EVIDENCE AND RATIONALE FOR INSPIRATORY MUSCLE TRAINING IN WEANING FAILURE

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1 EVIDENCE AND RATIONALE FOR INSPIRATORY MUSCLE TRAINING IN WEANING FAILURE Professor Rik Gosselink, PT, PhD Faculty of Kinesiology and Rehabilitation Sciences Department Intensive Care University Hospital Leuven KU Leuven Belgium

2 Weaning failure: 12-50% Jeong et al. Plos One 2015.

3 Different stages, from initiation to MV to weaning Boles et al. 2007

Recommendations regarding the management Statement of the 6th International Consensus Conference on Intensive Care Medecine J-M. Boles, J. Bion, A.

4 Recommendations regarding the management Statement of the 6th International Consensus Conference on Intensive Care Medecine J-M. Boles, J. Bion, A. Connors, M. Herridge, B. Marsh1, C. Melote, R. Pearl, H. Silverman, M. Stanchina, A. Vieillard-Baron, T. Welte Organised jointly by: ERS, ATS, ESICM, SCCM, SRLF

5 CNS output Respiratory drive Pump Capacity Respiratory muscle pump Load on the pump After Moxham J. Ventilatory Failure

6 FATIGUE NO FATIGUE Vassilakopoulos et al. Am.J.Respir.Crit.Care Med. 1998; 158:

7 Stimulus Rest Modality Intensity Duration

8 INSPIRATORY MUSCLE TRAINING ADJUNCT IN THE TREATMENT OF WEANING FAILURE?

9 INSPIRATORY MUSCLE TRAINING Strength training regimen: Intensity: 30-50%PImax perceived exertion 6-8 on 10 point scale 6 à 8 breaths per set 3-5 sets per day Threshold loading device

12 0 PImax (cmh 2 0) Before After -60 Sham * Experimental Martin et al. Crit. Care 15, R

13 100 Successfull weaning (%) * Sham Experimental 10 0 Martin et al. Crit. Care 15, R84; 2011

15 Is IMT usefull in all patients on mechanical ventilation

16 Elkins et al. J Physioth. 61, 125; 2015

17 PImax Elkins et al. J Physioth. 61, 125; 2015

18 Rapid Shallow Breathing (RSB) Index (br/min/l Elkins et al. J Physioth. 61, 125; 2015

19 Duration mechanical ventilation (days) NS Elkins et al. J Physioth. 61, 125; 2015

20 Duration mechanical ventilation (days) NS Elkins et al. J Physioth. 61, 125; 2015

21 Weaning succes (%) Elkins et al. J Physioth. 61, 125; 2015

22 Survival (RR) NS Elkins et al. J Physioth. 61, 125; 2015

23 Optimization of the training modalities l Type of loading: Threshold loading Tapered Flow Resistive loading l Feedback to the patient during the training session l Control during the training session: l HR/BP/SaO 2 l Tidal volume l Pressure l Power l Diaphragm contraction (US) l Symptoms

24 Mechanical Threshold Loading

25 Tapered flow resistive training

26 Mechanical Threshold Loading Tapered Flow Resistive Loading Langer et al. Physical Therapy 2015; 95:

27 Case F, Age: 44Y, BMI: 17,8 kg/m Diagnosis: Pulm.valve replacement, Aneurysm pulmonary artery Ventilatory support: PSV +12, Days on MV: 30, 3H per day SB Strength training: Intensity: 30-50%Pimax perceived exertion: 6-8 on 10 point scale 6 à 8 breaths per set 3-5 sets per day

30 How do these results affect our clinical practice in patients with weaning failure? l Inspiratory muscle weakness is associated with weaning failure: Assess musclestrength l When weakness is present: discuss its potential importance in the weaning failure and the application of IMT l Apply IMT strength training: limited number of higher intensity contractions, control of cardiorespiratory response, symptoms, rest period between series allows continuation of mode of ventilatory support l Support and feedback to the patient during the training session is essential and the basis for progressing the training over time.

31 CONCLUSIONS I l Weaning failure is a multifactorial clinical condition l Inspiratory muscle weakness is associated with weaning failure linspiratory muscle training is not effective as a preventive measure during mechanical ventilation linspiratory muscle training has been shown, as an adjunct to the treatment of weaning failure, to improve clinicaloutcome in patients withweaningfailure. l Future challenges: patient selection and assessment, training modality, feedback during the training for patient andsupervisor

Acknowledgements: Greet Van den Bergh Greet Hermans Marc Decramer Ilse Vanhorebeek Thierry Troosters Daniel Langer Frans Bruyninckx Geert Meyfroidt Ghislain Gayan-Ramirez Chris Burtin Johan Segers

32 Acknowledgements: Greet Van den Bergh Greet Hermans Marc Decramer Ilse Vanhorebeek Thierry Troosters Daniel Langer Frans Bruyninckx Geert Meyfroidt Ghislain Gayan-Ramirez Chris Burtin Johan Segers Som Charususin Helena Van Mechelen Alexander Wilmer Michael Casaer Patrick Ferdinande Tom Fivez Bieke Clerckx Else Merckx Bregje Frickx Tine Vanhullebusch Inge Demeyere Christophe Robbeets Goele Vanpee

33 ICU Physical Therapy Team

Recovery from ICU-acquired weakness; do not forget the respiratory muscles!

Recovery from ICU-acquired weakness; do not forget the respiratory muscles! Beatrix Clerckx Department of Rehabilitation Sciences, Department of Intensive Care Medicine, University Hospitals Leuven, Catholic