Ventilation Care Workshop

Weaning From Mechanical Ventilation

Charles Wiener, M.D. University of Malaya 8 June 2013

Ventilation Care Workshop

LIBERATION (!) From Mechanical Ventilation

Charles Wiener, M.D. University of Malaya 8 June 2013

Liberation

Weaning

Liberation From Mechanical Ventilation

Why? Physiology of intrathoracic pressure changes Identifying patients for liberation Weaning Who can do it? Recent approaches to liberation Causes of unsuccessful liberation and extubation Simple Approach

Liberation From Mechanical Ventilation

Correct underlying cause of respiratory failure
Gas exchange Circulatory Neurological/Anatomical

If the patient was breathing effectively before the event and no lung or respiratory control process was damaged, they should breathe after correction of the inciting event.

Why Liberate?
Complications of intubation
Larynx, vocal cords, trachea, nose, sinus

Respiratory complications
Nosocomial pneumonia, atelectasis, barotrauma, hypotension, ventilator-associated lung injury

Non-respiratory complications
Gastric, cardiac, renal, nutrition

Physiologic Effects of Positive Pressure

PEEP + increase in trans-pulmonary pressure
Reduce preload Reduce afterload

Over-distension of alveoli
VALI Increase dead space (Zone 1)

Physiologic Effects of Positive Pressure

Decrease Preload
Positive pleural pressure raises Pra, which is downstream pressure to venous return Increase lung volume/FRC may distort IVC increasing resistance to venous return
Decrease venous return/cardiac output, blood pressure

Decrease LV Afterload
Positive pleural pressure augments LV contraction, lowering impedance to emptying Equivalent to decrease in aortic root pressure

Potential Risks of Termination of Positive Pressure Ventilation

Increase preload and LV afterload
Provoke pulmonary edema Provoke LV failure Provoke myocardial ischemia

Increase atelectasis Increase work of breathing

Identifying Patients For Liberation

Criteria for Liberation: 1970-1990

Minute Ventilation < 10 L/min
Measured at RV Required cooperation

Ability to double (MVV > 20 L/min)

Negative Inspiratory Pressure < - 30 cm H2) Results:

76% met MV, MVV, and NIP criteria; successfully liberate 17 patients failed both criteria; unable to liberate 7 patients met MV, failed MVV, met NIP; liberate

Conclusion: MV and NIP criteria predictive of successful liberation; MVV helpful in tough calls

Criteria for Liberation: 1990-2010

Criteria for Liberation

f/Vt was most accurate >105 had 0.78 PPV of remaining extubated >24 hours < 105 had 0.95 NPV of successful liberation All indexes performed less well in patients with >8 days mechanical ventilation

Weaning

Weaning Methods
RCT- 546 patients with ARF/ALI
Mostly medical

A/C ventilation for 7.5 + 6.1 days

P/F > 200; PEEP < 5; no significant fever, anemia, vasoactive meds, sedation need Attending had to agree ready for liberation/wean

NEJM 1995;332:345-50

Weaning Methods
3 minute spontaneous breathing trial: T-piece
Measure NIP, Vt, f

If 2 of 3: NIP < -20, Vt >5 ml/kg, f < 35/min

And: SaO2 > 90%, stable HR, stable BP, no anxiety/agitatioin/diaphoresis EXTUBATED

If not: randomized to wean

Pressure support vs SIMV vs intermittant SBT vs single 2-hour SBT
NEJM 1995;332:345-50

Weaning Methods

NEJM 1995;332:345-50

Weaning
How long spontaneous breathing trial?

RCT 30 vs 120 min SBT

526 patients Similar methodology as previous trial

73-76% remained liberated for >48 hrs No difference between 30 and 120 min SBT
AM J RESPIR CRIT CARE MED 1999;159:512518.

Weaning
Tracheostomy Patients
RCT 500 patients in specialty hospital; patients referred for weaning; >30 days MV Almost 200 removed from MV after 5 day SBP Randomized to PS wean (3x/day) vs trach collar (up to 12hrs/day) 50% of patients liberated SBP had shorter median time to liberation (15 vs 19 days) No difference in mortality (60-66%)

Weaning
Who can do it?

Weaning
Who can do it?
117 Respiratory Therapists, 1067 patients, >9000 patient-days Daily Screen ready to wean physician order
MV < 15 L/min, FiO2 < 0.60, PEEP < 10

Pass Daily Screen

P/F > 200, PEEP < 5, f/Vt > 105, no vasoactive/sedative infusion, adequate cough

RT report results of Daily Screen to Physician

Physician orders SBT Physician orders extubation

Structured education and periodic reinforcement of protocols to RTs and Physicians necessary for success

Liberation Identifying Patients

Work of breathing/Respiratory drive
D P0.1 : Am Rev Respir Dis 135:107, 1987 Oxygen cost/work of breathing: Crit Care Med 12:258, 1984 Esophageal pressure: AJRCCM 171: 12521259, 2005

Respiratory muscles
Tension-time index: AJRCCM 180:982-8, 2009

Liberation
Identifying Patients
AJRCCM 2012; 186:12561263

RCT: 1x/day BNP vs. standard

304 patients, renal failure excluded Automated weaning system BNP group: fluid restriction, diuretic protocol

70% of patients had at least one elevated BNP BNP group received more diuretics (70% vs 85%)

Causes of unsuccessful efforts to liberate

Respiratory muscle weakness
Fatigue Nutrition, electrolytes, medications Neuropathy/Myopathy

Airway Resistance
Mucus, secretions Bronchospasm

Lung/Respiratory Compliance
Volume overload Abdominal distension

Hypoxemia/Atelectasis Metabolic Acidosis, Alkalosis Cardiac

Ischemia, LV/RV dysfunction

Extubation
Unassisted ventilation vs. Extubation
Airway protection, clearance of secretions, cough Mental status, frequent suctioning

Upper airway patency

Cuff-leak test

Post-extubation stridor
Pulmonary edema Nebulized epinephrine, systemic steroids, HeliOx

Non-invasive ventilation
Incentive spirometry

Summary
Liberation is often just a question of doing it
Minority of patients require weaning Correct underlying cause, reduce mechanical ventilatory support, optimize electrolytes and acidbase

Identification of eligible patients and timely test of ability to breathe

Keep things simple

If unable to breathe independently, identify potential reversible causes

Have patience!

Often patients are liberated more quickly with less involvement from physicians

Summary

My Approach
Assess for respiratory, metabolic, and neurologic stability
Minute ventilation Delirium, Sedation, Sleep/wake cycle

Not wet, even a little dry Is there a reason to keep on vent

RT rounds in early AM Consider measuring Vt/RR ratio

Spontaneous breathing trial (minimal machine resistance)

Can be initiated by RT so can be observed on AM ward rounds Consider some CPAP/PS depending on ET tube, habitus, local conditions 30 minutes usual, longer (but not greater than 2 hours) if want to stress

Airway/larynx consideration Extubate to humidified air/O2 mixture Follow clinically for at least 4 hours, longer if prolonged respiratory failure

Terima Kasih