Prolonged Mechanical Ventilator Weaning: Experience from...
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Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto Director of Research, Provincial Centre of Weaning Excellence, Toronto East General Hospital
Transcript of Prolonged Mechanical Ventilator Weaning: Experience from...
Prolonged Mechanical Ventilator Weaning:
Experience from OntarioLouise Rose
Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto
Director of Research, Provincial Centre of Weaning Excellence, Toronto East General
Hospital
Prolonged Mechanical Ventilator Weaning:
Experience from OntarioLouise Rose
Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto
Director of Research, Provincial Centre of Weaning Excellence, Toronto East General
Hospital
Simple weaning Wean to extubation on first attempt
Difficult weaning Fail initial weaning and require up to 3
SBTs or ≤ 7 days from first SBT
Prolonged weaning Fail > 3 weaning SBTs and > 7 days
weaning from first SBT
Boles et al. (2007) Eur Respir J. 29:1033-56
Weaning in the PMV patient should be slow-paced and
individualized include gradually lengthening TM trials non-fatiguing comfortable ventilatory
support between TM trials
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3 weaning units Inclusion:
COPD 15d vent Failed T-piece trial
Intervention PSV or SBTs
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3 weaning units Inclusion:
COPD 15d vent Failed T-piece trial
Intervention PSV or SBTs
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N = 52181 ± 161 (PSV) vs 130 ± 106 h (SB) = NS
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Weaning Method…
Esteban et al. 1995. N Engl J Med; 332, 345-350.
Brochard et al. 1994. Am J Respir Crit Care Med; 150, 896-903.
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Blackwood B et al. BMJ 2011;342:bmj.c7237©2011 by British Medical Journal Publishing Group
Weaning Duration
Blackwood B et al. BMJ 2011;342:bmj.c7237©2011 by British Medical Journal Publishing Group
Weaning Duration
Blackwood B et al. BMJ 2011;342:bmj.c7237©2011 by British Medical Journal Publishing Group
Weaning Duration
TIPS protocol - Barlow Respiratory Hospital.
Scheinhorn D J et al. Chest 2001;119:236-242
Scheinhorn D J et al. Chest 2001;119:236-242
©2001 by American College of Chest Physicians
N = 252 TIPS, 238 HC29 to 17 days (p < 0.001)
PMV: Reported Weaning success
25.6% to 80.7% Ventilator dependence
3.1% to 67.5% Mortality
4.5% to 50.4% One-year survival
23.0% to 69.0% Discharged home
0.8% to 80.0%
Review of 40 international studies
1991 - 2008
Rose et al. (2009) ICM 35: (Suppl 1): S186
Chronic Ventilation Strategy Taskforce, Final Report - June 2006
8-bed specialized centre for adult GTA ICU patients:
≥ 21 days MV in ICU
clinical team considers patient ‘weanable’ within 90 days
patient able to participate in care decisions
patient medically stable defined as: sepsis treated and controlled (if applicable) hemodynamically stable no new onset complex arrhythmias, or acute coronary
syndrome renal function stable adequate oxygenation tracheostomy in situ; and adequate nutrition support protocol
Provincial Centre of Excellence in Prolonged-Ventilation Weaning
Who we are not…..
Patients with ongoing need for a ventilator but have: clearly irreversible
disease such as high spinal cord injury progressive
neuromuscular disease
or advanced dementia
Patients stay for maximum of 12 weeks Individualized weaning program
progressive trach mask trials Individualized PT program
aim to mobilize early Optimize nutritional status SLP assessments for communication and
swallowing Manage anxiety and other psychological/social
issues
What we do…...
Who are our patients…..
All PatientsJan 2004 to Mar 2011n = 144
Invasive ventilation 115 (80%)
Non-invasive ventilation11 (8%)
Trach mask18 (12%)
Who are our patients…..
All PatientsJan 2004 to Mar 2011n = 144
Invasive ventilation 115 (80%)
Non-invasive ventilation11 (8%)
Trach mask18 (12%)
84 (58%) patients admitted from other ICUs60 (42%) patients from TEGH ICU
Who are our patients…..
Who are our patients…..
ICU LOS prior to admission56 (39-90) days
Outcomes…..
Outcomes…..
Median (IQR) LOS 64 (35-109) days
Outcomes…..
0
12.5
25.0
37.5
50.0
Weaned/decannulated NIV (PT) Vent dependent (FT) Dead
Outcomes…..
0
7.5
15.0
22.5
30.0
ICU HDU/Floor Rehab Home LTMV Nursing home
Long-term Outcomes
43/91 (47%) survived to 1 year27/78 (35%) to 2 years19/53 (36%) to 3 years7/22 (32%) to 5 years
Long-term Outcomes
43/91 (47%) survived to 1 year27/78 (35%) to 2 years19/53 (36%) to 3 years7/22 (32%) to 5 years
Long-term Outcomes
25 participantsMean time from dx 2.1 ±
1.4 yrs
9% IES-R >33 35% HADS anxiety >11
13% HADS depression
>11
Mean SF-36 50±22
SRI summary scale 62±15
126 patients with tracheostomy 103 survivors had 457 transitions in post-
discharge care 67% readmitted 44% dead 1 year 9% alive/functional $3.5 million per one-year independent
survivor
Unroe et al. (2010). Ann Intern Med. 153; 167-175
