Weaning from mechanical ventilation Weaning / Extubation failure: Is it a real problem in the PICU? Reported extubation failure rates in PICUs range from 4.1% to 19% Baisch SD, Wheeler WB, Kurachek SC, Cornfield DN. Extubation failure in pediatric intensive care incidence and outcomes. Pediatr Crit Care Med 2005; 6:312 318. Newth C et al. Pediatr Crit Care Med 2009; 10:1 11 Peter C. Rimensberger Pediatric and Neonatal ICU, Department of Pediatrics University Hospital of Geneva, Geneva, Switzerland Edmunds S, Weiss I, Harrison R. Extubation failure in a large pediatric ICU population. Chest 2001; 119:897 900. Fontela PS, Piva JP, Garcia PC, et al. Risk factors for extubation failure inmechanically ventilated pediatric patients. Pediatr Crit Care Med 2005; 6166 170. Effect of Mechanical Ventilator Weaning Protocols on Respiratory Outcomes in Infants and Children: A Randomized Controlled Trial Weaning: The key questions 1. Is the cause of respiratory failure gone or getting better? 2. Is the patient well oxygenated and ventilated? In contrast with adult patients, the majority of children are weaned from mechanical ventilator support in 2 days or less. Weaning protocols did not significantly shorten this brief duration of weaning. 3. Can the heart tolerate the increased work of breathing? Adrienne G. Randolph et al. JAMA 2002;288(20):2561-2568 Discontinuation of Mechanical Ventilation To discontinue mechanical ventilation requires: Patient preparation Assessment of readiness For independent breathing For extubation A brief trial of minimally assisted breathing An assessment of probable upper airway patency after extubation Either abrupt or gradual withdrawal of positive pressure, depending on the patient s readiness Factors that may contribute to extubation failure in pediatric patients young age duration of mechanical ventilation prolonged treatment with sedatives and analgesics Fontela PS, Piva JP, Garcia PC, et al. Risk factors for extubation failure in mechanically ventilated pediatric patients. Pediatr Crit Care Med 2005; 6166 170. 1
Failure rate of planned extubations of patients within the first 48 hrs of arrival in the pediatric intensive care unit (PICU) is, on average, half that of the rate for patients ventilated for longer than 48 hrs. Ventilation > 48 hours: contrary to common perception there is no relationship between the duration of MV and rates of failed extubation Kurachek SC et al.crit Care Med 2003; 31:2657 2664 Kurachek SC et al.crit Care Med 2003; 31:2657 2664 Classical Methods for Gradually Withdrawing Ventilator Support Concepts of Weaning The most common weaning approach: gradual reduction of ventilatory support 1) By reducing ventilatroy rate: IMV or SIMV 2) By reducing inspiratory pressure: PS PS is often combined with IMV/SIMV during weaning Volume support and volume-assured pressure support are special forms of PS available in certain ventilators that guarantee a minimal tidal volume per assisted breath. Weaning with volume support is semiautomatic, where the PS level required to maintain a certain tidal volume is reduced automatically as respiratory mechanics improve. Getting ready for extubation Weaning decrease the PEEP (4-5) decrease the rate decrease the PIP (as needed) What you want to do is decrease what the vent does and see if the patient can make up the difference. 2
Controlled ventilation Ventilator work Airway pressure Trigger patient Inspiration Expiration Assisted Ventilation P vent Paw = Pvent + Pmus Spontaneous Breathing Trials and Extubation Readiness Tests Patient work Ventilator work J.J. Marini, et al Am Rev Respir Dis 1986: 134: 902-909 Spontanoeus Breathing Test (SBT) SBT conducted on PS of 10 cm H2O versus SBT using a T-piece no difference Farias JA et al. Intensive Care Med 2001; 27:1649 1654 Of the 323 patients (77%) who passed the SBT and were extubated, 14% were reintubated within 48 hrs. Rapid Shallow Breathing Index (RSBI): f/vt The frequency to tidal volume ratio (or rapid shallow breathing index, RSBI) is a simple and useful integrative indicator of the balance between power supply and power demand. In adults: A rapid shallow breathing index < 100 generally indicates adequate power reserve. In this instance, the RSBI indicated that spontaneous breathing without pressure support was not tolerable, likely due in part to the development of gas trapping. Respiratory rate, tidal volume, rapid shallow breathing index (RSBI), and maximal negative inspiratory pressure (PImax) were all poor predictors of extubation outcome. Farias JA et al. Intensive Care Med 2002; 28:752 757 Limitations of RSBI in children Weaning failure: Objective Criteria wide range of age groups with different respiratory rates RR above normal age limits: < 6 months: 20 60 breaths/min < 2 years: 15 45 breaths/min < 5 years: 10 35 breaths/min or > 1,5 x normal F. Leclerc, O. Noizet, W. Chaari, A. Sadik, Y. Riou Principles of mechanical ventilation weaning in paediatric intensive care Annales Françaises d Anestésie et de Réanimation 28 (2009) 685 687 3
Rapid Shallow Breathing Index (RSBI): f/vt Compliance, Resistance, Oxygenation, Pressure Index (CROP Index): (Dynamic Compliance x Maximal Negative Inspiratory Pressure x (PaO2/PAO2)/ Respiratory Rate) Venkataraman ST et al. Crit Care Med 2000; 28:2991 2996 Rapid Shallow Breathing Index (RSBI): f/vt Compliance, Resistance, Oxygenation, Pressure Index (CROP Index): (Dynamic Compliance x Maximal Negative Inspiratory Pressure x (PaO2/PAO2)/ Respiratory Rate) Volumetric Capnography: physiologic dead space (VD/VT) Measurement of End-tidal CO 2 and Dead Space The Single Breath CO 2 Curve Phase 1: - airway deadspace Phase 2: - mixing of airway deadspace and alveolar gas Phase 3: - alveolar volume The Single Breath CO 2 Curve with added PaCO 2 value Deadspace to tidal volume ratio predicts successful extubation in infants and children VD/VT 0.50 reliably predicts extubation success with 75% sensitivity and 92% specificity, Area X = volume of CO 2 Area Y = wasted ventilation due to alveolar deadspace Area Z = wasted ventilation due to airway deadspace whereas a VD/VT > 0.65 identified patients at risk for failure Physiologic VD / VT Physiologic Deadspace Alveolar Deadspace = (Y+Z) / (X+Y+Z) = (VD / VT) * (VT) = VD phys - VD airway Hubble CL, Gentile MA, Tripp DS, et al: Crit Care Med 2000; 28:2034 2040 4
The Single Breath CO 2 Curve and VCO2 Airway deadspace (VD airway) = area p Volume of CO2 = area X. Adding volumes of each breath gives CO2 elimination in ml / min Volumetric CO2 recording Volumetric CO2 Monitoring MV SV not present VCO 2 Not ready to extubate Watch VCO2 (CO2 elimination) over time as wean ventilator If mechanical ventilation taken over by spontaneous ventilation with VCO2 remaining stable or increasing, then probably approaching extubation point Predictors of extubation success and failure in mechanically ventilated infants and children Predictors of extubation success and failure in mechanically ventilated infants and children Khan, Nadeem; Brown, Andrew; Venkataraman, Shekhar T. Critical Care Medicine 199624(9):1568-1579 Venkataraman ST Crit Care Med 2000; 28:2991 2996 5
Reasons for reintubation Preextubation variables easily obtained at the bedside can predict the relative risk of reintubation a spontaneous tidal volume that is at least normal, a low FIO2, a low Paw, a low OI, a low PIP, a high dynamic compliance, a low FrVe (fraction of total minute ventilation provided by the ventilator) a normal or high Vt/Ti (mean inspiratory flow) are associated with a low risk of failure Venkataraman ST et al. Crit Care Med 2000; 28:2991 2996 Venkataraman ST et al. Crit Care Med 2000; 28:2991 2996 Sedation? The air leak test to predict which patients are at risk for postextubation stridor and extubation failure 76% of the physicians routinely use the air leak test test prior to extubation Foland JA, Super DM, Dahdah NS, Mhanna MJ. The use of the air leak test and corticosteroids in intubated children: a survey of pediatric critical care fellowship directors. Respir Care 2002; 47:662 666 Adrienne G. Randolph et al. JAMA 2002;288(20):2561-2568 The air leak test to predict which patients are at risk for postextubation stridor and extubation failure Increased risk for post-extubation stridor or extubation failure when there is absence of a leak around the ETT or leak at a > 30 cm H2O Kemper KJ et al. Crit Care Med 1991; 19:352 355 Seid AB et al. Arch Otolaryngol Head Neck Surg 1991; 117:880 882 A leak around the ETT at > 20 cm H2O had a sensitivity of 83.3% in predicting post-extubation stridor in patients age > 6 years Mhanna MJ et al. Crit Care Med 2002; 30:2639 2643 3 x higher incidence of adverse events in patients without an air leak at 25cmH2O Suominen Pet al. Paediatr Anaesth 2006; 16:641 647. Prophylactic systemic corticosteroids in an attempt to minimize post-extubation stridor? Reduced incidence of post-extubation stridor in both neonatal and pediatric patients Trend towards decreased rates of re-intubation in the corticosteroid groups (statistically not significant) But there was considerable variation noted in the pediatric trials examined in this meta-analysis, which the authors attributed to possible differences in risk among the populations studied. Markovitz BP, Randolph AG. Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta analysis. Pediatr Crit Care Med 2002; 3:223 226. 6
Prophylactic systemic corticosteroids in an attempt to minimize post-extubation stridor? In neonates: RR 0.42; 95% CI 0.07 to 2.32 In children: significantly reduced in children with underlying airway abnormalities (n = 62) but not in the study that excluded these children (n = 153) In adults RR 0.48; 95% CI 0.19 to 1.22 for reintubation (n = 1953) RR 0.47; 95% CI 0.22 to 0.99 for stridor Markovitz BP, Randolph AG, Khemani RG: Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2008; (2):CD001000 Using corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates, children or adults. However, given the consistent trend toward benefit, this intervention does merit further study Markovitz BP, Randolph AG, Khemani RG: Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2008; (2):CD001000 Extubation Criteria 1. Neurologic 2. Cardiovascular 3. Pulmonary Neurologic Patient must be able to protect his airway, e.g, have cough, gag, and swallow reflexes. Level of sedation should be low enough that the patient doesn t become apneic once the ETT is removed. No apnea on the ventilator. Must be strong enough to generate a spontaneous TV of 5-7ml/kg on 5-10 cm H 2 O PS or have a negative inspiratory force (NIF) of 25cm H 2 O or higher. Being able to follow commands is preferred. Cardiovascular Patient must be able to increase cardiac output to meet demands of work of breathing. Patient should have evidence of adequate cardiac output without being on significant inotropic support. Patient must be hemodynamically stable. Pulmonary Patient should have a patent airway. Pulmonary compliance and resistance should be near normal. Patient should have normal blood gas and work-ofbreathing on the following settings: FiO 2 <40% PEEP ±5cm H 2 O PS 5-8cm H 2 O Spontaneous TV of 5-7ml/kg Close to normal breath rate according to age 7
Conclusions: Weaning Readiness and Extubation Criteria 1. Ability to protect upper airway Effective cough Alertness 2. Improving clinical condition 3. Adequate lumen of trachea and larynx Leak test during airway pressurization Conclusions: Weaning Readiness and Extubation Criteria Upper airway obstruction is the single most common cause of extubation failure. A reliable method of assessing readiness for weaning and predicting extubation success is not evident from the pediatric literature. Weaning is often not considered early enough in the course of ventilation. Extubation Control of airway reflexes Patent upper airway (air leak around tube?) Minimal oxygen requirement Minimize pressure support (0 - max 10) (Normal compliance = Vt 8 ml/kg with PS of 8) Comfortable spontaneous breathing Awake patient 8