Difficult weaning GIC 2015

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Barry Newton
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1 Difficult weaning GIC 2015

2 Normal weaning Clinical improvement, P/F ratio > 150 (FiO2 0.5 en PEEP 8), stable hemodynamics SBT (30 minutes) T-piece/CPAP/PSV Success Cough? Swallow? Extubation Failure 2-25% Heunks and van der Hoeven Critical Care 2010, 14:245 REVIEW Once daily + analysis Clinical review: The ABC of weaning failure - a structured approach Leo M Heunks* and Johannes G van der Hoeven

3 Does it matter how we perform a SBT? MV > 48h (N = 484) SBT T-piece PSV 7 P value 0.02 Failure 22% Extubated after 48 hrs 63% Failure 14% P value 0.14 Extubated after 48 hrs 70% Esteban A. Am J Respir Crit Care Med 1997;156:

4 However.. 2,5" 2" WOB$(J/L)$ 1,5" 1" Total"WOB" Elas7c"WOB" Resis7ve"WOB" 0,5" 0" T(Piece"start" T(Piece"end" Post(extuba7on" Straus C. Am J Respir Crit Care Med 1998;157:20-30

5 Type of SBT does make a difference N = 14 Failure one previous SBT 11 known with LVHF 60 minutes SBT in random order PSV 7/5 PSV 7/0 T-piece 3/14 failure 6/14 failure 14/14 failure Cabello B. Intensive Care Med 2010;36:

6 Cabello B. Intensive Care Med 2010;36:

7 Parameters at the end of a SBT ACV PSV/PEEP PSV/ZEEP T-piece PTPes (cmh2o.s/min) 66 (24-173) 128 (59-299) 148 ( ) 292 ( ) WOB (J/min) 3.1 ( ) 6.3 (1-15.1) 7.7 ( ) 12.6 ( ) Heart rate (/min) 88 (80-98) 89 (81-100) 94 (87-103) 98 (88-106) SBP (mmhg) 116 ( ) 124 ( ) 138 ( ) 158 ( ) PCWP (mmhg) 15 (12-18) 17 (14-21) 20 (15-25) 21 (18-24) SVO2 (%) 69 (64-73) 69 (65-71) 69 (65-74) 69 (64-74) Cabello B. Intensive Care Med 2010;36:

8 Weaning difficulty Simple weaning Difficult weaning Prolonged weaning Extubated at the first attempt of spontaneous breathing Extubated within 7 D from first trial of spontaneous breathing Fail at least 3 weaning attempts or require > 7 days of weaning Boles JM. Eur Resp J 2007;29:

9 Prolonged weaning N Prolonged weaning (%) Consequences Funk GC. Eur Respir J (14%) Hospital mortality prolonged versus simple weaning 32 and 13% respectively Sellares J. Intensive Care Med 2011 Peñuelas O. Am J Respir Crit Care Med (18%) (6%) Hospital mortality prolonged versus simple weaning 49 and 19% respectively ICU mortality prolonged versus simple weaning 13 and 7% respectively

10 Predictors of prolonged N = 2714 weaning Disease severity at admission Duration of MV before first attempt Chronic pulmonary disease Pneumonia PEEP before weaning % Simple weaning Difficult weaning Prolonged weaning 6 Peñuelas O. Am J Respir Crit Care Med 2011;184:

11 Predictors of prolonged N = 181 weaning 50 37, Chronic pulmonary disease Heart rate 105 during SBT PaCO2 54 mmhg during SBT % 25 12, Simple weaning Difficult weaning Prolonged weaning Sellares J. Intensive Care Med 2011;37:

12 Predictors of successful extubation Characteristics Successful extubation (N = 92) Failed extubation (N = 27) P-value Respiratory rate > (50%) 15 (56%) 0,612 Minute ventilation > (53%) 14 (52%) 0,897 Tidal volume < 5 ml/kg 27 (29%) 10 (37%) 0,448 RSBI > (46%) 14 (52%) 0,57 PI max < - 20 cm H2O 9 (10%) 2 (7%) 0,999 GCS > (71%) 18 (67%) 0,692 Ineffective cough 27 (29%) 23 (85%) < Abundant secretions 8 (9%) 2 (7%) 0,999 Purulent secretions 31 (34%) 9 (33%) 0,972 Positive fluid balance 22 (24%) 10 (37%) 0,176 MV for 25 ± 6 days Huang CT. Resp Care 2013;58:

13 Case study (1) A 68-year-old man Hypertension COPD (GOLD class IV) Acute exacerbation Admitted to another hospital Prolonged weaning failure (2 M) transfer

14 Case study (2) Physical examination: HR 75/min, BP 135/75, no peripheral edema, normal heart sounds without murmurs, no rales or wheezing, normal abdomen Quiet breathing on PSV 14/6 (RR 24, Tv 400 ml) Unable to complete first SBT > 2 hrs

15 Systematic approach Balance between WOB and capacity of the respiratory muscles? (A + D) Major problem with gas exchange? (A) Cardiac function? (C) Other contributing factors? (B + E)

16 Work of breathing is determined by.. Respiratory system elastance ( P/ V) Airway resistance Intrinsic PEEP Active expiration

17 Impression of RS elastance and resistance Switch to passive volume controlled ventilation If a patient is on PSV 14/6 with a mean Tv of 400 ml and a RR of 24/min start with a Tv of and a RR of 26. Wait a few minutes and once the patient is passive decrease Tv to decrease RR if possible

18 RS elastance & resistance Inspiratory hold Expiratory hold Ppeak P1 P2 Ventilator pressure PEEPi Ventilator flow

19 Calculations RS elastance = (P2 - Total PEEP) / Tv RS resistance = (Ppeak - P1) / V RS elastance patient = 24.4 cmh2o/l RS resistance patient = 11.5 cmh2o/l/s (N 10 cmh20/l) (N 2.5 cmh20/l/s) PEEPi = 6 cmh2o?

20 List of problems 2 to 3 fold increase in RS elastance 4 fold increase in RS resistance Presence of PEEPi working as an inspiratory threshold

21 The next small step.. Is the increase in RS elastance caused by the lung or the chest wall? Is there a problem in the major airways?

22 Chest wall elastance Stiff El 19.4 Etot Soft Ew 5 Soft Stiff El Ew Etot Normal Ew 0.5 Etot Same Paw may generate different transpulmonaryand pleural pressures

25 Spontaneous breathing Paralyzed

26 Example

27 In our patient.. Paw CW elastance = (PplEIS - PplEES) / Tv Ppl Pa P elastance = (TPPEIS - TPPEES) / Tv Palv Palv CW elastance patient = 8 cmh2o/l P elastance patient = 16.4 cmh2o/l/s (N 5 cmh20/l) (N 5 cmh20/l)

28 List of problems 2 to 3 fold increase in RS elastance mainly pulmonary 4 fold increase in RS resistance Presence of PEEP i working as an inspiratory threshold

29 The next small step.. Is the increase in RS elastance caused by the lung or the chest wall? Is there a problem in the major airways?

30 Bronchoscopy Preferably during spontaneous breathing Look for ET tube occlusion/narrowing, granulation tissue, position of tracheostomy tube in relation to tracheal wall, unexpected tracheal stenosis and tracheomalacia

31 In our patient.. Tracheostomy tube ID 8 Normal position No granulation tissue No tracheomalacia

32 List of problems 2 to 3 fold increase in RS elastance mainly pulmonary 4 fold increase in RS resistance without major airway obstruction Presence of PEEP i working as an inspiratory threshold

33 Intermezzo..if CW elastance would have been increased Potential reversible causes Chest wall edema Increased abdominal pressure Pleural fluid

34 PE drainage in MV patients PaO2/FiO2 18% (95 CI 5-33%) Pneumothorax 3.4% (95 CI %) Hemothorax 1.6% (95 CI %) Pneumothorax with ECHO OR 0.32 ( ) 19 observational studies (N = 1124) Goligher EC. Crit Care 2011;15:R46

Remove pleural fluid N = 168 Retrospective study P < 0.001 8 P = 0.

35 Remove pleural fluid N = 168 Retrospective study P < P = 0.03 Duration of MV (Days) Control PF drainage Kupfer Y. Chest 2011;139:

36 Kanai M. Chest 2015;147:e5-e7

37 The final step - measurements in assisted breathing PS 8 - PEEP 4

38 Measurement of PEEPi Decrease in pleural pressure from the onset of inspiration until the start of inspiratory flow minus the expiratory pressure induced by active expiration

39 PS 8 - PEEP 4 PEEPi = 11-3 = 8 cmh2o - 2 = 6 cm H2O

40 PSV 8 - PEEP 0 PSV 8 - PEEP 4 PSV 8 - PEEP 10 PSV 8 - PEEP 12

41 WOB and PEEP i during spontaneous breathing Lung$volume$ TLC$ ac9ve$infla9on$ (lung$elas9c$recoil)$ passive$infla9on$ $(relaxed$chestwall)$ Vt$ Vt$ resis9ve$inspiratory$wob$ elas9c$inspiratory$wob$ PEEPi FRC$ PEEPi$inspiratory$WOB$ expiratory$wob$ FRC$ -$ 0$ Ppl$/$Pes$ +$ Normal values WOB: J/L and 2.4 J/min

42 Work of Breathing (1) Cl 100 VC (%) Tv 35 FRC Pleural pressure (cmh2o)

43 Work of Breathing (2) 100 VC (%) Ccw FRC Pleural pressure (cmh2o)

44 Work of breathing (3) 100 VC (%) Elastic Insp. WOB Flow resistive WOB Pleural pressure (cmh2o)

45 Work of breathing (4) 100 VC (%) Elastic Insp. WOB 75 Flow resistive WOB PEEPi PEEPi Insp. WOB Expiratory WOB Pleural pressure (cmh2o)

46 Example TSA - 5 minutes TSA minutes

47 In our patient

48 In our patient.. WOB during SBT 1.48 J/L Slight increase in resistive WOB and elastic inspiratory WOB but not PEEPi during SBT

49 List of problems Approximately 3 fold increase in WOB due to 2 to 3 fold increase in RS elastance mainly pulmonary and a 4 fold increase in RS resistance without major airway obstruction and presence of PEEPi working as an inspiratory threshold

50 ICU acquired weakness Inflammation Malnutrition Immobilization Muscle wasting - Critical illness myopathy/neuropathy Eikermann M. Intensive Care Med 2013;39:

51 Diaphragmatic weakness 0 Jaber S. Am J Respir Crit Care Med 2011;183:

52 Muscle atrophy in prolonged MV 14 brain-dead organ donors (cases) and 8 patients undergoing surgery for benign lesions or localized lung cancer (controls) Diaphragm-biopsy and pectoralis specimens Histologic, biochemical, gene-expression measurements

53 Muscle atrophy in prolonged MV 50 Fiber Size Slow Myosin Heavy Chain Fast Myosin Heavy Chain A C E N = 14 N = 8 Case Control 50 µm 50 µm 50 µm B D F 50 µm 50 µm 50 µm Duration of MV (hrs) Controls P=0.001 Cases P= Levine S. N Engl J Med 2008;358:

54 Capacity of the respiratory muscles Normal activation of the diaphragm? Normal contraction of the diaphragm? Normal strength of the diaphragm? Normal strength of inspiratory/expiratory muscles? Endurance of diaphragm - neuromechanical- and neuroventilatory efficiency?

55 What do we need? Catheter for measurement of esophageal- and gastric pressures and electrical activity of the diaphragm ECHO machine Pressure transducer for measuring mouth opening pressure (MIP and MEP) Magnetic stimulator

56 !!

57 Capacity of the respiratory muscles Normal activation of the diaphragm? Normal contraction of the diaphragm? Normal strength of the diaphragm? Normal strength of inspiratory/expiratory muscles? Endurance of diaphragm - neuromechanical- and neuroventilatory efficiency?

58 PS 8 - PEEP 4

59 Magnetic stimulation phrenic nerve Normal values conduction time 7.5 ± 1 ms Normal values CMAP 0.8 ± 0.25 mv

60 Capacity of the respiratory muscles Normal activation of the diaphragm? Normal contraction of the diaphragm? Normal strength of the diaphragm? Normal strength of inspiratory/expiratory muscles? Endurance of diaphragm - neuromechanical- and neuroventilatory efficiency?

61 Diaphragm contraction!!

Lower limits of normal (cm) Men Women Quiet breathing 1 0.

62 Lower limits of normal (cm) Men Women Quiet breathing Voluntary sniffing Deep breathing Boussuges A. Chest 2009;135:

63 Capacity of the respiratory muscles Normal activation of the diaphragm? Normal contraction of the diaphragm? Normal strength of the diaphragm? Normal strength of inspiratory/expiratory muscles? Endurance of diaphragm - neuromechanical- and neuroventilatory efficiency?

64 MIP, MEP and Pdi Normal values MIP 100 ± 10 and MEP 110 ± 10 cmh2o

65 Capacity of the respiratory muscles Normal activation of the diaphragm? Normal contraction of the diaphragm? Normal strength of the diaphragm? Normal strength of inspiratory/expiratory muscles? Endurance of diaphragm - neuromechanical- and neuroventilatory efficiency?

66 NVE and NME Neuroventilatoty efficiency = Tv / EAdi: sensitive to diaphragm function and workload Neuromechanical efficiency = PDi / EAdi: excludes workload and adequate measure of diaphragm strength No normal values

The final test - SBT until failure Resp Rate TV Edi,peak SpO2 PaO2 PaCO2 ph PSV 25 339 13 100 10.9 6.6 7.45 10 min 22 354 23 98 19.

67 The final test - SBT until failure Resp Rate TV Edi,peak SpO2 PaO2 PaCO2 ph PSV min h h h h

68 The final test - SBT until failure PEEPi Pgastric Pesophagus Ptransdiaphragm NV efficiency NM efficiency PSV min h h 16 h 18 h

69 5 minutes 55 minutes

70 In our patient.. Normal diaphragm activation and contraction Normal diaphragm and respiratory muscles strength Normal endurance Insufficient capacity of respiratory muscles does not explain weaning failure

71 List of problems Threefold increase in WOB due to a 2 to 3 fold increase in pulmonary elastance (including PEEPi) and a 4 fold increase in resistance without major airway obstruction Normal respiratory muscle capacity Adequate gas exchange. However increased A-a gradient during SBT

72 Intermezzo..if respiratory muscle weakness was present Think about other neuromuscular disorders Potential reversible causes Titration of mechanical support Inspiratory muscle training Pharmacological support

73 Titration of mechanical support

74 Respiratory muscle training Baseline Follow-up 60 *** 60 *** MIP (cmh2o) MEP (cm H2O) Control group IMT group 0 Control group IMT group RCT N = 92 - IMT 2 DD 5 10 breaths (40% of MIP), 7 days/week No difference in duration of MV Condessa RL. Journal of Physiotherapy 2013;59:

Muscle training 4 sets of 6-10 breaths per day (5 days/week) 80 60 IMT 71 Sham

039 N = 69 % 40 47 20 0 Weaned D 28-20 Threshold PEP Respironics Inspiring

75 Muscle training 4 sets of 6-10 breaths per day (5 days/week) IMT 71 Sham P = N = 69 % Weaned D Threshold PEP Respironics Inspiring through exhalation port Threshold IMT Respironics PFlex IMT Respironics MIP (cmh2o) Pre IMT Sham P < Post Martin AD. Crit Care 2011;15:R84

76 Medication Myosin heavy chain slow van Hees HWH. Am J Respir Crit Care Med 2009;179:41-47

77 Levosimendan improves neuromechanical efficiency Doorduin J. Am J Respir Crit Care Med 2012;185:90-95

78 Normal cardiac function? Systolic function Diastolic function Ischemia Do the measurements when a patient fails a SBT

79 Left ventricular failure during a SBT Lamaire F. Anesthesiology 1988;69:

81 PCWP and LAP N = 117, mitral valve stenosis - PTMC Nagi AI. Am Heart J 2014;167:

82 Different causes for PCWP increase during SBT Lamaire F. Anesthesiology 1988;69:

83 Different causes for PCWP increase during SBT

84 Weaning from MV ITP Adrenergic tone Systemic venous return PaCO2 PaO2 Pulmonary vascular resistance WOB Myocardial ischemia RV dilatation Biventricular interdependence LV afterload LV preload LV compliance LVEDP

85 Diastolic dysfunction and weaning failure N = 50 - normal LV ejection fraction Failure Success Normal diastolic function Grade 1 diastolic dysfunction Grade diastolic dysfunction Pre-SBT doppler-echocardiography Specificity and PPV of pre-sbt E/Ea (lateral annulus) > 7.8 = 100% Papanikolaou J. Intensive Care Med 2011;37:

86 Before SBT After SBT exhausted

87 SvO2 PCWP PAP ABP CVP HR SpO2 PaO2 CO BNP Lactate PSV /24 150/ min /24 140/ h /27 171/ h 47/26 160/ h 45/22 137/ h /28 170/ PA catheter

88 Echocardiogram Systolic function Diastolic function Ischemia

89 In our patient.. LV EF ± 40% Diastolic dysfunction grade II / III (E/A 2.4, E/Ea 13.6 No regional wall motion abnormalities

90 List of problems Threefold increase in WOB due to a 2 to 3 fold increase in pulmonary elastance (including PEEPi) and a 4 fold increase in resistance without obstruction in major airways Normal respiratory muscle capacity Adequate gas exchange. However increased A-a gradient during SBT probably due to development of pulmonary edema predominantly explained by diastolic heart failure

91 Suspect cardiac origin for weaning failure if.. PA catheter Shows increase of PAOP 18 mmhg Echocardiography Shows increase in E/A or E/Ea ratio Blood sample Shows increase of BNP 48 ng/l or 12% Blood sample Shows increase of Hb and plasma proteins 6% TP thermodilution Shows increase in EVLW 14%

92 Intermezzo..What are the options if the heart is the main cause of weaning failure? Causal treatment - diuretics, ACE inhibitors Nitroglycerin Inotropic agents

93 BNP guided weaning Increases the use of diuretics and reduces cumulative FB 500 Control BNP Total duration of weaning (hrs) COPD LHF Neither Mekontso Dessap A. Am J Respir Crit Care Med 2012;186:

94 Nitrates during weaning from MV (COPD) N = # 35" 200# 30" Systolic)BP)(mmHg)) 180# 160# 140# Control# NTG# Wedgepressure)(mmHg)) 25" 20" 15" 10" Control" NTG" 120# 5" 100# MV# Start#SBT# End#SBT# 0" MV" Start"SBT" End"SBT" After failure SBT (control) 90% successful with NTG Routsi C. Crit Care 2010;14:R204

95 Levosimendan guided weaning COPD (N = 10) with increased LVEDP during weaning MV SBT PCWP (mmhg) Baseline 1 Dobutamine Basline 2 Levosimendan Ouanes-Besbes L. J Crit Care 2011;26:15-21

96 Other contributing factors Brain dysfunction - delirium, depression, anxiety, sleep disorder Endocrine - nutritional status, adrenal- and thyroid function

97 List of problems Threefold increase in WOB due to a 2 to 3 fold increase in pulmonary elastance (including PEEPi) and a 4 fold increase in resistance without obstruction in major airways Normal respiratory muscle capacity Adequate gas exchange. Increased A-a gradient during SBT probably due to development of pulmonary edema predominantly explained by diastolic heart failure

98 Weaning strategy Intensify measures to decrease airway resistance and level of PEEPi Nitroglycerin facilitated weaning with the aim of keeping systolic BP < 140 mmhg Presence of nurse at the bedside for the complete first weaning attempt Patient weaned from MV within 2 days after first attempt

99 Conclusions EB weaning ( If a SBT fails start analyzing underlying causes Structured approach based on sound physiology

Weaning from Mechanical Ventilation. Dr Azmin Huda Abdul Rahim

Weaning from Mechanical Ventilation Dr Azmin Huda Abdul Rahim Content Definition Classification Weaning criteria Weaning methods Criteria for extubation Introduction Weaning comprises 40% of the duration