Anda di halaman 1dari 49

Weaning from Mechanical Ventilation

Consensus Conference of the ATS, ERS, ESCIM,


SCCM and SRLF
Budapest 2005
ERJ 2007; 29: 1033-56

Tobias Welte
Dept. of Respiratory Medicine
Medizinische Hochschule Hannover
Germany
Esteban et al. JAMA 2002
Managing the Patient
Ventilated patients require care in an ICU unless they are
hemodynamically stable, free of hyperactive delirium, and have
stable airways

Country Year Cost/day/patient

Noseworthy CCM 1996;24:1168 Canada 1992 Can $1,500

Sznajder Int Care Med 2001;27:146 France 1996 $1,590

McCarthy Resp Care 1998; 43:114. U.S. 1995 $2,114


(Mech Vent patients)
Cooper CCM 2004; 32:2247 U.S. 2000 $2,462

Halpern CCM 2004; 32:1254 U.S. 2000 $2,674


Weaning

-“The process of liberating patients from the


ventilator,… begins as soon as the patient is
intubated by tailoring settings to the needs of
the patient…”

Hall JB, Wood L. JAMA 1987


25
Vent.time
Wean.time
20

Days 15
* CONTROL GROUP

10 40%

* 40%
5 50% *
43%

0
Esteban, Ely, Kollef, Esteban,
1994 1996 1997 2002
DAYS on MECHANICAL VENTILATION

15

post-surgery
10 Neur.Dis.
CHF
COPD
5

Troche et al. CHEST 112: 1997


UNPLANNED EXTUBATION DURING MV

59%
200

160
PATIENTS

63%
120 41%
26%
80
53%
33% 26% 54% 22%
40

0
471 PATIENTS SELF-EXTUBATED
WHILE ON MECHANICAL VENTIALTION

242 REINTUBATED

49% 51%

229 NON REINTUBATED


(i.e. no need for MV)
SELF EXTUBATION IN 75 PATIENTS

DURING FULL VENTILATORY DURING WEANING


SUPPORT 33 PATIENTS
42 PATIENTS

77% 31%

69%
23%

Epstein SK J at all. Am J Respir Crit Care Med: 2000; 161: 1912-1916


Thorens et al. CCM 1995;23:1807-15
Weaning Protocol
Krishnan J. AJRCCM 2004; 169: 673-8

MV for > 24 h in a 14 bed ICU


Weaning protocol
daily screen for readiness
f/Vt > 105
SBT (CPAP 7) for 1 hour
vs. Usual Care
2 attendes, 10 MD trainees
daily attend bedside round 3 h
nurse to patient ratio 1:2
+ 1-2 additional senior nurses
+ 1-2 respiratory therapists
Seven Stages of Weaning

3
Measure
1 Weaning 5 7
Predictors Extubation Reintubation
Pre-Weaning

4 6
2
Weaning NIV
Suspicion
Trials Post-Extubation

Admit Discharge

• Stage 2–Stage 3 Transition: Time of greatest


delay in weaning
• Goal of Weaning Predictors: Make Stage 2-Stage 3
transition as early as possible
Three Sequential Diagnostic Tests

1. Weaning Predictors See if ready for #2

2. Weaning Trial See if ready for #3

3. Trial of Extubation See if can sustain ventilation


and protect airway
Weaning from mechanical ventilation
• The “golden moment” (Petty TL, Intensive and
Rehabilitative Respiratory Care. Lea & Febiger
1982;232-8)
• ...certain parameters measured at the bedside can assess
the likelihood...a low spontaneous respiratory rate (i.e.,
less than 20) and MIP greater than -20 cmH2O...the
most encouraging situation is a rested, alert patient with
a twinkle in the eye seen on early morning rounds...
these observations indicate that the golden moment is at
hand...the patient is given a 30 min SBT attached to a T-
tube...no essential change is desirable...at this point is
placed back on the respirator (1h) and, if all looks well,
extubation is immediately accomplished.
Weaning - Predictors
Esteban A et al.: N Engl J Med 1995; 332: 345-50

• Spontaneous Breathing via T-Tube for 3 minutes,


FiO2 similar to mechanical ventilation
• Measurement of respiratory rate, tidal volume,
maximal inspiratory Pressure (< -20 cm H2O)
• Extubation, if
– RR < 35/min, RR / Vt > 105 / min / l
– SaO2 > 90%, pO2 / FiO2 > 200
– HR < 140/min
– BP < 180 mmHg oder > 90 mmHg
– Pat. is able to cough, awake and cooperative
300 Patients

Daily Screen

Intervention Group, 149 Control Group, 151

2 hr Spon Br Trial Screen: pO2/FIO2 > 200


PEEP ≤ 5
f/VT ≤ 105
Inform Attending Orally Cough on suction
& Prompt in Chart No pressors/sedation

Ely et al, NEJM 1996:335:1864


Ely EW, et al. NEJM 1996; 335:
1864-69

Intervention Control P-value


n=149 n=151
APACHE II 19.8 17.9 0.01
Weaning Days (M) 1 3 0.0001
Ventilator Days (M) 4.5 6 0.003
Reintubation (%) 6 (4) 15 (10) 0.04
Mech Vent >21d (%) 9 (6) 20 (13) 0.04
Any Complication(%) 30 (20) 62 (41) 0.001
Total ICU Costs $15,740 $20,890 0.03
The Hazard of Remaining on
Mechanical Ventilation

Passing a daily screen of weaning parameters is an independent


factor predictor of successful extubation and survival.

Ely EW, et al. ICM 1999;25:581-7


Three Sequential Diagnostic Tests

1. Weaning Predictors See if ready for #2

2. Weaning Trial See if ready for #3

3. Trial of Extubation See if can sustain ventilation


and protect airway
3 ICUs:
Creteil, Rome, Barcelona
-18 mo prospective study
-456 pts meeting weaning
criteria

MORTALITY
-SIMV: 23%
-T-piece: 23%
-PSV: 13%

Brochard et al., AJRCCM 1994, 150: 896


Multicenter trial

• PS was decreased twice a day


• RR < 35 breaths/min
• Minimal level of PS has to be tolerated 24
hours before extubation
Weaning
Esteban A et al.: Am J Respir Crit Care Med 1997; 156: 459-465

484 pts
MV > 48 h

249 pts 238 pts


T-Tube PSV
p=0.03
54 pts 192 pts 33 pts 205 pts
2-h Trial Failure 2-h Trial Success 2-h Trial Failure 2-h Trial Success

36 Reintubated mortality 27% vs. 2.6% 38 Reintubated


p<0.001
156 Successfully Extubated 167 Successfully Extubated
Mechanical Ventilation in COPD
additional problems

• Size of the endotracheal tube


• Secretions
• Nutritional Status
• Medication
– Sedatives
– Steroides
– Theophyllin and ß2-mimetics
Bronchoscopy
Weaning Problems

• Weaning Delay
– Delay in extubating a patient who should be
able to breathe spontaneously

• Weaning Failure
– Failure of a patient to wean in an expected
amount of time despite appropriate
management
NIV in the Weaning of COPD patients
Nava S et al.: Ann Intern Med 98;128: 721-28

• multicenter, randomized study


• 68 pts with acute respiratory failure
• T-piece weaning after 48 hours
– in 8 pts successful
• 50 pts randomized after T-piece weaning failure
– extubation and NIPSV via face mask
– invasive PSV via endotracheal tube
NIV in the Weaning of COPD patients
Nava S et al.: Ann Intern Med 98;128: 721-28

invasive PSV NIPSV


ventilation days 16.6 ± 11.8 10.2 ± 6.8
ICU days 24.0 ± 13.7 15.1 ± 5.4
death 7 (28%) 2 (8%)
home MV 2 1
VAP 7 (28%) 0
COPD: NIV in weaning failure
Invasive MV 3 d
(77% chronic respiratory diseases)

T-piece trial failure during


3 consecutive days

Standard weaning: Extubation +


daily T-piece trial (n=22) continuous NIV (n=21)

Ferrer M. et al AJRCCM 2003


COPD: NIV in weaning failure
Ferrer M. et al AJRCCM 2003; 168: 70-76

Noninvasive ventilation

100 Conventional weaning

Successfully weaned patients (%)


80

60

p=0.002
40

20

0
0 10 20 30 40 50

Days of intubation
COPD: NIV in weaning failure
Ferrer M. et al AJRCCM 2003; 168: 70-76
Non-invasive ventilation - when to stop?

Criteria for intubation


(Guidelines of the German Society of Respiratory Disease)

• respiratory parameters are not improving within the


first 15 min
• blood gas values persist on the same pathologic
level for 2 h
• every new worsening of the respiratory
situationduring non-invasive ventilation, which
cannot be corrected immediately.
Extubation Failure
• Definition:
– pH < 7.35/ pCO2 > 45 mmHg
– Clinical signs of muscle fatigue
– RR > 25/min
– Hypoxemia
• SaO2 < 90% or
• paO2 < 80 mmHg with FiO2 > 50%
Extubation Failure
30

25
MICU
20 Mixed
17.7 (16.7) Peds
15 SICU
14.1 (14.6) CTS
10 Trauma
13.3 (9.2) Neuro
5
6.3 (6.4)
0
N~34,000 (55 studies)
Outcome for Extubation Failure
12+90 days MV
21+70 days ICU
80

30+60 days Hosp

50
Failure
% of patients

40
Success
30

20

10
0
Died CCF Home >7d ICU >14d ICU N=287
Epstein Chest 1997 after reintubation
Timing of Extubation Failure –
Mortality (%)
60

50

40
Epstein 1998
30 Esteban 1999
Demling 1988
20 Tahvanainen 1983
10

0
0-12 hrs 13-24 hrs > 24 hrs
The Co$t of Extubation Failure
• Pronovost et al, Lang Arch Surg 2001
– Vascular surgery, EF increased hosp charges by 20%

• Seymour et al, Crit Care 2004


– Community Hospital, MICU, SICU
– Extubation Failure Increased
• Hospital Charges: $48,000 v 23,000
• Cost per day: $2000 v 1700
Factors Influencing Extubation Failure Rate

• Patient Population • Reduced Hgb-Hct


• Age • Duration of MV
• Use of Continuous IV • Gender
Sedation • Indication for MV
– Abn MS, delirium • Weaning Trial
• Semirecumbent position – Number of Trials
• Transport from ICU – Duration of the Trial
– Pre-extubation mode
• Severity of Illness of support
• MD staffing, N/P ratio – Protocol
980 Extubated Patients
Meeting Inclusion Criteria
“At-Risk” Cohort

23 Not Randomized
244 (25%) developed Resp 8 – Decreased LOC
fail within 48h 5 – Severe inc resp
effort
4 – Shock
221 Randomized 3 – Hypoxemia
2 - UAO

114 Noninvasive 107 Conventional Group


Ventilation Group

Esteban et al (N Engl J Med 2004)


Postextubation ARF
Esteban A. NEJM 2004; 350: 2452-60
Postextubation ARF
Esteban A. NEJM 2004; 350: 2452-60

• Problems of the Esteban Study


– Unexperienced centers
– Inspiratory Pressure too low
– NIV started too late
NIV to prevent Extubation Failure in
High Risk Patients
• Randomized controlled multicenter
study
• 79 pts. requiring MV > 48 hours and
at risk for reintubation
– hypercapnia
– congestive heart failure
– ineffective cough and excessive
tracheobronchial secretions
– more than one failure of a
weaning trial
– more than one comorbid
condition
– upper airway obstruction
• Extubation after succesful weaning
trial
• NIV for > 8 hours vs. Oxygen
Supplementation alone

Nava S. Crit Care Med 2005 Vol. 33, No. 11: 2465-70
NIV NIV
SUCCESS (n FAILURE p
= 65) (n = 43)
SAPS II 30  11 45 27 < 0.01

pH 7.36  0.09 7.30  0.10 < 0.01

Copious secretions 14% 34% < 0.05

Encephalopathy 28% 49% < 0.01

Tolerance 91% 37% < 0.01

Leaks 9% 72% < 0.01

Carlucci, AJRCCM 2001


Impact of Percutaneous
techniques ?

« The median time between


admission to ICU and
performance of tracheostomy
has decreased significantly
from a median of 8 days
(range 1-23) in 1992 to 4 days
(range 0-21) in 1997
(P=0.016) »

TP Simpson, Anesthesia, 1999;54:186.


Tracheostomy, When ?

Outcome Measures
Early Prolonged
p
Tracheotomy translaryngeal
intubation

Died (%) 19 (31.7) 37 (61.7) <.005


Pneumonia 3 (5) 15 (25) <.005
Days in ICU 4.8±1.4 16.2±3.8 <.001
Days MV 7.6±4.0 17.4±5.3 <.001
Ds sedated 3.2±0.4 14.1±2.9 <.001
Ds on high-
dose
pressors 3.5±1.44 3.0 ns

Rumbak MJ Crit Care Med 2004;32:1689


Weaning with Pressure Support Ventilation:
Three situations

• 1) Easy weaning (first attempt): detect as early as possible


with daily screening + T-piece or low PSV trials, or use of
CDS.
• 2) difficult weaning (more than one attempt): reduce
assistance (PSV) and daily tests with low PSV trials, or use
assisted ventilation (ACV or PSV) + once daily T-piece or low
PSV trials, or use of CDS.
• 3) prolonged weaning (multiple attempts, tracheostomy):
assisted ventilation (PSV or ACV) and prolonged “unassisted”
trials with T-piece or low PSV; NIV?
• For 2 and 3: search for factors impeding weaning.