Weaning: Neuro Ventilatory Efficiency
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1 Weaning: Neuro Ventilatory Efficiency Christer Sinderby Department of Critical Care Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael's Hospital Faculty of Medicine, University of Toronto, Canada Disclosure: Dr. Sinderby has made inventions related to neural control of mechanical ventilation that are patented. The license for these patents belongs to Maquet Critical Care. Use of this technology provides financial benefit to Dr. Sinderby through royalties. Dr Sinderby owns 50% of Neurovent Research Inc (NVR). NVR is a research and development company that builds the equipment and catheters for research studies. NVR has a consulting agreement with Maquet Critical Care.
2 Conflict of interest Disclosure: Dr. Sinderby has made inventions related to neural control of mechanical ventilation that are patented. The license for these patents belongs to Maquet Critical Care. Commercial use of this technology provides financial benefit to Dr. Sinderby through royalties. Dr Sinderby owns 50% of Neurovent Research Inc (NVR). NVR is a research and development company that builds the equipment and catheters for research studies. NVR has a consulting agreement with Maquet Critical Care.
3 Neuro-ventilatory efficiency = Vt/EAdi (ml/µv)
4 EAdi and Vt in health and disease Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013
5 Principle for Vt/EAdi Vt EAdi
6 We evaluated whether extubation failure could be characterized by increased respiratory drive and impaired efficiency to generate inspiratory pressure and ventilation. Following PSV of 10 cm H 2 O and PEEP of 5 cm H 2 O: 52 patients underwent 30-minutes of spontaneous breathing on CPAP of 5 cmh 2 O. Data was compared between successfully extubated patients and those patients that either failed spontaneous breathing or passed but failed within 48 h.
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11 Purpose: To compare breathing pattern descriptors and diaphragm electromyographic activity (EAdi) during a spontaneous breathing trial (SBT) in patients successfully and unsuccessfully separated from the ventilator and to assess their performance as a potential marker to discriminate these two categories of patients. Methods: Fifty-seven ready-to-wean patients were included in a prospective observational study. During a 30-min SBT (pressure support 7 cmh2o, zero end expiratory pressure), tidal volume (VT) and respiratory rate (RR) were obtained from the flow signal at baseline of PSV and at 3, 10, 20 and 30 min during the SBT.
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13 Note that this study describes the inverse of Neuro-Ventilatory Effiency
14 Conclusions EAdi-derived indices collected via the NAVA catheter during the SBT provide reliable predictors of successful separation from the ventilator. These indices can discriminate early in the SBT the ongoing success or failure of separation from the ventilator. However, the performance of these indices is not better than the performance of the rapid shallow breathing index. Therefore, the benefit of EAdi-derived indices during the SBT remains unclear.
15 In this pilot study we compared the EAdi to conventional weaning parameters in difficult-to-wean patients scheduled for a spontaneous breathing trial. Our primary goal was to observe the expected increase in the EAdi. A secondary goal was to compare the conventional weaning parameters to those derived from the EAdi. We studied 18 mechanically ventilated patients considered difficult to wean. For a spontaneous breathing trial (SBT) the patients were disconnected from the ventilator and given oxygen through a T-piece. The SBT was evaluated using standard criteria.
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19 This observational study included 12 patients breathing with neurally adjusted ventilatory assist (NAVA). When a spontaneous breathing trial (SBT) with pressure support of 7 cm H2O and PEEP was unsuccessful, NAVA was used and the level was adjusted to obtain an EAdi of 60% of maximal EAdi during SBT. VT and EAdi were recorded continuously. We compared changes in NVE between NAVA and SBT at the first failed and first successful SBT.
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22 Conclusions These results suggest that in patients after respiratory failure and prolonged mechanical ventilation, changes in VT and NVE, between SBTs are indicative of patient recovery. Larger clinical trials are needed to clarify whether changes in NVE reliably predict weaning in patients ventilated with NAVA.
23 Conclusion 4 studies in 138 patients indicate that neuroventilatory efficiency (Vt/EAdi) is reduced in weaning failure patients. Thus, clinical use of mechanical ventilation to unload inspiratory muscles due to weakness or load is justified. Vt/EAdi as a predictor of weaning during SBT equals that of Fb/Vt. Future studies of comparing patient-chosen changes in Vt, Vt/EAdi, and Fb/Vt between NAVA and SBT may introduce better prediction of weaning outcome.
24 Thank You VentQuest.ca
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Monitoring Neural Output
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