Weaning from Mechanical Ventilation

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1 CHAPTER 47 Victor Kim and Gerard J. Criner Weaning from Mechanical Ventilation CHAPTER OUTLINE Learning Objectives Case Study Determining the Cause of Respiratory Failure When is the Patient Ready to Wean? Predictors of Weaning Outcome Pulmonary Gas Exchange Respiratory Muscle Strength P 0.1 Work of Breathing Gastric Tonometry Mixed Venous Oxygen Content Respiratory Pattern during Spontaneous Breathing Specific Weaning Methods Trials of Spontaneous Breathing Intermittent Mandatory Ventilation Pressure-Support Ventilation Efficacy of Different Weaning Techniques Techniques to Aid Weaning Tracheostomy Daily Interruption of Sedatives Noninvasive Ventilation Protocol or Computer-Based Strategies Adjunctive Therapy Summary Review Questions Answers References Additional Reading LEARNING OBJECTIVES After studying this chapter, you should be able to: Determine when a patient is ready to begin the weaning process, based on clinical history, physical examination, and routine laboratory data. Use bedside weaning parameters to predict weaning outcome. Postulate a differential diagnosis of common and uncommon causes of weaning failure. Understand the advantages and disadvantages of the various weaning techniques. Realize that certain techniques, such as noninvasive ventilation after extubation and daily interruption of sedatives, can increase your likelihood of liberating the patient from mechanical ventilation. 902 During the past 25 years, there has been a significant increase in the number of patients who receive mechanical ventilation as a means of life support during surgery or life-threatening medical illness. Although mechanical ventilation has clear-cut benefits, it is also associated with a significant number of complications, such as decreased cardiac output, increased intracranial pressure, ventilator-associated pneumonia (VAP), and ventilator-induced lung injury (VILI). In addition, mechanical ventilation is expensive and hinders efficient patient movement through the intensive care unit.

2 CHAPTER 47 Weaning from Mechanical Ventilation 903 CASE STUDY A 70-year-old nursing home resident was intubated for aspiration pneumonia and respiratory distress. He was treated with antibiotics and clinically improved over the period of 5 days. During that time, he required 100% FiO 2 and needed sedatives to maintain patient comfort and patient ventilator synchrony, and frequent endotracheal tube suctioning for purulent secretions. He is now awake and alert with normal oxygen saturation on 40% FiO 2 and PEEP of 5 cm H 2 O. Minute ventilation (MV) is 10 L/ min. He appears cachectic and has lower extremity contractures. He has no fever and is hemodynamically stable off all vasopressor support. When the patient is placed on CPAP of 5 cm H 2 O and pressure support (PS) of 0 cm H 2 O, the patient s respiratory rate increases to 40 breaths/min and tidal volume (V T ) drops to 250 ml within 1 min. Weaning patients from mechanical ventilation remains one of the most challenging aspects of intensive care. Despite the advent of new and promising weaning indices, the skills to determine which patients should be weaned and when patients are ready for weaning remain a mix of art and science. These skills appear to be greatly enhanced by experience. About 20 25% of ventilated patients fail an initial attempt at discontinuing mechanical ventilation and will require more concentrated and prolonged attempts for discontinuance (i.e., weaning). For patients requiring prolonged mechanical ventilation, about 40% of the time spent on the ventilator is devoted to the weaning process. This percentage is even higher in patients with specific diseases such as chronic obstructive pulmonary disease (COPD), who may be undergoing active weaning attempts for as much as 60% of their total time spent receiving mechanical ventilation. In this chapter, we review the clinical parameters that determine which patients are ready to begin the weaning process, the interpretation of bedside parameters used to predict weaning outcome, and the merits and disadvantages of specific weaning techniques to successfully discontinue mechanical ventilation. DETERMINING THE CAUSE OF RESPIRATORY FAILURE Before mechanical ventilation can be safely withdrawn, the abnormality causing respiratory failure must be identified and show favorable signs of responding to treatment. To identify the physiologic causes of respiratory failure, it is useful to separate the causes into three major categories: (1) hypoxemic respiratory failure, (2) ventilatory pump failure, and (3) psychologic factors ( 47-1). Hypoxemic respiratory failure can result from hypoventilation shunting, impaired pulmonary gas exchange, or decreased mixed venous blood oxygen content. The chest radiograph, physical examination, and alveolar-arterial oxygen gradient are useful in distinguishing among intrapulmonary shunting, increased physiologic deadspace, and alveolar hypoventilation as possible causes of hypoxemic respiratory failure (see Chap. 15). Ventilatory pump dysfunction is considered by some authors to be the most common cause of failure to wean from mechanical ventilation. Failure of the respiratory system to sustain adequate ventilation to meet the demands imposed by the illness may occur whenever respiratory demand exceeds ventilatory pump capacity. Ventilatory pump failure may occur because of an increased ventilatory load (even in patients with normal respiratory system), resulting from increased deadspace, hypermetabolism due to sepsis and/or fever, or increased CO 2 production due to increased carbohydrate load. In contrast, normal or only slightly elevated respiratory loads may not be sustained by subjects with decreased ventilatory pump capacity due to impaired central respiratory drive, phrenic nerve dysfunction, thoracic wall abnormalities, or severe derangements of respiratory muscle function (e.g., underlying neuromuscular disease, electrolyte disturbances). Abnormalities of central respiratory drive can be seen in patients with structural injury to the central nervous system, overuse of sedative agents, and metabolic alkalosis. Diaphragm Before withdrawing mechanical ventilation, the cause of respiratory failure must be identified. Respiratory pump dysfunction is considered the most common cause of failure to wean.

3 904 V. Kim and G.J. Criner TABLE 47-1 CAUSES OF RESPIRATORY FAILURE Hypoxemic respiratory failure Impaired pulmonary gas exchange (shunt, V/Q mismatch) Pneumonia Congestive heart failure Pulmonary embolism ARDS Decreased mixed venous oxygen content Congestive heart failure Ventilatory pump failure Decreased minute ventilation with a relatively normal respiratory workload Thoracic wall abnormalities (flail chest, rib fractures) Peripheral neurologic disorder (phrenic nerve damage, critical care illness polyneuropathy) Muscular dysfunction (neuromuscular blocking agent-associated weakness/myopathy) Central respiratory depression (drug overdose, brainstem infarction) Severe metabolic alkalosis Increased respiratory workload with poor ability to maintain adequate ventilation Increased minute ventilation requirements (sepsis, fever, hyperthermia, increased CO 2 production) Increased deadspace Increased elastic workload (decreased lung and/or chest wall compliance, dynamic hyperinflation) Increased resistive workload (airway obstruction, secretions, endotracheal tube, ventilator circuit) Psychologic factors Anxiety Depression Hyperinflation is a frequently overlooked cause of weaning failure. dysfunction can be seen in patients with cold-induced phrenic nerve injury or direct diaphragm injury that may occur during cardiothoracic surgery. Diaphragm dysfunction has also been reported in patients following upper abdominal surgery. Impaired respiratory muscle function can also result from various underlying medical conditions. Hyperinflation occurs in patients with acute exacerbations of severe asthma or COPD and is frequently overlooked as a cause of weaning failure. It causes a shortening in the diaphragm s precontraction length, which causes the diaphragm to work on a disadvantageous portion of its tension length curve. Hyperinflation also alters the orientation of the diaphragmatic fibers medially inward, and decreases the length of the zone of apposition, factors that further decrease the diaphragm s force-generating capacity. Other disorders commonly encountered in the intensive care unit may cause abnormal respiratory muscle function, thereby hindering weaning. These include undernutrition, electrolyte disturbances (hypophosphatemia, hypokalemia, hypocalcemia, hypomagnesemia), and thyroid dysfunction. Recently, diaphragm muscle atrophy has been shown to occur as a consequence of inactivity in previously healthy brain-dead organ donors receiving fully assisted mechanical ventilation for periods of only h. 1 WHEN IS THE PATIENT READY TO WEAN? Resolution or significant improvement in the underlying cause of respiratory failure is the most important prerequisite before weaning is attempted. Before an attempt is made to wean a patient, certain prerequisites should be met (Table 47-2). The most important prerequisite appears to be resolution or significant improvement in the underlying cause of respiratory failure. Patients should be hemodynamically stable, with minimal or no need for vasopressor agents. The absence of sepsis or hyperthermia should be confirmed. Sedative drugs and neuromuscular blocking agents should be discontinued. Patients should be awake, alert, and able to manage secretions and protect their airway. Significant fluid, electrolyte, and metabolic disorders should be corrected before weaning attempts are made. Adequate gas exchange marked by a PaO 2 to FiO 2 ratio greater than 200, FiO 2 requirements of 50% or less, and positive end-expiratory pressure 5 cm H 2 O or less are desirable. Adequate respiratory muscle strength needs to be ensured (maximum inspiratory pressure [MIP] or negative inspiratory force at least 25 cm H 2 O).

4 CHAPTER 47 Weaning from Mechanical Ventilation 905 Resolution or significant improvement of the underlying cause of respiratory failure Stable hemodynamic state Absence of sepsis or hyperthermia Cessation of sedative drugs Cessation of neuromuscular blocking agents Cessation of vasopressor agents Patients should be awake, alert, and able to manage secretions and protect their airway Correction of metabolic and electrolyte disorders Adequate gas exchange PaO 2 to FiO 2 ratio greater than 200 FiO 2 requirements less than 50% PEEP requirements equal to or less than 5 cm H 2 O Adequate respiratory muscle strength TABLE 47-2 NECESSARY CONDITIONS TO DECIDE WHEN A PATIENT IS READY FOR WEANING PaO 2 partial pressure of arterial oxygen; FiO 2 inspired fraction of oxygen; PEEP positive end-expiratory pressure PREDICTORS OF WEANING OUTCOME Determining when a patient is ready to wean from the ventilator is a complicated task. Considerable research has been devoted to finding variables that predict weaning outcome. Pulmonary Gas Exchange The adequacy of pulmonary gas exchange must be assessed before initiating weaning. In the past, several indices derived from arterial blood gas analysis have been used to predict weaning outcome. These indices are derived from retrospective studies and, consequently, have limitations. An arterial blood to inspired O 2 ratio (PaO 2 /FiO 2 ) greater than 238 has a positive predictive value of 90%, yet its negative predictive value is only 10%. 2 In another study, an arterial/alveolar O 2 tension of 0.35 had positive and negative predictive values slightly greater than Although adequate arterial oxygenation is essential to initiate weaning, it is clear that the predictive value of this index by itself is insufficient to predict weaning outcome. Respiratory Muscle Strength The strength and endurance of the respiratory system seem to be major determinants of weaning outcome. Sahn and Lakshminarayan were among the first to describe the use of simple bedside criteria to assist decisions in discontinuing ventilatory support. 4 In a study involving 100 patients, these investigators measured resting MV, maximum voluntary ventilation (MVV) (i.e., maximum sustainable ventilation over 15 s... times 4, MVV), and MIP with a spirometer. Of these, 76 patients who had an MV less than 10 L/min, MIP of 30 cm H 2 O or less, and MVV twice their resting MV who were able to complete a 2-h spontaneous breathing trial via an endotracheal tube were successfully extubated; seven more patients with a MIP of 25 cm H 2 O or less and a mean MV of 10.2 L/min and able to successfully complete at least a 2 hours weaning trial were able to be extubated, although they were not able to double their resting MV. By contrast, 17 patients with an MIP greater than 22 cm H 2 O who could not complete a spontaneous breathing trial could not be extubated. Application of these criteria in subsequent studies, however, did not yield comparable results. When evaluating 47 patients on mechanical ventilation, Tahvanainen et al found that using a MIP less than 30 cm H 2 O as a weaning predictor produced a false-negative result in 11 of 11 patients and a false-positive result in 8 of 23 patients. 5 Similarly, other authors reported poor negative and positive predictive values when evaluating other weaning parameters such as vital capacity (VC), minute ventilation (V E ), and MVV. Factors that may account for the variability in bedside respiratory mechanics to predict weaning outcomes include different patient populations, variability in the duration of mechanical ventilation, different techniques used in measuring respiratory mechanics, and Adequate oxygenation is essential to initiate weaning, but its predictive value regarding weaning outcome is poor. Respiratory muscle strength and endurance are important determinants of weaning outcome.

5 906 V. Kim and G.J. Criner inability of the measurements to accurately assess the true cause of ventilatory dependency. For example, no matter what respiratory parameters are measured, if a patient develops an acute severe episode of heart failure, or bronchospasm post-extubation, respiratory failure will recur, and thus, weaning will fail. Because of the poor and variable results of bedside parameters to predict weaning outcome, investigators turned to more complicated measurements of respiratory mechanics, such as P 0.1, gastric tonometry, and measurements of the work of breathing and mixed venous oxygen content. P 0.1 The airway pressure generated 100 ms after initiating an inspiratory effort against an occluded airway (P 0.1 ) is believed to reflect central respiratory drive and has been proposed as a useful predictor of weaning outcome. The values for normal, healthy individuals are 2 cm H 2 O or less. Herrera et al observed that 89% of patients with a P 0.1 greater than 4 cm H 2 O failed weaning attempts. 6 In patients with COPD, Sassoon and Mahutte found that patients with a P 0.1 greater than 6 cm H 2 O were unable to wean from ventilatory support, but patients with a P 0.1 less than 6 cm H 2 O were successfully extubated. 7 Several studies have shown a large variation in outcome when P 0.1 is used, possibly because of its inability to predict endurance or its application to patient groups with different diseases causing respiratory failure. This technique also requires special equipment and trained personnel, which makes it less appealing. Work of Breathing Work of breathing can be measured by plotting the transpulmonary pressure against V T. Transpulmonary pressure is calculated from the difference between pleural pressure (estimated with an endoesophageal balloon catheter) and the airway pressure. One study found that mechanical ventilation was necessary when work of breathing exceeded 1.8 kg/m 2 /min. A similar study found a discriminating value of 1.34 kg/m 2 /min to separate ventilator-dependent from ventilator-independent patients. At this level, the rate of false-negative and falsepositive results was 13.8%. An additional study evaluated work of breathing in a group of 17 patients, six of whom required prolonged mechanical ventilation. A work index less than 1.6 kg/m 2 /min was observed in all patients who had a successful weaning trial; this was more accurate than conventional weaning parameters in determining weaning outcome. Furthermore, patients who went from unsuccessful to successful weaning did not show significant improvement in conventional weaning parameters, but did show improvement in work of breathing measurements. There are no large prospective studies comparing this parameter against more conventional weaning parameters. The relative invasiveness and complexity of data acquisition and analysis, and the requirement for dedicated staff and equipment to perform the test make it unappealing as an effective clinical tool. Gastric Tonometry It has been proposed that measurement of gastric ph during weaning can help predict weaning success. A fall in gastric ph during weaning from mechanical ventilation would indicate mucosal ischemia from hypoperfusion as a result of blood flow diverted toward the respiratory muscles to meet their increased metabolic demands. Mohsenifar et al measured gastric ph before and during weaning attempts in 29 patients who were intubated for respiratory failure. 8 All patients were ventilated for more than 48 h and were treated with ranitidine. Despite similar hemodynamic parameters, changes in respiratory breathing pattern, and gas exchange during weaning, those successfully liberated from the ventilator had no change in gastric ph, whereas those that failed had a fall in gastric ph. The authors concluded that this technique can help predict weaning success. However, it is unclear if these results are applicable to other disease states or to those not treated with gastric acid suppressive therapy. Additionally, the technique requires the placement of an orogastric or nasogastric tube. These drawbacks limit the routine utility of this technique.

6 CHAPTER 47 Weaning from Mechanical Ventilation 907 Mixed Venous Oxygen Content Mixed venous oxygen saturation (SvO 2 ) has also been measured during attempts at weaning from mechanical ventilation. In one study, the SvO 2 progressively fell during weaning in eight patients who failed a spontaneous breathing trial, compared to 11 patients who were successfully extubated and had no significant change in SvO 2. The fall in SvO 2 was hypothesized to result from an increased oxygen cost of breathing and increased oxygen extraction. Measurement of mixed venous oxygen content needs prospective validation prior to recommendation for routine use. Respiratory Pattern during Spontaneous Breathing Multiple studies have reported the role of breathing pattern in the outcome of weaning from mechanical ventilation. The development of rapid shallow breathing, the presence of asynchronous or paradoxical thoracoabdominal movements, and marked accessory muscle recruitment during a spontaneous breathing trial are physical exam findings that herald an unsuccessful weaning trial. Based on the premise that patients who fail weaning trials rapidly develop a high respiratory rate and a drop in V T, Yang and Tobin combined measurements of frequency (f) and V T into the rapid shallow breathing index, f/v T. 3 They obtained data in 36 patients and noticed that an f/v T ratio of 105 breaths/min/l best differentiated patients who weaned successfully from those who failed. They subsequently validated the rapid shallow breathing index in 64 patients, comparing it against conventional weaning indexes (Table 47-3). An f/v T ratio less than 105 predicted a successful weaning trial (Fig. 47-1). The positive and negative predictive values were 0.78 and 0.95, respectively. The predictive power of the f/v T ratio was better than any of its components, supporting the use of this index. The f/v T ratio is attractive because it is relatively easy to obtain and the determinant value (i.e.,»100) is easy to remember. It is important to recognize that this test is most accurate in patients who have received mechanical ventilation for less than 7 days. In a subsequent study, Epstein attempted to define the cause of extubation failure in patients whose f/v T predicted weaning success. 9 He analyzed 94 consecutive patients whose f/v T before the weaning trial predicted successful extubation. The f/v T was measured while patients breathed unassisted for 1 min. Of the 94 patients extubated, 84 had an f/v T less than 100 and 10 had an f/v T of 100 or more. Extubation failure, defined as the need to reintubate within 72 h, occurred in 14 of 84 patients in the group with f/v T below 100 and 4 of 10 patients with f/v T above 100 (Table 47-4). When the cause for respiratory failure was analyzed, the underlying respiratory process was responsible for extubation failure in all four patients with f/v T of 100 or more. In contrast, the initial respiratory process was the cause for extubation failure in only 1 of 14 patients with an f/v T less than 100; new problems, such as An f/v T ratio less than 105 predicts a successful weaning outcome in about 80% of patients. Patients who fail a weaning trial frequently exhibit a rapid respiratory rate and a drop in V T. The f/v T ratio is more accurate when an underlying respiratory process is responsible for mechanical ventilation. INDEX VALUE Minute ventilation (L/min) 15 Respiratory frequency (breaths/min) 38 Tidal volume (ml) ³325 Maximal inspiratory pressure (cm H 2 O) < 15 Dynamic compliance (ml/cm H 2 O) ³22 Static compliance (ml/cm H 2 O) ³33 PaO 2 /PAO 2 ³0.35 Frequency/tidal volume ratio (breaths/min/l) 105 CROP index (ml/breath/min) ³13 TABLE 47-3 THRESHOLD VALUES OF INDEXES USED TO PREDICT WEANING OUTCOME PaO 2 partial pressure of arterial oxygen; PAO 2 alveolar oxygen tension; CROP compliance/resistance/oxygenation/ mouth pressure index So u r c e: Yang and Tobin. 3 Copyright 1991 Massachusetts Medical Society. All rights reserved

7 908 V. Kim and G.J. Criner FIGURE 47-1 Isopleths for the ratio of breathing frequency to tidal volume, representing different degrees of rapid shallow breathing (from Yang and Tobin, 3 with permission. Copyright 1991 Massachusetts Medical Society. All rights reserved). Frequency (breaths/min) (1.2, 14) Tidal Volume (liters) TABLE 47-4 PREDICTIVE ACCURACY OF THE EXTUBATION f/v T f/v T < 100 f/v T ³ 100 Extubation success 70 (TP) 6 (FN) Extubation failure 14 (FP) 4 (TN) SENSITIVITY SPECIFICITY PPV NPV All patients <6 days MV >6 days MV MV mechanical ventilation; PPV positive predictive value; NPV negative predictive value; TP true positives; FP false positives; FN false negatives; TN true negatives So u r c e: reprinted with permission from Epstein, 9 Official Journal of the American Thoracic Society American Thoracic Society If patients exhibit satisfactory weaning parameters, 80% will wean after a spontaneous breathing trial on a T-piece circuit. heart failure and upper airway obstruction, were the most common causes (Table 47-5). When the author further analyzed the 57 patients in whom a respiratory process was the original cause for mechanical ventilation, the positive predictive value for their f/v T index approached unity (Table 47-6). This study confirmed the high positive predictive value of the f/v T index in predicting weaning outcome. It is important to recognize that successful weaning from ventilatory support does not ensure that a patient will successfully remain extubated. These are two distinct phases in the process of liberating a patient from mechanical ventilation. This realization is particularly important because reintubation carries an increased risk of nosocomial pneumonia. Currently, there are no objective measurements to determine the outcome of extubation; therefore, clinical assessment is paramount in establishing which patients can be safely extubated. Important factors include the patient s level of consciousness, which should be adequate for airway protection, the presence of a gag reflex, and the ability to cough and clear the airway. Upper airway patency is one of the most difficult aspects to evaluate. Postintubation laryngeal edema can lead to respiratory failure, especially in patients with decreased respiratory reserve. Some investigators advocate the use of the cuff-leak test, ensuring the presence of an air leak around the endotracheal tube when the cuff is deflated and the tube is occluded. The presence of an air leak is reassuring and relatively sensitive in predicting a positive outcome from extubation, but the specificity of the test is very low. Despite this, it is clear from most studies that about 80% of patients will be extubated after a spontaneous breathing

8 CHAPTER 47 Weaning from Mechanical Ventilation 909 f/v T ³ 100 f/v T < 100 Original respiratory process Alone 4 1 Plus CHF 1 CHF Alone 4 Plus UAO 1 New aspiration Alone 3 Plus encephalopathy 1 UAO 2 New pneumonia 1 TABLE 47-5 CAUSES OF EXTUBATION FAILURE IN 18 PATIENTS WHO REQUIRED REINTUBATION WITHIN 72 H OF EXTUBATION CHF congestive heart failure; UAO upper airway obstruction; PE pulmonary embolism; f/v T respiratory rate/tidal volume (rapid shallow breathing index) So u r c e: reprinted with permission from Epstein, 9 Official Journal of the American Thoracic Society American Thoracic Society SENSITIVITY SPECIFICITY PPV NPV Original pulmonary process New or nonpulmonary process PPV positive predictive value; NPV negative predictive value So u r c e: reprinted with permission from Epstein, 9 Official Journal of the American Thoracic Society American Thoracic Society TABLE 47-6 PREDICTIVE ACCURACY OF THE EXTUBATION f/v T FOR EXTUBATION FAILURE RESULTING FROM THE ORIGINAL RESPIRATORY PROCESS trial and the remaining 20% will require more concentrated weaning efforts; however, the majority will eventually be successfully extubated. SPECIFIC WEANING METHODS Trials of Spontaneous Breathing Once patients show an improvement or resolution of the underlying cause of respiratory failure and fulfill the previously mentioned criteria, weaning attempts can be initiated. Placing the patient on a T-tube system and allowing them to breathe spontaneously is probably the simplest method of assessing the patient s ability to wean from mechanical ventilation. A T-tube system is a continuous high flow source of oxygen delivered by corrugated tubing that is attached to the distal end of the endotracheal tube, with an additional 6-in. tail of tubing that limits the entrainment of room air oxygen. Patients who have spent relatively short periods on mechanical ventilation (less than 7 days), or in whom no problems with the resumption of unassisted breathing is expected, can be placed on a spontaneous breathing trial on a T-tube circuit. Traditionally, patients are placed on T-tube circuit for anywhere from 30 min to 2 h. If they do not develop signs of respiratory distress, such as nasal flaring, tachypnea, abdominal ribcage paradoxical movements or tachycardia, arrhythmias, oxygen desaturation, or hypo- or hypertension during this time, they can be extubated. If signs of intolerance occur, mechanical ventilation is resumed, and weaning attempts are resumed in 24 h. About 75% of the patients who undergo a T-tube weaning trial can be extubated. The 2-h duration of the spontaneous breathing trial had been the prior dogma, but has been recently challenged. In a study of more than 500 patients, patients underwent a traditional 120-min spontaneous breathing trial compared to a 30-min trial. There was no significant

9 910 V. Kim and G.J. Criner difference within groups in the percentage of patients who were extubated, the percentage of patients who remained extubated at 48 h, and in-hospital mortality. In difficult-to-wean patients, mechanical ventilation is gradually discontinued. Short trials of spontaneous breathing are followed by periods of rest on the ventilator in the assistcontrol mode. The duration of the trials is slowly increased; when patients are able to tolerate 2 h of spontaneous breathing, the weaning process is completed and the patient can be extubated. The importance of careful observation of the patient during T-piece trials cannot be overemphasized. Resistance of the endotracheal tube imposes an additional load and increases the work of breathing during spontaneous breathing; therefore, T-piece trials are also thought to test endurance of the weaning patient. Intermittent Mandatory Ventilation During intermittent mandatory ventilation (IMV) or synchronized IMV (SIMV; synchronous with inspiratory effort), a specified number of volume-preset breaths are delivered to the patient each minute by the ventilator. In addition, the patient is allowed to breath spontaneously between machine-delivered breaths. As a weaning method, the backup respiratory rate is gradually reduced until the patient is able to tolerate a minimal backup rate (i.e., 2 4 breaths/min) for 2 h. IMV is frequently criticized because patients are generally subjected to an additional inspiratory load imposed by breathing through a demand valve. Most importantly, this mode has also been shown to prolong the weaning process over all other modalities (see following). It is difficult, therefore, to encourage the use of this mode as an appropriate weaning alternative. The SIMV mode results in a prolonged weaning process when compared to all other weaning modalities. Daily spontaneous breathing trials lead to extubation twice as quickly as PSV weaning and 3 times more quickly than SIMV. Pressure-Support Ventilation Pressure-support ventilation (PSV) is a pressure-targeted ventilatory mode that provides support to the patient s inspiratory effort with a preset inspiratory pressure. During PSV, the patient determines the respiratory rate. The patient s effort and the level of PS determine the delivered volume. Initial settings are aimed at achieving tidal volumes from 8 to 10 ml/kg and a respiratory rate between 20 and 28 breaths/min. Weaning can be accomplished by gradually reducing the level of PS by 3 6 cm H 2 O, titrated on the basis of respiratory rate. In two prospective, randomized trials, extubation was considered when patients were able to comfortably tolerate 5 8 cm H 2 O for 2 h. PSV has been shown by several authors to decrease the work of breathing imposed by the endotracheal tube and the ventilator circuit, which suggested that patients who tolerate a weaning trial at this compensatory pressure are ready to sustain spontaneous ventilation. 10 There appears to be great variability in the compensatory level of PS between patients, and there is no reliable method to determine it. Occasionally, patients with severe obstructive disease or COPD may have problems with PSV. PSV is set to cycle at a predetermined flow, usually 25% of peak inspiratory flow; patients with COPD may require more time to reach this preset level during expiration, causing ventilator inflation during neural expiration and patient ventilator asynchrony. Efficacy of Different Weaning Techniques Two recent rigorously controlled studies have prospectively compared the efficacy of three different weaning techniques: IMV, PS, and spontaneous breathing trials (Table 47-7). Brochard et al found that a significantly greater number of patients could be weaned successfully after 21 days with PSV than with the other methods. 11 This group also reported that weaning time was significantly shorter with PS (5.7 days) than with spontaneous breathing trials (8.5 days) or IMV (9.9 days). In contrast, Esteban et al found that a once-daily trial of spontaneous breathing led to extubation twice as quickly as PSV and about 3 times more quickly than IMV. 12 There was no difference between a once-daily spontaneous breathing trial and multiple daily spontaneous breathing trials (attempted at least twice daily). Some of the differences in these studies are the result of different criteria to assess tolerance to

10 CHAPTER 47 Weaning from Mechanical Ventilation 911 INVESTIGATOR WEANING TECHNIQUE n DURATION OF VENTILATION BEFORE WEANING (DAYS) Brochard et al 11 SIMV ± ± 8 PSV ± 17 6 ± 4 T-piece ± 31 8 ± 8 Esteban et al 12 SIMV 29 6 ± 4 4 ± 3 PSV ± ± 3 T-piece ± ± 2 WEANING PERIOD (DAYS) TABLE 47-7 COMPARISON BETWEEN BROCHARD AND ESTEBAN STUDIES EVALUATING DIFFERENT WEANING TECHNIQUES SIMV synchronized intermittent mandatory ventilation; PSV pressure-support ventilation Source: data from Brochard et al 11 and from Estaban et al 12 (modified from Esteban et al 20 ) weaning and weaning completion, and therefore, the aggressiveness of utilizing PS or T-piece as weaning techniques. Esteban s group considered extubation if patients tolerated 5 cm H 2 O of PS for 2 h compared to 8 cm H 2 O in Brochard s study. During application of SIMV, Esteban and colleagues extubated patients once they were able to tolerate a backup rate of 5 breaths/min for 2 h; in contrast, Brochard s group s criteria required patients to tolerate 24 h at 4 breaths/min (a significant ventilatory challenge). Both studies similarly concluded that SIMV was less efficient in weaning patients, but differed as to whether PS or T-piece was the superior weaning method. Overall, either PS or T-piece weaning techniques can be successful if patients are properly selected and the method is appropriately implemented. TECHNIQUES TO AID WEANING Tracheostomy A small percentage of all patients placed on mechanical ventilation fail to wean and require more prolonged and concentrated efforts. The medical and respiratory status of these patients should be carefully reevaluated, and efforts should be made to correct any abnormalities. Additionally, tracheostomy placement should be contemplated. After several days, the endotracheal tube becomes coated with a biofilm comprised of secretions, denuded mucosal epithelial cells, and most likely pathologic bacteria. This not only decreases the effective diameter of the tube, thereby making efforts at spontaneous respiration more difficult, but also puts the patient at increasing risk for nosocomial infection. In addition, as the endotracheal tube warms to body temperature, it elongates and the curvature of the tube in the posterior oropharynx becomes more acute, resulting in greater airway resistance at the point of greatest inflection. Tracheostomy has been shown to reduce the resistive work of breathing over the continued use of an endotracheal tube 13 (see Fig. 47-2). The question regarding the appropriate timing for tracheostomy remains unanswered. It has been suggested that patients who are likely to require mechanical ventilation for more than 21 days should have a tracheostomy. Evidence regarding the advantages of early vs. late tracheotomy and the relative advantages of tracheostomy over endotracheal tube is controversial. Besides decreasing airways resistance and avoiding laryngeal injury, tracheotomy enhances the potential for improved patient mobility, improves secretion clearance, facilitates the patient s transfer to a lower level of care, and improves oral hygiene and patient comfort. Overall, the most common practice is to perform a tracheostomy if a patient has been on mechanical ventilation for at least days. Daily Interruption of Sedatives The use of continuous infusions of sedating medications is common in the intubated patient. The concern about continuous sedation is the prolonged duration of action which unnecessarily extends the duration of mechanical ventilation. Moreover, continuous sedation Tracheostomy has been shown to reduce the resistive work of breathing compared to an endotracheal tube. Daily interruption of continuous sedative infusions can decrease the duration of mechanical ventilation.

11 912 V. Kim and G.J. Criner FIGURE 47-2 Work of breathing (WOB), expressed as joules/liter, at the beginning of pressuresupport weaning in eight patients, before and after tracheostomy (T). The results were statistically significantly different (p < 0.05) and show decreased WOB following tracheostomy. (reprinted with permission from Diehl et al, 13 Official Journal of the American Thoracic Society American Thoracic Society). WOB (J/L) before T P<0.05 after T complicates the assessment of the neurological status of critically ill patients and may lead to the performance of unnecessary tests. Kress et al tested the hypothesis that daily interruption of sedatives would expedite recovery and decrease ICU length of stay. 14 They randomized 128 mechanically ventilated patients who were receiving continuous sedative infusions, to daily interruption of sedative infusions, until the patient was awake or to usual care (UC) (control of the sedative infusion was left to the discretion of the treating physician). The median duration of mechanical ventilation was significantly less in the group where continuous sedation was interrupted daily, as was ICU length of stay. By comparison, more patients underwent diagnostic testing to assess changes in mental status in the UC group. The authors concluded that daily interruption of sedatives can decrease the duration of mechanical ventilation. Noninvasive positive pressure ventilation (NPPV) appears to facilitate the weaning process in patients with acute on chronic respiratory failure, particularly in those with COPD. Noninvasive Ventilation Because NPPV has been successfully used to avoid the need for intubation in patients with acute and acute on chronic respiratory failure, its use has been expanded to facilitate early extubation. Udwadia et al were the first to report the usefulness of NPPV in facilitating the weaning process. 15 The causes for respiratory failure included neuromuscular disease, primary lung disease (i.e., COPD), or postoperative respiratory failure following cardiac surgery. Patients were placed on NPPV once they met the following criteria: intact upper airway function, minimal airway secretions, low oxygen requirement, hemodynamic stability, ability to sustain spontaneous ventilation for min, and functional gastrointestinal tract. NPPV was initially used for h/day and was gradually decreased. In this study, 18 of 22 patients were successfully converted to NPPV and discharged home in a mean of 11 days. The results of this study have to be carefully interpreted, because the majority of these patients had acute on chronic respiratory failure, a significant percentage were discharged with nocturnal noninvasive ventilation, and all the patients had a tracheostomy in place, which made resuming invasive ventilatory support relatively easy. In a study by Nava et al, 40 patients with severe COPD who required mechanical ventilation and failed a T-piece trial 48 h postintubation were randomized to extubation and application of NPPV or weaning by PS via endotracheal tube. 16 At 60 days follow-up, 22 of 25 patients were successfully weaned in the NPPV group compared to 17 of 25 patients in the invasive ventilation group. Patients in the NPPV group had shorter duration of mechanical ventilation, shorter ICU stay, and improved mortality at the time of discharge. None of the patients receiving NPPV developed pneumonia, compared to 7 of 25 patients in the invasive mechanical ventilation arm of the study. Girault et al randomized 33 patients with acute on chronic respiratory failure to conventional PS weans or extubation and NPPV after they

12 CHAPTER 47 Weaning from Mechanical Ventilation 913 AUTHOR n DISEASES (n) IPPV (DAYS) NPPV (DAYS) OUTCOME Udwadia et al CWD (9) % weaned NMD (6) 63% used chronic NPPV Cardiac (7) Restrick et al COPD (8) % weaned CWD (4) 21% used chronic NPPV One patient died Hilbert et al COPD 12 ± 4 5 ± 2 Compared with historical controls Reintubation by 47% ICU LOS by 42% Duration mechanical Ventilation by 54% TABLE 47-8 COMPARISON AMONG STUDIES USING NONINVASIVE POSITIVE PRESSURE VENTILATION (NPPV) FOR WEANING FROM INVASIVE MECHANICAL VENTILATION IPPV invasive positive pressure ventilation; NPPV noninvasive positive pressure ventilation; CWD chest wall disorders; NMD neuromuscular disorders; COPD chronic obstructive pulmonary disease; ICU intensive care unit; LOS length of stay failed a 2-h T-piece trial. 17 The NPPV group had a shorter course of mechanical ventilation and a trend toward fewer complications, but mortality, hospital length of stay, and ICU length of stay were similar among groups. The results of these trials indicate that there may be a role for NPPV in patients who fail a T-piece wean in reducing mechanical ventilation duration and its associated complications. It is important to notice that these trials enrolled patients with chronic or acute on chronic respiratory failure (Table 47-8), and that, in some cases, noninvasive ventilation was continued beyond the hospital admission. The results are, therefore, more likely to be applicable in patients with acute exacerbations of chronic respiratory failure, especially in those with COPD. Whether these results can be extrapolated to other patient populations is unclear at this time, and further studies are needed. The use of NPPV has also been used in both the prevention and treatment of postextubation respiratory failure. The efficacy of NPPV in this setting, however, is not as great as in others. In a recent large prospective randomized trial, NPPV was no better than UC in the prevention of reintubation. In addition, there was a suggestion that those receiving NPPV had a higher mortality, perhaps related to a delay in intubation. However, NPPV may be of benefit in select patient groups. NPPV in postextubation respiratory failure is described at length in Chap. 46. Protocol or Computer-Based Strategies It has been proposed by many that protocol-based strategies for weaning patients shorten time to extubation and decrease ICU cost. This hypothesis is based on the theory that a regimented daily screening of all intubated patients will more rapidly identify those ready to be weaned and that weaning is initiated before the patients are seen by their physicians. There have been several randomized trials addressing this issue, unfortunately with different results. In a randomized, prospective trial, Ely et al studied 300 consecutive medical and coronary care unit ventilated patients. 18 The intervention group (n = 149) underwent daily screening of respiratory function to identify those patients capable of spontaneous breathing. Patients had to satisfy five criteria to be considered for a spontaneous breathing trial (e.g., PaO 2 /FiO 2 ratio <200, PEEP < 5 cm H 2 O, adequate coughing during suctioning, f/v T ratio <105, and no need for sedative or vasopressor agents). Intervention patients meeting these criteria underwent a 2-h T-piece spontaneous breathing trial. Physicians were notified if patients successfully completed the trial (Fig. 47-3). Control patients received daily screening, but no other interventions. Patients assigned to the intervention group received mechanical ventilation for a median of 4.5 days vs. 6 days in the control group (p = 0.003). The group assigned to the intervention had a significant reduction in the incidence of self-extubation, reintubation, Protocol-based weaning strategies have been shown by some, but not all, studies to decrease time to extubation and ICU length of stay.

13 914 V. Kim and G.J. Criner FIGURE 47-3 Study algorithm evaluating daily screening and spontaneous breathing trial in patients on mechanical ventilation. RT respiratory technician; PT patient; PaO 2 arterial oxygen tension; FiO 2 inspired fraction of oxygen; PEEP positive end-expiratory pressure; f/v T rapid shallow breathing index; CPAP continuous positive airway pressure; RR respiratory rate; HR heart rate; SBP systolic blood pressure (data from Ely et al. 18 Copyright 1991 Massachusetts Medical Society. All rights reserved). RT Screens PT 6:30 7:30 AM INTERVENTION 2 Hours Spontaneous Breathing Trial T-Piece or Flow by/5 CPAP Supervised by RT/RN PATIENTS ENROLLED RANDOMIZED RR < 35 SPO 2 > 90% HR < 140 OR < 20% Change 180 > SBP > 90 Diaphoresis, Distress Notify Attending 55% Extubated Same Day CONTROL DAILY SCREENING USUAL CARE PaO 2 /FiO 2 > 200 PEEP < 5 cmh 2 O Adequate Cough f/v T < 105 No Pressors Protocol-based weaning strategies require significant resources to implement and sustain, and cannot replace physician judgment for weaning eligibility. Malnutrition, deconditioning, and psychiatric disorders are commonly seen in ventilator-dependent patients and treatment of these comorbidites should be included in the treatment plan. tracheostomy, and mechanical ventilation for more than 21 days. ICU costs were significantly reduced in the intervention group. A more recent multicenter trial (2006) that randomized 144 patients to UC or a computer driven weaning protocol found similar results, with a decrease in weaning duration, total duration of mechanical ventilation, and ICU length of stay, without an increase in reintubation rate or adverse events. These studies suggest that protocol-based weaning strategies do indeed improve care and decrease cost. However, the implementation of weaning protocols by nursing and respiratory care staff requires significant resources, and the replacement of physician scrutiny by protocol or computer-based practices is not without flaws. Another trial by Krishnan et al had less optimistic results than Ely s study. 19 Two hundred and ninety-nine intubated patients were randomized to a protocol-based weaning strategy (PW) or UC, where eligibility for weaning and weaning technique were determined by the treating physician team. The baseline patient characteristics and protocol for weaning were similar to the Ely study. In contrast to the study by Ely, the patients in the PW group needed to tolerate 1 h of spontaneous breathing in order to be considered ready for extubation. There were no differences in duration of mechanical ventilation, ICU or hospital mortality, ICU length of stay, and rates of reintubation between the two groups. The authors concluded that a rigorous protocol-based weaning strategy may not be necessary as long as the team of physicians carefully and frequently scrutinized each patient for signs of respiratory failure reversal and ventilator weaning is performed in a judicious fashion. Adjunctive Therapy It has become increasingly apparent that supportive therapy, not only for medical illnesses but also for malnutrition, deconditioning, and psychiatric disorders, is essential for managing patients who are difficult to wean from mechanical ventilation. Critical illness requiring mechanical ventilation is associated with malnutrition secondary to increased metabolic demands relative to the provided nutritional supplementation, muscle wasting related to systemic inflammatory response and being bedridden, and finally anxiety from numerous factors including sleep deprivation, ventilator dependence, and the severe medical illness. These comorbidities increase difficulty in weaning from mechanical ventilation.

14 CHAPTER 47 Weaning from Mechanical Ventilation 915 PATIENT SHOWS SIGNIFICANT IMPROVEMENT OR RESOLUTION OF UNDERLYING CAUSE FOR RESPIRATORY FAILURE OFF PRESSORS/OFF NMBA/ SEDATIVE AGENTS Adequate Cough, MIP< 30cmH 2 O PaO 2 /FiO 2 >200, PEEP<5cmH 2 O f/v T ratio<105 Spontaneous Breathing Trial on T-Piece or Flowby/CPAP 5cmH 2 O PATIENT FAILS INITIAL WEANING TRIAL Reassess Medical/Respiratory Status Incremental Daily T-piece/ Flowby Trials PS Wean, adjust PS to obtain V T of 4 6ml/kg RR Decrease PS by 2 4 cmh 2 O FIGURE 47-4 Weaning algorithm. NMBA neuromuscular blocking agents; PaO 2 arterial oxygen tension; FiO 2 inspired fraction of oxygen; MIP maximal inspiratory pressure; f/v T rapid shallow breathing index; CPAP continuous positive airway pressure; PS pressure support; RR respiratory rate; HR heart rate; SBP systolic blood pressure. RR<35,SpO 2 >92 HR<140, 180<SBP>90mmHg No Diaphoresis/Distress PATIENT TOLERATES 2 HOURS PATIENT FAILS Reassess PATIENT TOLERATES WEANING TRIAL EXTUBATE Consider Tracheostomy SLOW WEANING Treatment of these comorbidities is associated with improved outcome in several small studies, and the clinician should have a heightened suspicion for them in all ventilated patients and include treatment regimens for them as part of a comprehensive treatment plan. Malnutrition and deconditioning may decrease respiratory muscle strength and endurance and may increase the ventilatory response to hypoxia. Aggressive nutritional support in patients with prolonged mechanical ventilation has been shown in small studies to increase the likelihood of successful liberation from mechanical ventilation. The patient should be mobilized out of bed as soon as medically possible. Physical rehabilitation should begin as soon as the patient is medically stable to improve muscle strength and mobility. A retrospective analysis of 49 patients with prolonged mechanical ventilation found that whole body rehabilitation was associated with improvement in muscle strength and conditioning and was associated with liberation from mechanical ventilation. In addition, a case series of ten ventilator-dependent patients revealed that inspiratory muscle strength training, in addition to usual medical care, allowed them to become ventilator independent. Finally, techniques such as anxiolytics, hypnosis, and biofeedback may decrease anxiety associated with the process of weaning, thereby increasing chances of success. SUMMARY Weaning from mechanical ventilation blends the art and science aspects of pulmonary and critical care medicine. Successful weaning requires knowledge of the cause of the patient s respiratory failure, a certain degree of clinical stability for the patient, and interpretation of some easily obtainable respiratory function bedside tests (Fig. 47-4). These assessments, in addition to careful observation of a patient s breathing pattern and tolerance of a spontaneous breathing trial on T-piece or PS, can successfully enhance weaning from mechanical ventilation.

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