Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning:...

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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 … · Prolonged Mechanical Ventilator Weaning:...

Page 1: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

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

Page 2: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

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

Page 3: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

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

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Weaning in the PMV patient should be slow-paced and

individualized include gradually lengthening TM trials non-fatiguing comfortable ventilatory

support between TM trials

3

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3 weaning units Inclusion:

COPD 15d vent Failed T-piece trial

Intervention PSV or SBTs

4

Page 6: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

3 weaning units Inclusion:

COPD 15d vent Failed T-piece trial

Intervention PSV or SBTs

4

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

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Blackwood B et al. BMJ 2011;342:bmj.c7237©2011 by British Medical Journal Publishing Group

Weaning Duration

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Blackwood B et al. BMJ 2011;342:bmj.c7237©2011 by British Medical Journal Publishing Group

Weaning Duration

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TIPS protocol - Barlow Respiratory Hospital.

Scheinhorn D J et al. Chest 2001;119:236-242

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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)

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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

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Chronic Ventilation Strategy Taskforce, Final Report - June 2006

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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

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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

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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…...

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Who are our patients…..

All PatientsJan 2004 to Mar 2011n = 144

Invasive ventilation 115 (80%)

Non-invasive ventilation11 (8%)

Trach mask18 (12%)

Page 22: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

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

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Who are our patients…..

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Who are our patients…..

ICU LOS prior to admission56 (39-90) days

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Outcomes…..

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Outcomes…..

Median (IQR) LOS 64 (35-109) days

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Outcomes…..

0

12.5

25.0

37.5

50.0

Weaned/decannulated NIV (PT) Vent dependent (FT) Dead

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Outcomes…..

0

7.5

15.0

22.5

30.0

ICU HDU/Floor Rehab Home LTMV Nursing home

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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

Page 30: Prolonged Mechanical Ventilator Weaning: Experience … · Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical

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

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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

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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

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Thank you for your attentionQuestions?

[email protected]