Weaning from mechanical Ventilation/CCM Board review

8/10/2019 Weaning from mechanical Ventilation/CCM Board review

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John F. McConville, M.D.

Associate Professor

University of Chicago


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Objectives:

Pinpoint patient readiness for spontaneousbreathing trials (SBT)

List criteria for passing an SBT

Identify non-ventilator strategies for reducing

duration of mechanical ventilation


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A. RR: 40 and Vt: 250 ml after 1 min CPAP of 5 cmH2O

B. MV settings of AC 20/450/12/60%

C. BP of 90/45 mmHg on norepinephrine, vasopressin,

dobutamine

D. 65 yr old male with lung cancer, pneumonia, acute

renal failure, and CHF on CXR with a RR of 30 andVt of 300 ml after 1 min CPAP (5 cmH2O)

Audience Response Question

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Mechanical ventilation: Primary

prevention! EGDT in the initial treatment of sepsis

!

Use of NIV in selected patients with:

AECOPD

Acute cardiogenic pulmonary edema

Rivers. N Engl J Med. 2001; 345:13681377.

Brochard. N Engl J Med 1995;333:817-822.

Masip. JAMA. 2005;294:3124-3130.

Gray. N Engl J Med. 359;(24): 142-151.


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McConville JF, Kress JP. N Engl J Med 2012;367:2233-2239


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Intubation

Tx RF etiology

Extubation

liberation duration

MV International Study Group

:;>=?=@ABCDEFCEEG

69% Acute respiratory failurepost-surgical, pneumonia, CHF, sepsis, trauma, ARDS


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Intubation

Tx RF etiology

Extubation

liberation duration

Duration of time on MV

60% 40%Esteban Chest 1994;106:1186

Esteban JAMA 2002;287:345

Esteban AJRCCM 2008;177:170


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136 brain injury-MV pts. Readiness criteria daily

Extubation delay = days b/t readiness and extubation

Complications of MV

Coplin AJRCCM 2000;162:1530

0

5

10

15

20

25

30

3540

Pneum (%) Mortality

(%)

Hosp LOS

Delay (37/136) No delay (99/136)


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Intubation

Tx of RF

Extubation

Liberation duration

GOAL: minimize time on MV


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1970 through early 1980s

Weaning = disconnect patients from MV

for gradually increasing periods

Predictors sought to identify earliest time

a patient could resume spontaneous

breathing


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Yang and Tobin NEJM 1991;324:1445-50.

Frequency/tidal volume ratio (f/Vt)

Calculated during a 1 minute spontaneousbreathing trial (SBT)

Ratio of < 105 best determines success

If clinical equipoise about SBT success

" f/Vt of 80 #LR of 7.5 and 95% success rate


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Weaning predictors

Meade Chest 2001;120:400S

Systematic review and meta-analysis

51 weaning predictors

Take home:

No ideal predictors for liberation readiness

5 predictors minimally helpful

NIF, VE, Vt, RR and f/Vt


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Intermittent mandatory ventilation (IMV)

had replaced disconnecting MV for shortperiods time as the primary means of

weaning

By the mid 1980s


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1990s: Mode of weaning studies

Brochard and Esteban studies

1002 medical surgical MV patients SIMV vs. PSV vs. T-piece

Brochard AJRCCM 1994;150:896-903

Esteban NEJM 1995;332:345-350

76% passed the initial SBT


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Mode of weaning studies

Duration of weaning (days)

Brochard AJRCCM 1994;150:896-903

Esteban NEJM 1995;332:345-350


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300 adult patients

Intervention group received

- daily screen respiratory function

- SBT: if passed #M.D. notified

Control pts were screened daily

Ely NEJM 1996;335:1864-1869

When can they breathe?


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To pass screen test:

PaO2:FiO2ratio >200

PEEP !5

adequate cough

no vasopressor or sedatives in use

f/Vt ratio !105 during 1 min CPAP 5 cmH20

Ely NEJM 1996;335:1864-1869


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2 hour SBT on CPAP of 5 cm H20

SBT terminated if:

RR > 35 for more than 5 minutes

O2% < 90%

HR > 140/min

sustained "in HR by 20%

SBP > 180 mmHg or < 90 mmHg

increased anxiety or diaphoresis

Ely NEJM 1996;335:1864-1869


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PtsonMV

(%)

Days after passed screen

Intervention group was sicker( higher APACHE and LIS)

Median duration of MV until successful screen

test#3 vs. 2 days (intervention and control)

Ely NEJM 1996;335:1864-1869


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Decreased in intervention group:

Duration of MV Reintubation rate

Cost of ICU stay

Ely NEJM 1996;335:1864-1869


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Take home points

Most patients can be liberated

quickly

Systematic approaches are needed

Physicians are bad at recognizing

when the weaning period begins Assess readiness early


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What mode for SBT

T-piece = PSV 7 cm H2O

T-piece: 78% liberated and 38 reintubated

PSV: 86% liberated and 36 reintubated



30 min SBT = 120 min SBT88% and 85% passed

13.5% and 13.4% reintubated

Duration of SBT


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Patients are ready to breathe earlier

than we think

Systematic approach is much more

important than SBT mode and

duration

SBT summary


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Why do patients fail SBTs?

Worsening respiratory mechanics

increased respiratory resistance

decreased lung compliancegas trapping

Cardiac etiology

Tobin AJRCCM 1997;155:906-15



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McConville JF, Kress JP. N Engl J Med 2012;367:2233-2239

Load > Strength



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Jubran AJRCCM 1998; 158:1763


SvO2(%)


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Weaning classification

Boles ERJ 2007;29:1033-1056

Simple: 1stSBT & liberation successful

Difficult: requires up to 3 SBTs

< 7 days 1stSBT to liberation

Prolonged: fail at least 3 SBTs or

> 7 days weaning after 1stSBT


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Weaning classification

Funk ERJ 2010;35:88-94

257 patients prospective study

Simple: 59% #13% hospital mortality

Difficult: 26% #9% hospital mortality

Prolonged: 14% #32% hospital

mortality


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Other factors effecting liberation

Sedation strategies

- medications- interruption

Timing of awakening and SBT Physical therapy


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Wake Up! Daily Sedation Interruption

Kress NEJM 2000;342:1471

Intervention(wake-up)

Control Pvalue

N 68 60MV duration, d 4.9 (2.5-8.6) 7.3 (3.4-16.1) 0.004

ICU LOS, d 6.4 (3.9-12.0) 9.9 (4.7-17.9) 0.02

Hosp LOS, d 13.3 (7.3-20.0) 16.9 (8.5-26.6) 0.19

W k ! A d b th


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Wake up! And breathe.SBT only SAT +SBT p value

n = 168 167Vent free

days

11.7 14.8 0.01

Duration ofMV (days) 6.0 4.8 0.02

ICU LOS 12.8 9.1 0.02

Hosp LOS 19 14.8 0.04

Self

Extubation

6 16 0.03


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Wake up! And move?Intervention Patients

Daily passive ROM and PT/OT

Control Patients

PT and OT per primary team

Both groups received protocol-directedSBT

Daily sedation interruption

Nutrition

Glycemic control


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Outcome

Intervention

(n = 49)

Control

(n = 55) P value

Ventilator-free days 23.5 [7.4,25.6] 21.1 [0.0,23.8] 0.05

MV duration, days 3.4 [2.3,7.3] 6.1 [4.0,9.6] 0.02

ICU LOS, days 5.9 [4.5,13.2] 7.9 [6.1,12.9] 0.08

Hospital LOS, days 13.5 [8.0,23.1] 12.9 [8.9,19.8] 0.93

Hospital mortality, % 18 26 0.53

Wake up! And move?

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Take home points

Stop sedation every day

SBT early! (awake if possible)

Awakening and Breathing Coordination,

Delirium monitoring, Early mobilization

and Exercise #ABCDE approach

H d d i f MV


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How to reduce duration of MV Daily interruption of sedative infusions

Paired interruption of sedatives and SBT

Early physical and occupational therapy

No sedative use in MV patients

ARDS

$

Vt of 6ml/kg (ideal body weight)$

Conservative fluid strategy

$ Prone positioning

$ Early paralysis

Strategies to reduce VAP

N Engl J Med 2000, 342:1301-1308.

Strm. Lancet. 2010; 375: 475-480.

N Engl J Med. 2006; 354: 1-12.

N Engl J Med 2010, 363:1107-1116.

N Engl J Med. 2013; 368: 2159-2168.

Dezfulian. A. J. Med. 2005;118,11-18


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Mode of weaning studies: part II

Computer driven weaning

automated reduction in PSV based oncontinuous evaluation of:

RR, Vt and end-tidal CO2


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Computer driven weaning

Closed-loop, automated system (Drger Smartcare)

- 144 Subjects: SBT when minimal PSV achieved

- Reduced weaning time (median 5.0 v 3.0d),

days ventilated, ICU LOSLellouche et.al: Am J Respir Crit Care Med 174: 894, 2006

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Extubation failure

0

2

4

6

8

10

12

14

16

18

MICU

Mixed

Peds

SICU

CTS

Trauma

Neuro

%

patients

extubated

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Extubation failure = increased mortality

0

10

20

30

40

50

60

70

Death ICU LOS Home

Failure Success

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Liberation readiness vs. SBT success

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37 ICUs in 8 countries Liberation failure in 121 of 900 pts (13.4%)

Logistic regression identified:

f/Vt (OR 1.009 per unit)

+ fluid balance in 24 hr prior (OR 1.70)

MV for pneumonia (OR 1.77)

Frutos-Vivar Chest 2006;130:1664


Liberation readiness vs SBT success


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R

eintubationrate(%)

f/Vt ratio


Liberation readiness vs SBT success


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Re

intubatio

nrate(%

)

Fluid balance



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NIPPV in liberation failure

Post liberation respiratory distress- Keenan, JAMA 2002 #NO

- Esteban, NEJM 2004 #NO

Preventive for high risk patients

- Nava, CCM 2005 #YES

- Ferrer, AJRCCM 2006 #YES


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Failure of more than one consecutive SBT Chronic heart failure

PaCO2> 45 mmHg after extubation

More than one co-morbidity other than heart

failure Weak cough

Upper airway stridor at extubation

Age > 65

APACHE II score > 12 on the day of extubation Medical, pediatric or multispecialty ICU patient

Pneumonia as etiology of respiratory failure

Risk factors for liberation failure


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Time to reintubation likely matters

Time to reintubation (hrs) Deaths (%)

0-12 24

13-24 3925-48 50

49-72 69

Epstein. AJRCCM. 1998; 158:489493.


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Progressive withdrawal vs. SBT

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Meade. Chest 2001;120:400S

Ely. NEJM 1996;335:1864-1869

MacIntyre. Chest. 2001 120: 375S-396S.

Girard. Lancet 2008, 371:126-134

Salam. Intensive Care Med 2004, 30:1334-1339

Esteban. NEJM 2004,350:2452-2460

Nava. CCM 2006,33:2465-2479


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Weaning from mechanical Ventilation/CCM Board review

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