1、Weaning from Mechanical VentilationConsensus Conference of the ATS, ERS, ESCIM, SCCM and SRLFTobias WelteDept. of Respiratory Medicine Medizinische Hochschule HannoverGermanyEsteban et al. JAMA 2002Managing the PatientCountryYearCost/day/patientNoseworthy CCM 1996;24:1168Canada1992Can $1,500Sznajder
2、 Int Care Med 2001;27:146France1996$1,590McCarthy Resp Care 1998; 43:114. (Mech Vent patients)U.S.1995$2,114Cooper CCM 2004; 32:2247U.S.2000$2,462Halpern CCM 2004; 32:1254U.S.2000$2,674Ventilated patients require care in an ICU unless they are hemodynamically stable, free of hyperactive delirium, an
3、d have stable airways Weaning-“The process of liberating patients from the ventilator, begins as soon as the patient is intubated by tailoring settings to the needs of the patient”Hall JB, Wood L. JAMA 1987Vent.timeWean.timeDays40%50%43%40%Esteban,1994Ely, 1996Kollef, 1997Esteban,2002*CONTROL GROUP*
4、051015DAYS on MECHANICAL VENTILATIONTroche et al. CHEST 112: 1997post-surgeryNeur.Dis.CHFCOPDUNPLANNED EXTUBATION DURING MV04080120160200PATIENTSZwillich, 1974Vassal,1993Whelan, 1994Atkins, 1997Chevron, 1998Epstein, 2000Esteban, 2002Tindo, 1994Coppolo, 199059%41%63%26%22%54%26%33%53%471 PATIENTS SEL
5、F-EXTUBATED WHILE ON MECHANICAL VENTIALTION(i.e. no need for MV)49%242 REINTUBATED229 NON REINTUBATED51%Epstein SK J at all. Am J Respir Crit Care Med: 2000; 161: 1912-1916SELF EXTUBATION IN 75 PATIENTS23%77%DURING FULL VENTILATORY SUPPORT42 PATIENTSDURING WEANING33 PATIENTS69%31%Weaning ProtocolKri
6、shnan J. AJRCCM 2004; 169: 673-8MV for 24 h in a 14 bed ICUWeaning protocol daily screen for readinessf/Vt 105SBT (CPAP 7) for 1 hourvs. Usual Care2 attendes, 10 MD traineesdaily attend bedside round 3 hnurse to patient ratio 1:2+ 1-2 additional senior nurses+ 1-2 respiratory therapistsAdmitDischarg
7、ePre-WeaningMeasureWeaningPredictorsSuspicionWeaningTrialsExtubationNIVPost-ExtubationReintubation1234567Seven Stages of Weaning Stage 2Stage 3 Transition: Time of greatest delay in weaning Goal of Weaning Predictors: Make Stage 2-Stage 3 transition as early as possibleThree Sequential Diagnostic Te
8、sts1. Weaning Predictors2. Weaning Trial3. Trial of ExtubationSee if ready for #2See if ready for #3See if can sustain ventilation and protect airwayWeaning from mechanical ventilation The “golden moment” (Petty TL, Intensive and Rehabilitative Respiratory Care. Lea & Febiger 1982;232-8) .certain pa
9、rameters measured at the bedside can assess the likelihood.a low spontaneous respiratory rate (i.e., less than 20) and MIP greater than -20 cmH2O.the most encouraging situation is a rested, alert patient with a twinkle in the eye seen on early morning rounds. these observations indicate that the gol
10、den moment is at hand.the patient is given a 30 min SBT attached to a T-tube.no essential change is desirable.at this point is placed back on the respirator (1h) and, if all looks well, extubation is immediately accomplished. Weaning - Predictors Esteban A et al.: N Engl J Med 1995; 332: 345-50 Spon
11、taneous Breathing via T-Tube for 3 minutes, FiO2 similar to mechanical ventilation Measurement of respiratory rate, tidal volume, maximal inspiratory Pressure ( -20 cm H2O) Extubation, if RR 105 / min / l SaO2 90%, pO2 / FiO2 200 HR 140/min BP 90 mmHg Pat. is able to cough, awake and cooperative300
12、PatientsDaily ScreenIntervention Group, 149Control Group, 1512 hr Spon Br TrialInform Attending Orally& Prompt in ChartEly et al, NEJM 1996:335:1864Screen: pO2/FIO2 200 PEEP 5 f/VT 105 Cough on suction No pressors/sedationInterventionControlP-valuen=149n=151APACHE II19.817.9 0.01Weaning Days (M)1 3
13、0.0001Ventilator Days (M)4.56 0.003Reintubation (%) 6 (4) 15 (10) 0.04 Mech Vent 21d (%) 9 (6) 20 (13) 0.04Any Complication(%) 30 (20) 62 (41) 0.001Total ICU Costs$15,740$20,890 0.03Ely EW, Ely EW, et alet al. NEJM. NEJM 1996; 335: 1996; 335: 1864-691864-69The Hazard of Remaining on Mechanical Venti
14、lationEly EW, et al. ICM 1999;25:581-7Passing a daily screen of weaning parameters is an independentfactor predictor of successful extubation and survival.Three Sequential Diagnostic Tests1. Weaning Predictors2. Weaning Trial3. Trial of ExtubationSee if ready for #2See if ready for #3See if can sust
15、ain ventilation and protect airwayMulticenter trial PS was decreased twice a day RR 35 breaths/min Minimal level of PS has to be tolerated 24 hours before extubationWeaning Esteban A et al.: Am J Respir Crit Care Med 1997; 156: 459-465p=0.03mortality 27% vs. 2.6%p 48 hMechanical Ventilation in COPDa
16、dditional problems Size of the endotracheal tube Secretions Nutritional Status Medication Sedatives Steroides Theophyllin and 2-mimeticsBronchoscopyWeaning Problems Weaning Delay Delay in extubating a patient who should be able to breathe spontaneously Weaning Failure Failure of a patient to wean in
17、 an expected amount of time despite appropriate managementNIV in the Weaning of COPD patientsNava S et al.: Ann Intern Med 98;128: 721-28 multicenter, randomized study 68 pts with acute respiratory failure T-piece weaning after 48 hours in 8 pts successful 50 pts randomized after T-piece weaning fai
18、lure extubation and NIPSV via face mask invasive PSV via endotracheal tubeNIV in the Weaning of COPD patientsNava S et al.: Ann Intern Med 98;128: 721-28invasive PSVNIPSVventilation days16.6 11.810.2 6.8ICU days24.0 13.715.1 5.4death7 (28%)2 (8%)home MV21VAP7 (28%)0Ferrer M. et al AJRCCM 2003Invasiv
19、e MV 3 d(77% chronic respiratory diseases) T-piece trial failure during 3 consecutive daysExtubation + continuous NIV (n=21)Standard weaning:daily T-piece trial (n=22)COPD: NIV in weaning failureDays of intubation01020304050Successfully weaned patients (%)020406080100Noninvasive ventilationConventio
20、nal weaningp=0.002COPD: NIV in weaning failureFerrer M. et al AJRCCM 2003; 168: 70-76COPD: NIV in weaning failureFerrer M. et al AJRCCM 2003; 168: 70-76Non-invasive ventilation - when to stop?Criteria for intubation(Guidelines of the German Society of Respiratory Disease) respiratory parameters are
21、not improving within the first 15 min blood gas values persist on the same pathologic level for 2 h every new worsening of the respiratory situationduring non-invasive ventilation, which cannot be corrected immediately. Extubation Failure Definition: pH 45 mmHg Clinical signs of muscle fatigue RR 25
22、/min Hypoxemia SaO2 90% or paO2 50%Extubation Failure N34,000 (55 studies)17.7 (16.7)14.1 (14.6)13.3 (9.2)6.3 (6.4)Outcome for Extubation Failure% of patientsafter reintubation12+ days MV21+ days ICU30+ days HospN=287% of patientsEpstein Chest 1997Timing of Extubation Failure Mortality (%)The Co$t o
23、f Extubation Failure Pronovost et al, Lang Arch Surg 2001 Vascular surgery, EF increased hosp charges by 20% Seymour et al, Crit Care 2004 Community Hospital, MICU, SICU Extubation Failure Increased Hospital Charges: $48,000 v 23,000 Cost per day: $2000 v 1700Factors Influencing Extubation Failure R
24、ate Patient Population Age Use of Continuous IV Sedation Abn MS, delirium Semirecumbent position Transport from ICU Severity of Illness MD staffing, N/P ratio Reduced Hgb-Hct Duration of MV Gender Indication for MV Weaning Trial Number of Trials Duration of the Trial Pre-extubation mode of support P
25、rotocol980 Extubated PatientsMeeting Inclusion Criteria“At-Risk” Cohort244 (25%) developed Respfail within 48h221 Randomized23 Not Randomized8 Decreased LOC5 Severe inc resp effort4 Shock3 Hypoxemia2 - UAO114 NoninvasiveVentilation Group107 Conventional GroupEsteban et al (N Engl J Med 2004)Postextu
26、bation ARFEsteban A. NEJM 2004; 350: 2452-60Postextubation ARFEsteban A. NEJM 2004; 350: 2452-60 Problems of the Esteban Study Unexperienced centers Inspiratory Pressure too low NIV started too lateNIV to prevent Extubation Failure in High Risk PatientsRandomized controlled multicenter study79 pts.
27、requiring MV 48 hours and at risk for reintubationhypercapniacongestive heart failureineffective cough and excessive tracheobronchial secretionsmore than one failure of a weaning trialmore than one comorbid conditionupper airway obstruction Extubation after succesful weaning trialNIV for 8 hours vs.
28、 Oxygen Supplementation aloneCrit Care Med 2005 Vol. 33, No. 11: 2465-70NIV SUCCESS (n = 65)NIV FAILURE (n = 43)pSAPS II30 1145 27 0.01pH7.36 0.097.30 0.10 0.01Copious secretions14%34% 0.05Encephalopathy28%49% 0.01Tolerance91%37% 0.01Leaks9%72% 0.01Carlucci, AJRCCM 2001The median time between admiss
29、ion to ICU and performance of tracheostomy has decreased significantly from a median of 8 days (range 1-23) in 1992 to 4 days (range 0-21) in 1997 (P=0.016) TP Simpson, Anesthesia, 1999;54:186. Rumbak MJ Crit Care Med 2004;32:1689Died (%)PneumoniaDays in ICUDays MVDs sedatedDs on high-dosepressors19
30、 (31.7)3 (5)4.81.47.64.03.20.43.51.4437 (61.7)15 (25)16.23.817.45.314.12.93.0.005.005.001.001.001nsEarlyTracheotomyProlongedtranslaryngealintubationp1) Easy weaning (first attempt): detect as early as possible with daily screening + T-piece or low PSV trials, or use of CDS.2) difficult weaning (more
31、 than one attempt): reduce assistance (PSV) and daily tests with low PSV trials, or use assisted ventilation (ACV or PSV) + once daily T-piece or low PSV trials, or use of CDS.3) prolonged weaning (multiple attempts, tracheostomy): assisted ventilation (PSV or ACV) and prolonged “unassisted” trials with T-piece or low PSV; NIV?For 2 and 3: search for factors impeding weaning.
