All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical...

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All I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS Pittsburgh

Transcript of All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical...

Page 1: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

All I’ve Learned About Weaning

Patients From Mechanical Ventilation

John J. Marini

University of Minnesota

Minneapolis / St. Paul

FOCUS Pittsburgh

Page 2: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Until recently, the subject has been

seemingly dead or sleeping…

Page 3: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 4: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 5: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 6: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 7: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

What Have We Really Learned? General Principles

• Do not let patient work too hard or too little.

• Keep an appropriate fluid balance.

• Pay attention to cardiac issues.

• Restore diurnal and sleep rhythms.

– Mobilize by day, sleep at night.

• Prevent and treat delirium.

• Minimize sedation but avoid asynchrony.

• Test your assumptions with daily breathing trials.

PROTOCOLS HELP!

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What Have We Really Learned? General Principles for the MD & RT

• Do Not Delay Progress

• Pay Close Attention to Post-Extubation

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Long Sought Goals in Weaning

• Perfect predictive index

• Easy formula for preparing the patient

• Ideal weaning mode

– Foolproof

– Effective

– Works for everybody

Return on investment has not

been very impressive…

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VE, VT, frequency, P0.1, Pmax,

Pressure-time product…etc

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Liberation Sequence

• Preparation

• Evaluation

• Withdrawal of Support

– Ventilator

– Endotracheal Tube

• Peri-Extubation Care

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Why Does Extubation Fail?

• Respiratory – Imbalance of capability/demand

• Secretion Retention

• Dynamic Hyperinflation / Auto-PEEP

• Bronchospasm

• Upper airway obstruction

• Atelectasis

• Cardiac – Lung edema

– Blood Translocation

– Ischemia / Diastolic Dysfunction

– Arrhythmia

• Mental Issues / Sedation & Delirium

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Clinician-Perceived Reasons for Re-intubation Decision

• Inadequate ventilatory capability for demand

• O2 desaturation and/or CO2 retention

• Arrhythmia

Key Causes of Post-extubation Distress

• Retention of airway secretions

• Upper airway dysfunction

• Marked fluid excess (positive fluid imbalance)

• Inadequate cardiovascular reserve

Often Best Revealed After Extubation

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Important Considerations

Before Extubation

• Electrolytes

• Cardiovascular status

• Nutrition

• Hydration

• Distension

• Comfort

• Infection

• Secretions

• Position

• Anxiolysis

• Sedation

• Sleep

Trajectory

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Congestion Precipitated by Breathing

Effort is Often Diastolic Dysfunction

LeMaire, Anesthesiology 1987

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Detection of Cardiac Dysfunction By

NT- Pro BNP in COPD

Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease *. Grasso, Salvatore; Leone, Antonio; De Michele, Michele; Anaclerio, Roberto; Cafarelli, Aldo; Ancona, Giovanni; Stripoli, Tania; Bruno, Francesco; Pugliese, Paolo; Dambrosio, Michele; Dalfino, Lidia; Di Serio, Francesca; Fiore, Tommaso Critical Care Medicine. 35(1):96-105, January 2007. DOI: 10.1097/01.CCM.0000250391.89780.64

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De-Conditioning

Ventilator Support

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Fluid Retention

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A C B

Unsuspected Retention of Secretions

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E B M

No Data??

No Evidence??

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Preparation

• Encourage sleep; Use hypnotics to complement sedation

• Daily wake-up during full support

• Diurnal rhythms, light modulation, noise reduction

• Relieve discomfort—skeletal & visceral (bowel, bladder) – Opiates relieve pain and improve depth of breathing (↓ f/Vt)

• Early conversion to dexmedetomedine

• Mobilize to the extent possible

• Re-establish “baseline” fluid balance – Consider albumin and furosemide (drip) / CVVH

• Address cardiac issues—ischemia, rhythm, CHF

• Rx infection, secretions, pleural effusions, anemia

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An Often Overlooked Cause of

Pain & Agitation

Position of Body & Head

Analgesic Spray

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Chair* Positioning

* 70 O

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Obesity, Auto-PEEP & Position

Lemyze Crit Care Med 2013

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Upright Sitting Position May

Reduce Gas Trapping

Lemyze Crit Care Med 2013

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Preparation Tricks (?)

• Consider depakote, quetiapine, risperidone,

olanzepine and dexmedatomidine (Precedex) for

delirious or combative patients

– Hydromorphone often better than fentanyl (‘D&D’)

– Reduce benzodiazepine use

• Consider anti-arrhythmic & ischemia prophylaxis

• Consider trial of methylphenadate (Ritalin)

modafenil (Provigil), for patients slow to awaken

• Inspect the central airway prior to attempt in long

ventilated patients

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Liberation Sequence

• Preparation

• Evaluation

• Withdrawal of Support

– Ventilator

– Endotracheal Tube

• Peri-Extubation Care

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‘Snapshot’ (Static) Predictive

Indicators in Weaning

•NIF more negative than -20 cm H2O

• VC > 10 ml/kg

• VE<10 L/min

• Respiratory rate < 30-35

• VT > 5 ml/kg

• f/ VT ratio < 100

• Able to double resting minute

ventilation

All are brief assessments of load and/or

capability of respiratory pump

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Elevated RSBI…Better Than f or VE

…But Many False Positives

Many Patients Can Succeed

Despite Shallow Breathing

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Well Compensated Restrictive Disease Often

Shows Relatively ‘Rapid Shallow Breathing’

Tobin Chest 1983

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Trends Are Often Better Than Point

Predictors of Eventual Outcome

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Breathing Pattern Components

• Minute Ventilation

• Respiratory Rate

• Tidal Volume

• Inspiratory Time Fraction (Ti/Ttot)

• f/Vt

• Esophageal Pressure

• Edi

• P0.1

Outputs (Mechanics & Timing)

Inputs (Drive & Effort)

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Breathing Pattern Variability

• Innate characteristic of health

– Breath-to-breath variation

– Complexity

• Improves pulmonary gas exchange

• May lessen atelectasis

• Declines as load/capacity ratio increases

• Normally declines during sleep

• Influenced by mode and level of support

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A Useful Weaning Indicator?

Page 35: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

f/VT Equilibrates Relatively Quickly

Compared to Pes Effort (Swing)

From Jubran and Colleagues

Appro

ach

to

Equili

briu

m

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But RSBI Often Varies During A Trial…

Zamora 2012

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Pes Swing Amplitude and Trend

Predict Weaning Outcome

From Jubran and Colleagues

P

es S

win

g (

cm

H2O

)

Failure

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Pes Swings vs. RSBI-- Success

Jubran and Colleagues

P

es S

win

g

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Pes Swings vs. RSBI -- Failure P

es S

win

g

Page 40: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Variation of Breathing Pattern

Helps Predict Weanability

Wysocki 2006

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Edi (NAVA) Catheter

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Variability Increases as Muscles

Are Unloaded

More NAVA, less load & more variation

Page 43: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

But Variability May Also Increase In

Response to Distress

LeMaire, Anesthesiology 1987

Pwedge

Pes

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No Data??

No ‘Evidence’??

Page 45: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Prediction…Key Indicators

• Prior Variability in Requirements

• Correlate RSBI with VE

• If VE and RSBI both increase → exercise response

• If VE does not rise, high RSBI suggests problems

• Observe Variation of Breathing Patterns

– VE before trial

– Pattern of breathing on low level of PSV

• Observe ‘Cough Inspiratory Capacity’ & PEF?

– If > 2 x VT good power reserve

Page 46: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Normal Exercise Response

…Falling, then Rising f /VT

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Readiness Evaluation

• Awake, oxygenated, stable & optimally prepared?

• Power Requirement

– Minute Ventilation…minimum sustained value is important

– Work per liter (mean airway pressure)

• Power Reserve – Cough inspiratory capacity (catheter or saline stimulation)

– Peak expiratory flow (catheter stimulation)

– Current & prior minute ventilation levels and variation ( over 6-8 hours) • Sleep vs. awake

• Spontaneous Breathing Test (SBT) – Variation of tidal volume, VE , I:E ratio

– Assess f/Vt ratio in relation to: • Respiratory compliance, chronic neuromuscular background

• Directional change in minute ventilation

Page 48: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Liberation Sequence

• Preparation

• Evaluation

• Withdrawal of Support

– Ventilator

– Endotracheal Tube

• Peri-Extubation Care

Page 49: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 50: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 51: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Does Mode or Method Matter?

• Literature suggests No

– Spontaneous breathing trial (SBT) on minimal

support

– Up or Down decision to extubate based on

SBT

• Bi-Pap if needed afterward

• Experience suggests Yes

– Cardiac Issues

– Emotional issues

– Debility

Graded PSV, PAV, NAVA

Page 52: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

It’s All In Just How You Do It

Page 53: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

A Few Years Later…

Page 54: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS
Page 55: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Nice Early Try

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Where ventilator technology has

currently brought us…

Page 57: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Emerging Economic Realities

• Fewer Trained Personnel per Patient

– Observation

– Intervention

• Faster Hospital Throughput

• More Demands For Documentation

Less Time at Bedside

Page 58: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Optimized Management How Do We Time Our Therapeutic ‘Flip’ ?

Rescue Phase

Stabilization Phase

Re-loading (Strengthening) Phase

Recovery Phase

+

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Key Principles of ICU Management

• Therapeutic efficacy depends on

appropriate & early intervention.

• Clinician must weight and integrate all

important factors.

• Timely mid-course corrections are vital.

Page 60: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Sustaining a Bedside Presence is

Problematic for Today’s Caregivers

Tim

e T

ime

Page 61: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Electronic Medical Records Are

Part of the Problem

Need for data entry

Detachment from the

patient and bedside

care giving team

Page 62: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

‘Closed Loop’ Automation Helps Us

Stay Vigilant & React Quickly

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Challenges for Automated Modes

Of Ventilation

• Integrate all vitally relevant information

• Appropriate reactive timing of adjustments

• Correct intervention paradigm for the task

• Patient acceptance of imposed changes

Page 64: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Automated Approaches To

Ventilator Weaning

• Let the patient determine ventilation

rhythm

• Coordinate airway pressures within the

individual tidal cycle

• Evaluate the breathing pattern and

exhaled CO2 & readjust to keep in desired

ranges

• Withdraw unnecessary support

Page 65: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Proportional Assist Synchronizes With &

Mirrors Muscular Effort

Assessed By Mechanical Output

20-80%

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PCV vs. PAV+

PCV

15

cmH2O

PAV+

at 75%

P

T

P

T

P

T

P

T

P

T

P

T

From Javier Fernandez

Off-switch & Power

Page 67: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Phrenic nerve traffic

guides the breathing

support provided.

Diaphragmatic EMG may

offer diagnostic info.

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NAVA Provides Flexible Energy Boost

Response To Tidal Efforts

Sinderby et al, Nature Medicine; 5(12):1433-1436

Volume

PAW

DGM EMG

Page 69: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Can the Patient & Caregiver Be

Trusted With Control?

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Potential Applications of ‘Closing The

Loop’ By Automation

• Safely Optimize Physiological Targets

• Minimize Time of Support (‘Weaning’)

• Avoid

– Asynchrony

– VILI

– Unnecessary supplemental oxygen (FiO2)

Page 71: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Adaptive Support Manipulates Pressure &

Machine Rate to Keep in Desired Range

Page 72: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Automated Modes Candidates for Automated Weaning?

• SmartCare

• Proportional Pressure Support

• Adaptive Support

• Automode

• Intellivent-ASV

• PAV

• NAVA

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AJRCCM 2006

What is the ‘comparator’ limb?

Who are the patients?

What is the protocol?

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Protocols avoid weaning delays

and missed opportunities.

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Page 77: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Is Automated Weaning Superior? It All Depends…

• Which population?

• What is your staffing and surveillance?

• How good is your implementation?

– Algorithm

• Inclusive of gas exchange?

• Inclusion of non-respiratory variables?

– Weaning protocols

• ABCDEF guidelines followed?

• Etc…

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Automated Weaning Still Incomplete

Transpulmonary Pressure

Adjustment Timing

Cardiovascular Tolerance

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Justification for ‘Closed Loop’ Automated

Control of ‘Weaning’ Readiness

• Potential to Lower Costs

• Increased Demand for Ventilation

• Staffing Issues

• Widespread Failure to Implement Best

Practice

• Need for Better Surveillance

(after R Branson)

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Liberation Sequence

• Preparation

• Evaluation

• Withdrawal of Support

– Ventilator

– Endotracheal Tube

• Peri-Extubation Care

Page 81: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

A C B

Zamanian, Marini Crit Care Med Jan 2006

Inspect The Airway Before Extubation!

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Peak Flow During Induced Cough

Chan LY Am J Crit Care May 2010

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Upper Airway Patency

• Test Cuff “Clearance” Prior to Extraction

• Use High PEEP to Break Mucus Seal

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Mucus Seal—Cuff Deflation Test

20 cmH2O PEEP

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Cuff Leak?

• Always perform CLT prior to extubation

– High PEEP (12-20 cmH2O) and volume assist control

– Monitor set vs. recovered VT

• If no leak …

– Upright position

– Move head in orthogonal planes

– Steroids +/- diuretics x 12-24 hours?

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Endotracheal Tube Removal

High PEEP (15 cmH2O) for a few breaths just prior

and while the tube is extracted

Avoids false cuff deflation test

Often breaks mucus seal

Head position

Tube advance or withdrawal

Helps eliminate upper tract mucus

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Tube Extraction

++

+ +

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Cuff-induced muscle tone

Compressive edema

Sequelae of Cuff Inflation

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Regional ischemia

Sustained Pharyngeal Pressure

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PCV with PEEP and Cuff Deflated

+

+ +

Head Upright

Page 91: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Cuff Leak?

• Always perform CLT prior to extubation

– High PEEP (12-20 cmH2O)

– Monitor set vs. recovered VT

• If no leak …

– Upright position

– Move head in orthogonal planes

– Keep cuff deflated for 15-60 min

• 10 cmH2O PEEP

• 7-15 cmH2O PCV

– Steroids +/- Diuretics x 24 hours

Page 92: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

The Weaning Process

• Preparation

• Evaluation

• Withdrawal of Support

– Ventilator

– Endotracheal Tube

• Peri-Extubation Care

Page 93: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Peri-Extubation

• Aggressive secretion clearance, respiratory care, and fluid balance

• Consider nasal trumpet pre-extubation

• Inspect Airway prior to extubation

• Humidified intermittent Bi-PAP

• Consider nasal high flow

• Nasal prongs whenever possible

Pre

Post

Page 94: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Post-Extubation

Consider Modafenil

Head at > 45 degrees

Page 95: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Pharyngeal and Glottic Edema

Impaired Swallow

Residual Sedation

Sleep Deficit

Page 96: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Flow-Volume Curves Before

and After Extubation

Page 97: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Humidify the Airstream!

High VE, Mouth Open, Increased FiO2

Especially helpful during sleep and early post extubation

Page 98: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Preferable if Secretions and Cough?

Page 99: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Humidified High Flow Nasal

Cannula

Deadspace Washout

Expiratory Retard

Mild CPAP

Reflex

Unimpeded Cough

Page 100: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

One-Site VV-ECMO

Two-Site VV-ECMO

Dual-lumen Cannula

Page 101: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Can We Promote Early Liberation With Veno-Venous

CO2 Removal and Oxygenation?

Pump Regulated Blood Flow

Page 102: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

Tips or Tricks?

Show us the EVIDENCE!!

Page 103: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

END

Page 104: All I’ve Learned About Weaning - foocus.com I’ve Learned About Weaning Patients From Mechanical Ventilation John J. Marini University of Minnesota Minneapolis / St. Paul FOCUS

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