progress: Requirement of NIV after extubation
Weaning failure is defined as one of the following:
1)Failed SBT
2) Reintubation and/or resumption of ventilatory support 48 hs
following successful extubation; or
3) Death within 48 hs following extubation.du to ventilatory
insufficiency.
Classification of Patients According to the Weaning Process
Group Definition Frequency
ICU
mortality
Hospital
mortality
)1)Simple
weaning
Patients who proceed fromPatients who proceed from
initiation of weaning toinitiation of weaning to
successful extubation onsuccessful extubation on
the first attempt withoutthe first attempt without
difficultydifficulty
69% 5% 12%
)2)Difficult
weaning
Patients who fail initialPatients who fail initial
weaning and require up toweaning and require up to
three SBT or as long as 7three SBT or as long as 7
days from the first SBT todays from the first SBT to
achieve successful weaningachieve successful weaning
16%
25%
)3)Prolonged
weaning
Patients who fail at leastPatients who fail at least
three weaning attempts orthree weaning attempts or
requirerequire >> 7 days of7 days of
weaning after the first SBTweaning after the first SBT
15%
Boles, et al. Eur Respir J 2007
The Causes and Pathophysiology of Weaning
Failure
Cardiac load
Respiratory load
Neuromuscular
causes
DIFFICULT WEANING
Neuropsychological
causes
Metabolic
AnaemiaNutrition Thorough &
Systematic search for
these
potentially
reversible
pathologies
Metabolic and endocrine factors
Hypophosphatemia
Hypomagensemia
Hypokalemia
Role in difficult
weaning needs
further clarification
Hypothyroidism
Hypoadrenalism
Corticosteroids
Glycemic control
Difficult
weaning
Muscle
weakness
REINTUBATION VAP WEANING
FAILURE
6-8 FOLD
INCREASED RISK
Causes of Difficult Weaning
Imbalance
Respiratory muscle pump Respiratory muscle load
A) Increased Ventilatory Needs
Increased resistive load Increased chest Wall Load Increased parenchyma load
-Bronchospasm
- Airway edema
- Airway obstruction
- Tube kinking
- Sleep Apnea
- Secretions
- Circuit resistance
- Pleural effusion
- Pnumothorax
- Flail chest
- Obesity
- Ascites
- Distension
-Hyperinflation
- Inflammation
- Atelectasis
- Alveolar edema
B) Decreased Neuromuscular compliance:
Decreased Drive Muscle Weakness Impaired Transmission
Drug overdose - Electrolyte derangement - Critical illness polyneuropathy
Brain-stem lesion - Malnutrition - Neuromuscular blockers
Sleep deprivation - Myopathy - Aminoglycosides
Hypothyroidism - Hyperinflation - Guillain–Barré syndrome
Starvation/malnutrition - Drugs, corticosteroids - Mysthenia gravis
Metabolic alkalosis - Sepsis - Phrenic nerve injury
Myotonic dystrophy
HOW DOES LATENT MYOCARDIAL DYSFUNCTION
BECOME MANIFEST DURING WEANING ?
PPV  SPONTANEOUS
 MYOCARDIAL O2 CONSUMPTION
- VE INTRATHORACIC PRESS. 
VENOUS RETURN
 LV AFTERLOAD
Latent
ischaemia
Manifest
ischaemia
 LV
Compliance
 WOB –
Weaning failure
Decreased lung
compliance
Pulmonary
edema
SBT
CRITICAL ILLNESS OXIDATIVE STRESS
Loss of diaphragm force-generating capacity that is specifically related
to use of controlled mechanical ventilation
Mitochondrial swelling, myofibril damage and increased lipid vacuoles.
Oxidative modifications noted within 6 h
Muscle atrophy
Structural injury
Fibre remodeling
The Usual Process of Initial Weaning
from the Ventilator
As EARLY as possible < 72 hs
UnderestimaUnderestimatete the ability of patients to be successfully weaned
Discontinuation ofof sedationsedation is a critical step ( dexmetedomedine
might be a good choice)
2 step strategy
1- Assessment readiness for weaning / extubationAssessment readiness for weaning / extubation
22-- Spontaneous breathing trial (SBT)Spontaneous breathing trial (SBT)
-Preparing the Patient for Weaning:
- Electrolyte Disturbance
- Volume Overload
- Altered Mental status
- Fatigue of the diaphragm
- Adequacy of sleep and sleep deprivation
- Malnutrition
-Criteria to consider Patients for Weaning:
- Reversal of underlying pathology
- Po2, PEEP, FiO2, PH
- ABG
- Vital Data
- CXR
-Parameters Predicting successful Weaning:
- Respiratory rate
- Tidal Volume
- Minute Ventilation
- Negative inspiratory force
- Maximal Inspiratory pressure
- RSBI
Considerations for Assessing Readiness toConsiderations for Assessing Readiness to
WeaningWeaning
Clinical
assessment
-Adequate cough , Absence of excessive
thick tracheobronchial secretion
-Resolution of disease acute phase for
which the patient was intubated
Objective
measurements
Clinical stabilityClinical stability
Stable cardiovascular status (i.e. HR ≤ 140
beats/min, systolic BP 90–180
mmHg, no or minimal vasopressors(
Stable metabolic status Negative fluid
balance adequate nutrition
Objective
measurements
Adequate oxygenationAdequate oxygenation
SaO2 > 90% on ≤ FIO2 0.4 (or PaO2/FIO2
≥ 200 mmHg(
PEEP ≤ 5 -8 cmH2O
P(A-a)O2 < 35 on FIO2 = 1.0
SvO2 > 60%
Oxygen index = FIO2 x MAP x 100/ PaO2
very good < 5 medium 10 – 20
poor > 25
Objective
measurements
AdequateAdequate pulmonary functionpulmonary function
fR ≤ 34 breaths/min Vd?Vt < 0.6 (0.25-0.4(
NIF ≤ -20 cmH2O
VT > 5 mL/kg
VC > 10 mL/kg
RSBIRSBI
fR/VT 60-105 breaths/min/L Or ≤130→ age > 65
No significant respiratory acidosis
Adequate mentationAdequate mentation
No sedation or adequate mentation on
sedation (or stable neurologic patient(
RSBI = respiratoryRSBI = respiratory
frequency (ffrequency (fRR) / V) / VTT
Predicts successful SBTPredicts successful SBT
sensitivity 0.97 &sensitivity 0.97 &
specificity 0.65specificity 0.65
RSBI = respiratoryRSBI = respiratory
frequency (ffrequency (fRR) / V) / VTT
Predicts successful SBTPredicts successful SBT
sensitivity 0.97 &sensitivity 0.97 &
specificity 0.65specificity 0.65
Spontaneous Breathing TrialSpontaneous Breathing Trial
T-tube trialT-tube trial
Low levels of pressure support (PS)Low levels of pressure support (PS)
6~8 cmH2O in adults, 10 cmH2O in pediatrics
3-14 cmH2O inspiratory pressure is needded to overcome
resistance of endotracheal tube
CPAPCPAP
AUTOMATIC TUBE COMPENSATION (ATC)AUTOMATIC TUBE COMPENSATION (ATC)
Designed to reduce work associated with ET resistance
Duration:Duration:
Patients who fail an SBT do so within first ~20 min
Success rate for an initial SBT is similar for a 30-min
compared with a 120-min trial
Reintubation rate:Reintubation rate:
Passing SBT  13%; Do not receive SBT  40%
Low levels PEEP:Low levels PEEP:
≤5 cmH2O PEEP during an SBT
COPD More likely to pass 30-min SBT with 5~7.5
cmH2O CPAP.
Passing SBTPassing SBT
Respiratory pattern
Gas exchange
Haemodynamic stability
Subject comfort
Repeated frequently (daily) SBT
Unnecessary prolongation of a failed SBT can result in muscle fatigue,
hemodynamic instability, discomfort or worsening gas exchange.
Nonfatiguing mode of mechanical ventilationNonfatiguing mode of mechanical ventilation (A/C or PSV) 
ESTEBAN et al. AJRCCM 2000: Weaning method
PS 36%, SIMV 5%, SIMV + PS 28%, intermittent SBT 17% & daily SBT 4%
ESTEBAN et al. JAMA 2002: Weaning trial
Once-daily SBT in 89%: T-tube 52%, CPAP 19%, PS 28%
Failed SBT
Termination of SBTTermination of SBT
-RR > 30 for 5 min
-SpO2 < 90% for 30 sec
-20% change in HR for > 5 min
-P SYS > 180 or < 90 for 1 min
-Anxiety, agitation or diaphoresis
for 5 min
Extubation:
Neurological status
Although depressed mentation is frequently considered a contra-indication
to extubation, a low reintubation rate (9%) in stable brain-injured
patients with a Glasgow coma score ≤4 COPLIN et al. 2001
KOH et al. 2005 GCS did NOT predict extubation failure
Excessive secretions
KHAMIEES et al. 2006 Poor cough strengthPoor cough strength and excessiveexcessive
secretionssecretions were common in patients who failed extubation
following a successful SBT.
Airway obstruction
Positive leak test is adequate before proceeding with extubation.A
successful cuff leak test does not guarantee that post-extubation
difficulties will not arise.
Criteria for extubation failureCriteria for extubation failure
-fR >25 breaths/min for 2 h
-HR >140 beats/min or sustained increase or decrease
of > 20%
-Clinical signs of respiratory muscle fatigue or
increased work of breathing
-SpO2 < 90%; PaO2 <80 mmHg on FiO2 ≥0.50
-Hypercapnia (PaCO2 > 45 mmHg or ≥ 20% from pre-
extubation), pH < 7.33
Weaning ProtocolWeaning Protocol
Standardising process of weaning
Protocol-directed daily screening of resp. function & SBT
Advantage:
↓ % of patients who required weaning from 80 to 10%
↓ time required for extubation
↓ incidence of self-extubation
↓ incidence of tracheostomy
↓ ICU costs
↓ incidence of VAP and death (Dries et al, 2004)
No increase or even a decrease in incidence of reintubation
Less likely effective
Majority of patients are rapidly extubated
Physicians do not extubate following a successful SBT
When the quality of critical care is already high
Daily SBT
<105
Mechanical Ventilation
RR > 35/min
Spo2 < 90%
HR > 140/min
Sustained 20% increase in HR
SBP > 180 mm Hg, DBP > 90 mm Hg
Anxiety
Diaphoresis
30-120 min
PaO2/FiO2 ≥ 200 mm Hg
PEEP ≤ 5 cm H2O
Intact airway reflexes
No need for continuous infusions of vasopressors or inotrops
RSBI
Extubation
No
> 105
Rest 24 hrs
Yes
Stable Support Strategy
Assisted/PSV
24 hours
Low level CPAP (5 cm H2O),
Low levels of pressure support (5 to 7 cm H2O)
“T-piece” breathing
Algorithm for weaning Protocol
Is there a role for different ventilator modes in
difficult weaning ?
DIFFICULT WEANING-MODE OF VENTILATIONDIFFICULT WEANING-MODE OF VENTILATION
•Maintainence of a favourable balance
between respiratory system capacity and
load
•Attempt to avoid diaphragm muscle
atrophy
•Aid in the weaning process
New Advances in Ventilators to assist Weaning
- Automated tube compensation (ATC)
- Proportional Assisted ventilation (PAV)
Pressure support ventilation
Noninvasive ventilation
Continuous positive airway pressure
Automatic tube compensation
Proportional assist ventilation
Servo-controlled ventilation (ASV/Smartcare)
PSV: should be favoured
-As a weaning mode after initial failed SBT ((group 2group 2))
Brochard et al. CCM 1995Brochard et al. CCM 1995
-May be helpful after several failed attempts at SBT
((group 3group 3)) Vittaca et al. AJRCCM 2000Vittaca et al. AJRCCM 2000
NIV:
-Selected patients, esp. hypercapnic respiratory failure (
COPD)
-Should NOTNOT be routinely used as in the event of
extubation failure
-Its use CANNOTCANNOT be recommended for all patients failing
a SBT Keenan et al, 2002 & Esteban et al, 2004Keenan et al, 2002 & Esteban et al, 2004
-Group 2 & 3: NONO firm recommendations
CPAP:
- NoNo clear improvement in outcomes (compared to
T-piece)
-May be effective in preventing hypoxic resp.
failure after major surgery Squadrone et al, 2005Squadrone et al, 2005
-Group 1: CPAP may be an alternative modes
- Group 2 & 3: NOTNOT been clearly evaluated
ATC:
-As successful as simple T-tube or low-level PS
-Lack of trials in groups 2 and 3
PAV:
NOT been investigated thoroughly in weaning trials
ASV:
2 non-randomised trials & 1 randomised trial:
Post-cardiac surgery patient
EarlierEarlier extubation & fewerfewer ventilator adjustments
ReducedReduced need for ABG & high-pressure alarms
ASV was compared with SIMV (the worst mode)
Smartcare
-Maintain a patient in the comfort zone more successfully than
clinician-directed adjustments
-Additional studies needed to evaluate weaning efficacy
Management of patients with prolongedManagement of patients with prolonged
weaning failureweaning failure
-
31.2% of ICU admissions
-Significant amount of the overall ICU patient-days and 50% of financial
resources
-20% of MICU patients remained dependent on MV after 21 days
VALLVERDU et al 1995VALLVERDU et al 1995 reported that weaning failure occurred in as many
as 61% of COPD patients, in 41% of neurological patients and in 38% of
hypoxaemic patients
• Reversible factors?
Neuromuscular and chest wall disorders:
Less likely to be weaned completely but also less mortality
COPD: highest mortality
How to Wean Difficult to Wean Patients
Correction of Causes
Choice of appropriate mode
Tracheostomy
Tracheostomy
Specialized
weaning units
Rehabilitation
Home
ventilation
Terminal care
No AdvantageNo AdvantageNo AdvantageNo Advantage
Timing of TracheostomyTiming of Tracheostomy
30-day mortality rate
Pneumonia
Accidental Extubation
ICU length of stay
30-day mortality rate
Pneumonia
Accidental Extubation
ICU length of stay
Little evidence to guide optimal timingLittle evidence to guide optimal timing
Need for better predictorsNeed for better predictors
Little evidence to guide optimal timingLittle evidence to guide optimal timing
Need for better predictorsNeed for better predictors
OutcomeOutcome
Longer durationLonger duration of MV & ICU & hospital stay
Engoren et al, 2004Engoren et al, 2004: poorpoor survival & functional outcomes
North Carolina Medicare database:North Carolina Medicare database:
Rate of tracheostomy increased
25%25% died in hospital
23%23% discharged to a skilled-nursing facility
35%35% discharged to rehabilitation or long-term care units
8%8% discharged home
Long Term OutcomeLong Term Outcome  Study? Study? Study?Study? Study? Study?
Percutaneous TracheostomyPercutaneous Tracheostomy::
Cost-effective & Fewer complication; NO diff. in outcomeCost-effective & Fewer complication; NO diff. in outcome
Percutaneous TracheostomyPercutaneous Tracheostomy::
Cost-effective & Fewer complication; NO diff. in outcomeCost-effective & Fewer complication; NO diff. in outcome
RehabilitationRehabilitation
Spitzer et al, 1992:Spitzer et al, 1992:
62%62% of difficult-to-wean pts had neuromuscular disease
severe enough to account for ventilator dependency
Lack of studiesLack of studies demonstrating an impact of rehabilitation on the
prevention or reversal of weaning failure or other outcomes.
Efforts to prevent / treat respiratory muscle weakness mightEfforts to prevent / treat respiratory muscle weakness might
have a role in reducing weaning failurehave a role in reducing weaning failure..
Specialized Weaning UnitsSpecialized Weaning Units
‘‘Bridge to home’’
Relieve pressure on ICU beds
2 types:
Step-down / respiratory care units in acute care hospitals
Regional weaning centres that serve acute care hospitals
34–60% in SWU can be weaned successfully
Successful weaning can occur up to 3 months after admission
Long-term mortality rate is not adversely affected by transfer
Sucessfully weaned patients in SWUSucessfully weaned patients in SWU  70% (50~94%) discharged home alive70% (50~94%) discharged home alive
1-YSR 381-YSR 38––53%53%  only 5only 5––25% of patients admitted to SWU can be expected to be25% of patients admitted to SWU can be expected to be
ventilator independent and alive at home 1 yr after their initial respiratory failureventilator independent and alive at home 1 yr after their initial respiratory failure
Sucessfully weaned patients in SWUSucessfully weaned patients in SWU  70% (50~94%) discharged home alive70% (50~94%) discharged home alive
1-YSR 381-YSR 38––53%53%  only 5only 5––25% of patients admitted to SWU can be expected to be25% of patients admitted to SWU can be expected to be
ventilator independent and alive at home 1 yr after their initial respiratory failureventilator independent and alive at home 1 yr after their initial respiratory failure
Specialized Weaning UnitsSpecialized Weaning Units
(SWU)(SWU)
Weaning successful rate:
Post-operative patients (58%)
Acute lung injury (57%)
COPD or neuromuscular disease (22%)
Outcomes of care between SWUs & ICUs: Few studies
SWUs may be cost-effective alternatives to acute ICUs
In difficult-to-wean patients, the use of clearly defined
protocols, independent of the mode used, may result in
better outcomes than uncontrolled clinical practice.
Admission criteria:
Two documented failed weaning trials
Presence of a tracheostomy tube
Clinical stability & potential to benefit from rehabilitation
Minimum operating standards & staff qualifications
Acceptable nurse/patient ratios (1:2)
Requirement for a supervising pulmonary physician
Qualifications of respiratory therapists
Presence of certain specialised staff members (e.g.
nutritionists, psychologists, etc.)
Home VentilationHome Ventilation
Cleveland (OH, USA):
ARDS, cardiothoracic surgery or COPD
9% were discharged home with partial ventilatory support
1% using NIV & 8% requiring partial MV via tracheostomy
Schönhofer et al: COPD
75% discharged home from an SWU
31.5% required home NIV
UK study:
35% required further home ventilation, mostly NIV
Terminal care forTerminal care for
Ventilator-Dependent PatientsVentilator-Dependent Patients
-Poor Quality of Life & Low survival
rates
-Withdrawal of mechanical
ventilation ?
-Full disclosure of prognostic data
-Routine palliative care or ethics
consultation can improve the
quality of decision making in the
acute ICU setting.
Recommendations
Evaluate readiness for weaning earlyEvaluate readiness for weaning early
Be aggressive and search for reversible causes in difficult to weanBe aggressive and search for reversible causes in difficult to wean
patientspatients
DIFFICULT TO WEAN PROTOCOLDIFFICULT TO WEAN PROTOCOL Most valuable physicians should‐ Most valuable physicians should‐
adhere to standardised weaning guidelines.adhere to standardised weaning guidelines.
PSV – Preferred mode in difficult to wean. T piece trials also‐PSV – Preferred mode in difficult to wean. T piece trials also‐
appropriate. Do not use SIMV.appropriate. Do not use SIMV.
NIV – Select subgroups. “Weaning in progress”NIV – Select subgroups. “Weaning in progress”
RecommendationsRecommendations
Evaluate readiness for weaning early
Be aggressive and search for reversible causes in difficult to wean
patients
DIFFICULT TO WEAN PROTOCOL Most valuable physicians should‐
adhere to standardised weaning guidelines.
PSV – Preferred mode in difficult to wean. T piece trials also‐
appropriate. Do not use SIMV.
NIV – Select subgroups. “Weaning in progress”
Thank youThank you

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difficult weaning from Mechanical ventilator

  • 1. Difficult WeaningDifficult Weaning Dr. Tarek Sabry HelmyDr. Tarek Sabry Helmy (INTENSIVIST)(INTENSIVIST) Fujairah HospitalFujairah Hospital UAEUAE
  • 2. Objectives: 1) Definition of weaning , difficult weaning , weaning success, weaning failure and prolonged weaning . 2) The Causes and Pathophysiology of difficult weaning. 3) The usual process of initial weaning from the ventilator and weaning protocol. 4) Management of difficult and prolonged weaning. 5) Recommendations .
  • 3. Definition Of Weaning - Gradual reduction of ventilatory support from pts. whose condition is improving. - 80% of patients requiring temporary mechanical ventilation do not require a slow withdrawal process and can be disconnected within hours or days of initial support. - 20 % of all initial weaning attempts in mechanically ventilated ICU patients failed. - Prolongation of mechanical ventilation is associated with weaning failure.
  • 4. Schematic Representation of the Different Stages Occurring in a Mechanically Ventilated Patient Definition of the different stages, from initiation to mechanical ventilation to weaning Stages Definitions Treatment of ARF Period of care and resolution of the disorder that caused respiratory failure and prompted mechanical ventilation Suspicion The point at which the clinician suspects the patient may be ready to begin the weaning process Assessing readiness to wean Daily testing of physiological measures of readiness for weaning (NIF, fR/VT) to determine probability of weaning success Spontaneous breathing trial Assessment of the patient’s ability to breathe spontaneously Extubation Removal of the endotracheal tube Reintubation Replacement of the endotracheal tube for patients who are unable to sustain spontaneous ventilation
  • 5. Definitions of Weaning Success and Failure Weaning success is defined as Extubation and the absence of ventilatory support 48 hs following the extubation. Weaning in progress: Requirement of NIV after extubation Weaning failure is defined as one of the following: 1)Failed SBT 2) Reintubation and/or resumption of ventilatory support 48 hs following successful extubation; or 3) Death within 48 hs following extubation.du to ventilatory insufficiency.
  • 6. Classification of Patients According to the Weaning Process Group Definition Frequency ICU mortality Hospital mortality )1)Simple weaning Patients who proceed fromPatients who proceed from initiation of weaning toinitiation of weaning to successful extubation onsuccessful extubation on the first attempt withoutthe first attempt without difficultydifficulty 69% 5% 12% )2)Difficult weaning Patients who fail initialPatients who fail initial weaning and require up toweaning and require up to three SBT or as long as 7three SBT or as long as 7 days from the first SBT todays from the first SBT to achieve successful weaningachieve successful weaning 16% 25% )3)Prolonged weaning Patients who fail at leastPatients who fail at least three weaning attempts orthree weaning attempts or requirerequire >> 7 days of7 days of weaning after the first SBTweaning after the first SBT 15% Boles, et al. Eur Respir J 2007
  • 7. The Causes and Pathophysiology of Weaning Failure
  • 8.
  • 9. Cardiac load Respiratory load Neuromuscular causes DIFFICULT WEANING Neuropsychological causes Metabolic AnaemiaNutrition Thorough & Systematic search for these potentially reversible pathologies
  • 10. Metabolic and endocrine factors Hypophosphatemia Hypomagensemia Hypokalemia Role in difficult weaning needs further clarification Hypothyroidism Hypoadrenalism Corticosteroids Glycemic control Difficult weaning Muscle weakness
  • 12. Causes of Difficult Weaning Imbalance Respiratory muscle pump Respiratory muscle load A) Increased Ventilatory Needs Increased resistive load Increased chest Wall Load Increased parenchyma load -Bronchospasm - Airway edema - Airway obstruction - Tube kinking - Sleep Apnea - Secretions - Circuit resistance - Pleural effusion - Pnumothorax - Flail chest - Obesity - Ascites - Distension -Hyperinflation - Inflammation - Atelectasis - Alveolar edema
  • 13. B) Decreased Neuromuscular compliance: Decreased Drive Muscle Weakness Impaired Transmission Drug overdose - Electrolyte derangement - Critical illness polyneuropathy Brain-stem lesion - Malnutrition - Neuromuscular blockers Sleep deprivation - Myopathy - Aminoglycosides Hypothyroidism - Hyperinflation - Guillain–Barré syndrome Starvation/malnutrition - Drugs, corticosteroids - Mysthenia gravis Metabolic alkalosis - Sepsis - Phrenic nerve injury Myotonic dystrophy
  • 14. HOW DOES LATENT MYOCARDIAL DYSFUNCTION BECOME MANIFEST DURING WEANING ? PPV  SPONTANEOUS  MYOCARDIAL O2 CONSUMPTION - VE INTRATHORACIC PRESS.  VENOUS RETURN  LV AFTERLOAD
  • 15. Latent ischaemia Manifest ischaemia  LV Compliance  WOB – Weaning failure Decreased lung compliance Pulmonary edema SBT
  • 16. CRITICAL ILLNESS OXIDATIVE STRESS Loss of diaphragm force-generating capacity that is specifically related to use of controlled mechanical ventilation Mitochondrial swelling, myofibril damage and increased lipid vacuoles. Oxidative modifications noted within 6 h Muscle atrophy Structural injury Fibre remodeling
  • 17. The Usual Process of Initial Weaning from the Ventilator
  • 18. As EARLY as possible < 72 hs UnderestimaUnderestimatete the ability of patients to be successfully weaned Discontinuation ofof sedationsedation is a critical step ( dexmetedomedine might be a good choice) 2 step strategy 1- Assessment readiness for weaning / extubationAssessment readiness for weaning / extubation 22-- Spontaneous breathing trial (SBT)Spontaneous breathing trial (SBT)
  • 19. -Preparing the Patient for Weaning: - Electrolyte Disturbance - Volume Overload - Altered Mental status - Fatigue of the diaphragm - Adequacy of sleep and sleep deprivation - Malnutrition
  • 20. -Criteria to consider Patients for Weaning: - Reversal of underlying pathology - Po2, PEEP, FiO2, PH - ABG - Vital Data - CXR -Parameters Predicting successful Weaning: - Respiratory rate - Tidal Volume - Minute Ventilation - Negative inspiratory force - Maximal Inspiratory pressure - RSBI
  • 21. Considerations for Assessing Readiness toConsiderations for Assessing Readiness to WeaningWeaning Clinical assessment -Adequate cough , Absence of excessive thick tracheobronchial secretion -Resolution of disease acute phase for which the patient was intubated Objective measurements Clinical stabilityClinical stability Stable cardiovascular status (i.e. HR ≤ 140 beats/min, systolic BP 90–180 mmHg, no or minimal vasopressors( Stable metabolic status Negative fluid balance adequate nutrition
  • 22. Objective measurements Adequate oxygenationAdequate oxygenation SaO2 > 90% on ≤ FIO2 0.4 (or PaO2/FIO2 ≥ 200 mmHg( PEEP ≤ 5 -8 cmH2O P(A-a)O2 < 35 on FIO2 = 1.0 SvO2 > 60% Oxygen index = FIO2 x MAP x 100/ PaO2 very good < 5 medium 10 – 20 poor > 25
  • 23. Objective measurements AdequateAdequate pulmonary functionpulmonary function fR ≤ 34 breaths/min Vd?Vt < 0.6 (0.25-0.4( NIF ≤ -20 cmH2O VT > 5 mL/kg VC > 10 mL/kg RSBIRSBI fR/VT 60-105 breaths/min/L Or ≤130→ age > 65 No significant respiratory acidosis Adequate mentationAdequate mentation No sedation or adequate mentation on sedation (or stable neurologic patient( RSBI = respiratoryRSBI = respiratory frequency (ffrequency (fRR) / V) / VTT Predicts successful SBTPredicts successful SBT sensitivity 0.97 &sensitivity 0.97 & specificity 0.65specificity 0.65 RSBI = respiratoryRSBI = respiratory frequency (ffrequency (fRR) / V) / VTT Predicts successful SBTPredicts successful SBT sensitivity 0.97 &sensitivity 0.97 & specificity 0.65specificity 0.65
  • 24. Spontaneous Breathing TrialSpontaneous Breathing Trial T-tube trialT-tube trial Low levels of pressure support (PS)Low levels of pressure support (PS) 6~8 cmH2O in adults, 10 cmH2O in pediatrics 3-14 cmH2O inspiratory pressure is needded to overcome resistance of endotracheal tube CPAPCPAP AUTOMATIC TUBE COMPENSATION (ATC)AUTOMATIC TUBE COMPENSATION (ATC) Designed to reduce work associated with ET resistance
  • 25. Duration:Duration: Patients who fail an SBT do so within first ~20 min Success rate for an initial SBT is similar for a 30-min compared with a 120-min trial Reintubation rate:Reintubation rate: Passing SBT  13%; Do not receive SBT  40% Low levels PEEP:Low levels PEEP: ≤5 cmH2O PEEP during an SBT COPD More likely to pass 30-min SBT with 5~7.5 cmH2O CPAP.
  • 26. Passing SBTPassing SBT Respiratory pattern Gas exchange Haemodynamic stability Subject comfort
  • 27.
  • 28. Repeated frequently (daily) SBT Unnecessary prolongation of a failed SBT can result in muscle fatigue, hemodynamic instability, discomfort or worsening gas exchange. Nonfatiguing mode of mechanical ventilationNonfatiguing mode of mechanical ventilation (A/C or PSV)  ESTEBAN et al. AJRCCM 2000: Weaning method PS 36%, SIMV 5%, SIMV + PS 28%, intermittent SBT 17% & daily SBT 4% ESTEBAN et al. JAMA 2002: Weaning trial Once-daily SBT in 89%: T-tube 52%, CPAP 19%, PS 28% Failed SBT
  • 29. Termination of SBTTermination of SBT -RR > 30 for 5 min -SpO2 < 90% for 30 sec -20% change in HR for > 5 min -P SYS > 180 or < 90 for 1 min -Anxiety, agitation or diaphoresis for 5 min
  • 30. Extubation: Neurological status Although depressed mentation is frequently considered a contra-indication to extubation, a low reintubation rate (9%) in stable brain-injured patients with a Glasgow coma score ≤4 COPLIN et al. 2001 KOH et al. 2005 GCS did NOT predict extubation failure Excessive secretions KHAMIEES et al. 2006 Poor cough strengthPoor cough strength and excessiveexcessive secretionssecretions were common in patients who failed extubation following a successful SBT. Airway obstruction Positive leak test is adequate before proceeding with extubation.A successful cuff leak test does not guarantee that post-extubation difficulties will not arise.
  • 31. Criteria for extubation failureCriteria for extubation failure -fR >25 breaths/min for 2 h -HR >140 beats/min or sustained increase or decrease of > 20% -Clinical signs of respiratory muscle fatigue or increased work of breathing -SpO2 < 90%; PaO2 <80 mmHg on FiO2 ≥0.50 -Hypercapnia (PaCO2 > 45 mmHg or ≥ 20% from pre- extubation), pH < 7.33
  • 32. Weaning ProtocolWeaning Protocol Standardising process of weaning Protocol-directed daily screening of resp. function & SBT Advantage: ↓ % of patients who required weaning from 80 to 10% ↓ time required for extubation ↓ incidence of self-extubation ↓ incidence of tracheostomy ↓ ICU costs ↓ incidence of VAP and death (Dries et al, 2004) No increase or even a decrease in incidence of reintubation Less likely effective Majority of patients are rapidly extubated Physicians do not extubate following a successful SBT When the quality of critical care is already high
  • 33. Daily SBT <105 Mechanical Ventilation RR > 35/min Spo2 < 90% HR > 140/min Sustained 20% increase in HR SBP > 180 mm Hg, DBP > 90 mm Hg Anxiety Diaphoresis 30-120 min PaO2/FiO2 ≥ 200 mm Hg PEEP ≤ 5 cm H2O Intact airway reflexes No need for continuous infusions of vasopressors or inotrops RSBI Extubation No > 105 Rest 24 hrs Yes Stable Support Strategy Assisted/PSV 24 hours Low level CPAP (5 cm H2O), Low levels of pressure support (5 to 7 cm H2O) “T-piece” breathing
  • 34.
  • 36. Is there a role for different ventilator modes in difficult weaning ?
  • 37. DIFFICULT WEANING-MODE OF VENTILATIONDIFFICULT WEANING-MODE OF VENTILATION •Maintainence of a favourable balance between respiratory system capacity and load •Attempt to avoid diaphragm muscle atrophy •Aid in the weaning process
  • 38. New Advances in Ventilators to assist Weaning - Automated tube compensation (ATC) - Proportional Assisted ventilation (PAV)
  • 39. Pressure support ventilation Noninvasive ventilation Continuous positive airway pressure Automatic tube compensation Proportional assist ventilation Servo-controlled ventilation (ASV/Smartcare)
  • 40. PSV: should be favoured -As a weaning mode after initial failed SBT ((group 2group 2)) Brochard et al. CCM 1995Brochard et al. CCM 1995 -May be helpful after several failed attempts at SBT ((group 3group 3)) Vittaca et al. AJRCCM 2000Vittaca et al. AJRCCM 2000 NIV: -Selected patients, esp. hypercapnic respiratory failure ( COPD) -Should NOTNOT be routinely used as in the event of extubation failure -Its use CANNOTCANNOT be recommended for all patients failing a SBT Keenan et al, 2002 & Esteban et al, 2004Keenan et al, 2002 & Esteban et al, 2004 -Group 2 & 3: NONO firm recommendations
  • 41. CPAP: - NoNo clear improvement in outcomes (compared to T-piece) -May be effective in preventing hypoxic resp. failure after major surgery Squadrone et al, 2005Squadrone et al, 2005 -Group 1: CPAP may be an alternative modes - Group 2 & 3: NOTNOT been clearly evaluated ATC: -As successful as simple T-tube or low-level PS -Lack of trials in groups 2 and 3
  • 42. PAV: NOT been investigated thoroughly in weaning trials ASV: 2 non-randomised trials & 1 randomised trial: Post-cardiac surgery patient EarlierEarlier extubation & fewerfewer ventilator adjustments ReducedReduced need for ABG & high-pressure alarms ASV was compared with SIMV (the worst mode) Smartcare -Maintain a patient in the comfort zone more successfully than clinician-directed adjustments -Additional studies needed to evaluate weaning efficacy
  • 43. Management of patients with prolongedManagement of patients with prolonged weaning failureweaning failure
  • 44. - 31.2% of ICU admissions -Significant amount of the overall ICU patient-days and 50% of financial resources -20% of MICU patients remained dependent on MV after 21 days VALLVERDU et al 1995VALLVERDU et al 1995 reported that weaning failure occurred in as many as 61% of COPD patients, in 41% of neurological patients and in 38% of hypoxaemic patients • Reversible factors? Neuromuscular and chest wall disorders: Less likely to be weaned completely but also less mortality COPD: highest mortality
  • 45. How to Wean Difficult to Wean Patients Correction of Causes Choice of appropriate mode Tracheostomy
  • 47. No AdvantageNo AdvantageNo AdvantageNo Advantage Timing of TracheostomyTiming of Tracheostomy 30-day mortality rate Pneumonia Accidental Extubation ICU length of stay 30-day mortality rate Pneumonia Accidental Extubation ICU length of stay Little evidence to guide optimal timingLittle evidence to guide optimal timing Need for better predictorsNeed for better predictors Little evidence to guide optimal timingLittle evidence to guide optimal timing Need for better predictorsNeed for better predictors
  • 48. OutcomeOutcome Longer durationLonger duration of MV & ICU & hospital stay Engoren et al, 2004Engoren et al, 2004: poorpoor survival & functional outcomes North Carolina Medicare database:North Carolina Medicare database: Rate of tracheostomy increased 25%25% died in hospital 23%23% discharged to a skilled-nursing facility 35%35% discharged to rehabilitation or long-term care units 8%8% discharged home Long Term OutcomeLong Term Outcome  Study? Study? Study?Study? Study? Study? Percutaneous TracheostomyPercutaneous Tracheostomy:: Cost-effective & Fewer complication; NO diff. in outcomeCost-effective & Fewer complication; NO diff. in outcome Percutaneous TracheostomyPercutaneous Tracheostomy:: Cost-effective & Fewer complication; NO diff. in outcomeCost-effective & Fewer complication; NO diff. in outcome
  • 49. RehabilitationRehabilitation Spitzer et al, 1992:Spitzer et al, 1992: 62%62% of difficult-to-wean pts had neuromuscular disease severe enough to account for ventilator dependency Lack of studiesLack of studies demonstrating an impact of rehabilitation on the prevention or reversal of weaning failure or other outcomes. Efforts to prevent / treat respiratory muscle weakness mightEfforts to prevent / treat respiratory muscle weakness might have a role in reducing weaning failurehave a role in reducing weaning failure..
  • 50. Specialized Weaning UnitsSpecialized Weaning Units ‘‘Bridge to home’’ Relieve pressure on ICU beds 2 types: Step-down / respiratory care units in acute care hospitals Regional weaning centres that serve acute care hospitals 34–60% in SWU can be weaned successfully Successful weaning can occur up to 3 months after admission Long-term mortality rate is not adversely affected by transfer
  • 51. Sucessfully weaned patients in SWUSucessfully weaned patients in SWU  70% (50~94%) discharged home alive70% (50~94%) discharged home alive 1-YSR 381-YSR 38––53%53%  only 5only 5––25% of patients admitted to SWU can be expected to be25% of patients admitted to SWU can be expected to be ventilator independent and alive at home 1 yr after their initial respiratory failureventilator independent and alive at home 1 yr after their initial respiratory failure Sucessfully weaned patients in SWUSucessfully weaned patients in SWU  70% (50~94%) discharged home alive70% (50~94%) discharged home alive 1-YSR 381-YSR 38––53%53%  only 5only 5––25% of patients admitted to SWU can be expected to be25% of patients admitted to SWU can be expected to be ventilator independent and alive at home 1 yr after their initial respiratory failureventilator independent and alive at home 1 yr after their initial respiratory failure
  • 52. Specialized Weaning UnitsSpecialized Weaning Units (SWU)(SWU) Weaning successful rate: Post-operative patients (58%) Acute lung injury (57%) COPD or neuromuscular disease (22%) Outcomes of care between SWUs & ICUs: Few studies SWUs may be cost-effective alternatives to acute ICUs In difficult-to-wean patients, the use of clearly defined protocols, independent of the mode used, may result in better outcomes than uncontrolled clinical practice.
  • 53. Admission criteria: Two documented failed weaning trials Presence of a tracheostomy tube Clinical stability & potential to benefit from rehabilitation Minimum operating standards & staff qualifications Acceptable nurse/patient ratios (1:2) Requirement for a supervising pulmonary physician Qualifications of respiratory therapists Presence of certain specialised staff members (e.g. nutritionists, psychologists, etc.)
  • 54. Home VentilationHome Ventilation Cleveland (OH, USA): ARDS, cardiothoracic surgery or COPD 9% were discharged home with partial ventilatory support 1% using NIV & 8% requiring partial MV via tracheostomy Schönhofer et al: COPD 75% discharged home from an SWU 31.5% required home NIV UK study: 35% required further home ventilation, mostly NIV
  • 55. Terminal care forTerminal care for Ventilator-Dependent PatientsVentilator-Dependent Patients -Poor Quality of Life & Low survival rates -Withdrawal of mechanical ventilation ? -Full disclosure of prognostic data -Routine palliative care or ethics consultation can improve the quality of decision making in the acute ICU setting.
  • 56. Recommendations Evaluate readiness for weaning earlyEvaluate readiness for weaning early Be aggressive and search for reversible causes in difficult to weanBe aggressive and search for reversible causes in difficult to wean patientspatients DIFFICULT TO WEAN PROTOCOLDIFFICULT TO WEAN PROTOCOL Most valuable physicians should‐ Most valuable physicians should‐ adhere to standardised weaning guidelines.adhere to standardised weaning guidelines. PSV – Preferred mode in difficult to wean. T piece trials also‐PSV – Preferred mode in difficult to wean. T piece trials also‐ appropriate. Do not use SIMV.appropriate. Do not use SIMV. NIV – Select subgroups. “Weaning in progress”NIV – Select subgroups. “Weaning in progress”
  • 57. RecommendationsRecommendations Evaluate readiness for weaning early Be aggressive and search for reversible causes in difficult to wean patients DIFFICULT TO WEAN PROTOCOL Most valuable physicians should‐ adhere to standardised weaning guidelines. PSV – Preferred mode in difficult to wean. T piece trials also‐ appropriate. Do not use SIMV. NIV – Select subgroups. “Weaning in progress” Thank youThank you

Editor's Notes

  1. These studies failed to account for the increased resistance of the inflamed natural upper airways following extubation, so that post-extubation WOB is best approximated without such compensation. Thus, it does not make sense to use PS for the purpose of overcoming the resistance of the endotracheal tube. The same line of reasoning applies to other modes of ventilation that have been proposed for this purpose, such as ATC.
  2. COPD pts may have improved pulmonary function
  3. in patients who failed extubation following a successful SBT.
  4. Studies of accidentally or self-extubated: 23% of patients receiving full mechanical ventilation and 69% of patients who have begun weaning do not require reintubation 35% of patients who were considered to be unweanable when referred from one facility to another could be extubated without any additional weaning attempts
  5. 528
  6. Acute phase: Optimising and preserving physiological reserve Chronic phase: Restore health Improving muscle power and endurance through passive and active movements, posture and different forms of exercise Since multifaceted interventions such as self-help rehabilitation programmes can improve physical function after critical illness, it is possible that improvements in clinical outcomes for difficult-to-wean patients might be achieved using a methodology similar to that of ventilator bundles. Rehabilitation is the process of restoring health or normal life by training and therapy after illness, but it would seem preferable to do this proactively by optimising and preserving physiological reserve at the earliest possible stage in acute disease, as well as trying to restore it during the later phases of chronic critical illness. Patients who survive the acute phase of critical illness experience a wide range of physical disabilities [74], including: neuromyopathies; muscle wasting, weakness and fatigability; joint deformities and contractures; and the additional residual disease-related damage to specific organ systems. Patients who remain ventilator-dependent in the ICU may suffer the additional burden of continued systemic inflammation and catabolism combined with limited mobility and suboptimal nutrition, and this particularly affects the neuromuscular system. One study showed that 62% of difficult-to-wean patients had neuromuscular disease sufficiently severe enough to account for ventilator dependency [48]. These observations suggest that efforts to prevent or treat respiratory muscle weakness might have a role in reducing weaning failure. Rehabilitation efforts have focused on improving muscle power and endurance through passive and active movements, posture and different forms of exercise. Many studies show effects of modest magnitude on various surrogate measures, such as respiratory physiology, oxygen consumption, muscle fibre atrophy and protein loss. There is, however, a lack of studies demonstrating an impact of rehabilitation on the prevention or reversal of weaning failure or other clinically important outcomes. In addition to neuromuscular disorders, patients experience other physical and psychosocial effects, such as: changes to skin and hair; endocrine impairment; disorders of sleep, mood and libido; and pain. The high symptom burden of survivors of chronic critical illness is accompanied by mortality rates of ,50% at 3 months [191]. Close family members are also affected by what is in effect a form of post-traumatic stress syndrome [192]. Since multifaceted interventions such as self-help rehabilitation programmes can improve physical function after critical illness [193], it is possible that improvements in clinical outcomes for difficult-to-wean patients might be achieved using a methodology similar to that of ventilator bundles.
  7. Several observational studies estimate lower daily costs of care for ventilator-dependent patients in SWUs [157, 203–205], primarily through lower salaries, and reduced building charges, monitoring (e.g. noninvasive), technical equipment (e.g. portable ventilators), cost of diagnostics and therapeutics. Weaning strategies used in SWUs have included intermittent mandatory ventilation/PS, PSV, and T-tube trials [26, 202, 203, 206, 207]. VITACCA et al. [26] studied 75 COPD patients