Have we really come that far since the days of Negative Pressure Ventilation?

Prolonged Mechanical
Ventilation
Weaning Strategies in the ICU

When is MV Prolonged?

Numerous Definitions
NAMDRC Consensus Statement
>21 consecutive days for >6 h/d
(recommendation #1)
Estimated 5% of MV patients will require PMV
(Pierson et al.)
But, nearly 34% of patients intubated for >48
hours will require extended intubations

Patient Type

Older
Comorbid Conditions
Underlying Obstructive Lung Disease

Ventilator Dependence

Systemic
Chronic comorbid conditions
Chronic Hypercapnia
Organ Failure (Renal failure especially can
dramatically increase the mortality rate)
Mechanics
Increased Work of Breathing
Decreased Respiratory Muscle Capacity
Intrinsic PEEP
Airway Patency (eg. tracheal stenosis)
Iatrogenic
Unrecognized withdrawal potential
Inappropriate vent settings
MEDS (Suppress drive and muscle weakness)
Long-term hospital stay
Infection (VAP, Sepsis/SIRSdecrease O2 uptake)
Recurrent Aspiration
DVT
Psych
Sedation
Depression
Anxiety

Dependence/Failure to Wean

Additional Features
Cardiovascular Function
Ischemia
Heart Failure

Metabolic Derangements

Hypophosphatemia
Hypocalcemia
Hypomagnesemia
Hypothyroidism (severe)

Nutrition
Poorprotein catabolism
Overfeedingexcess CO2

Deconditioning

Complications of PMV

Infection

Bacterial Pneumonia
Line sepsis
C. Diff

Volume Overload
Laryngeal Edema
Pneumothorax
Tracheal Bleeding
Renal Failure
Ileus
GI Bleeding
DVT
Additional Complications if Tracheostomy is necessary

Weaning

Start as soon as possible

Success depends generally on
1)
2)
3)

Strength of Respiratory muscles

Load Applied
Drive to Breath

Has the problem which led to intubation been

resolved? Is there a new problem?
Identify those factors contributing to
dependence that are potentially reversible
(NAMDRC Rec #4)
Sedative-based depression of respiratory drive
can lead to inappropriately prolonged
dependence on MV

Initiate Weaning

When there is:

1. Adequate Oxygenation
A) PaO2/FiO2 >150-200
B) Vent Settings: PEEP <8 and FiO2 <0.5

2.
3.
4.
5.

pH >7.25
Hemodynamic stablility
Ability to Initiate an Inspiratory Effort
Sedation (esp. with resp-depressing
drugs) has itself been weaned

Predicting Success

A number of criteria have been

proposed
Vital Capacity
Tidal Volume (using a cutoff of 4 mL/Kg)

PPV 0.67, NPV 0.85

PaO2/FiO2
Max Insp. Pressure
RR/VT (Rapid Shallow Breathing Index)

RSBI

First described by Yang and Tobin in

1991
Simply the f/VT
Observation that those who fail
weaning trials decrease their tidal
volumes and increase their rate
Threshold <105
PPV: 0.78 and NPV: 0.95

In PMV

Even with these indices predicting weaning

success in this population is difficult.
Some attempts have been made

Success has been correlated with number of

comorbid diagnoses as well as length of MV
Scheinhorn et al used A-a gradient, gender, and BUN
(recognizing the increased mortality when renal
failure was involved) to attempt to score the
likelihood of successful weaning. Unfortunately this
has shown limited success in repeat studies.

Additionally, the up and coming use of

post-ICU weaning facilities has improved
weaning outcome.

Methods of Weaning

Synchronized Intermittent Mandatory

Ventilation (SIMV)
Pressure Support Ventilation (PSV)
SBT

No Support
CPAP
PS

NB: These methods are the same used with acute patients.
The important difference is PMV patients generally require a
more gradual weaning course

SIMV

Breaths are either spontaneous (+/- pressure support) or

mandatory vent-controlled. Mandatory breaths are synchronized
with patients own efforts
Allows for a gradual decrease in ventilator-provided support and a
gradual increase in the patients respiratory workload

Rate is Reduced Progressively (2 breaths every 1-2 hours)

Blood gasses are checked
Patient is monitored for ability to accept increased work of breathing (HR,
RR, Sats, clinical signs)

But, studies have shown that respiratory muscles are unable to

rest during the mandatory ventilator breaths (the respiratory
center fails to adapt to the intermittent support).
Can delay weaning by contributing to the development of
respiratory muscle fatigue and therefore can delay extubation

Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical
ventilation. Spanish lung failure collaborative group. N Engl J Med 1995; 332:345-350

Pressure Support Ventilation

All breaths are spontaneous. But when PS is high

relative to patient effort, support is almost fully
from MV
Enough PS is given with each breath to ensure an
adequate VT.
Method

Gradually decrease the amount of PS (transferring the work

to the patient)
Once PS approaches 5-6 cmH2O extubation can be
considered

Reduces the work of breathing

Can be used in conjunction with SIMV during
weaning
Reduces the likelihood of reintubation but was
shown to be only slightly better than SIMV in
duration of weaning

SBTSink or Swim

Applications

Extubation readinessa 90 minute test (though at

least one studyEsteban et alsuggested that only
30 min may be necessary)
Weaning
Length of SBT is increased daily
Periods of ventilation are alternated with these trials
T-piece Trials
Requires removing patient from vent and providing
supplemental humidified O2 to their airway
(through a tube that looks like a T.)
These trials can also now be done with the patient
still directly connected to the vent which allows
closer observation (and all the bells and whistles
that the vent provides)

Types of SBTs
1.
2.
3.

No Vent Support
Low level of CPAPclosing pressure
Low Level of PSairway resistance
No controlled studies have demonstrated superiority of any of these
modes. However, in certain patient populations such as those with marginal
left ventricular function, a low level of CPAP and the subsequent increase in
intrathoracic pressure can help prevent heart failure. But, its removal, may
lead to acute heart failure following extubation secondary to increased LV
preload and LVEDP

Trial

30-90 minutes
Once daily

Following each SBT evaluate for possible

extubation

A number of studies have demonstrated equivalent results

between multiple daily tests and once daily tests

BP, RR, HR, ABG should all be considered

Level of sedation

SBTs are superior to both IMV and PS in duration

of weaning and likelihood of success after
weaning
In patients on PMV, daily trials may be required
for a longer period of time.

Seminal Study (Esteban et al)

546 Patients

All underwent a 2-hr SBT to evaluate for

extubation

130 had respiratory distress during the SBT

and were not extubated
These pts were randomized to 1 of 4 groups
SIMVinitial rate of 10.0 breaths per minute, then
decreased at least twice a day, by 2 to 4 bpm (29)
PSVinitially set at 18.0 cm H2O then reduced by 2 to 4
cm H2O at least twice a day (37)
Once a day SBT (31)
Multiple daily SBTs (33)

Conclusion

A once-daily SBT led to extubation

about three times more quickly than
IMV and about twice as quickly as
PSV. Multiple daily SBTs were equally
successful.

Weaning Protocol

Improve overall outcome

Example:

1.

Is patient is a candidate for weaning?

2.

Screen for readinessRSB Trial

3.

Ensure intact airway reflexes

4.

Patient can now be subject to SBTs

5.

SBT can be terminated if patient:

i) PaO2 > 60mmHg

ii) FiO2 <0.5
iii) PEEP < 8 cm H2O
i)

SBT for one minute to calculate RSBI

i)

Coughing during suctioning

i) PS, CPAP, or T-piece

ii) Up to 120 minutes

i) Successfully tolerates the SBT from 30-120 minutes

ii) Shows s/sx of failure

Weaning Failure

HR >140 bpm or a sustained increase of

>20%
RR >35 breaths/min for >5 min
O2 Sats <90% for >30s
HR with a sustained decrease of >20%
SBP>180 for > 5 min
SBP<90 for > 5 min
Clinical features: Anxiety, agitation,
diaphoresis

NB: May not be due to weaning failure and should be

treated appropriately

Problems with Failure

Failing can put significant stress on

the respiratory system
Inspiratory effort can increase 4-6
times following a failed SBT (Jubran
et al.)

Who should run the Trial?

Protocols are driven by RT and/or nurses

Studies have shown that protocol-driven
weaning by these individuals is superior to
independent physician-directed weaning
(Horst et al.)
Sending PMV patients to institutions
dedicated specifically to weaning improves
outcomes (ie, Long-Term Assisted Care
facilities)

The Future

Automatic Tube Compensation

Proportional-Assist Ventilation

Compensates for pressure drop across ET tube

Delivers the exact amount of pressure to overcome the
resistive load of the tube given the flow across the tube
measured at that instant (variable pressure support)
Studies by Cohen and others have demonstrated that ATC
improves weaning outcome compared to PSV and CPAP
No studies as of yet have compared ATC vs. T-piece
Ventilator adjusts airway pressure in proportion to patients
instantaneous effort. This occurs from breath-to-breath and
continuously through each inspiration
No set tidal volume, pressure, or flow rate.
The patients work of breathing remains constant despite
changing effort or demand

Computer-Driven Protocols

Using knowledge-based algorithms

Decreased MV duration from 12 to 7.5 days in a recent trial
(Lellouche et al.)

Used automatic gradual reduction in pressure support

Automatic Performance of SBTs

Outcomes in PMV Patients

Population is very diverse

Results are therefore difficult to generalize
For example, patients who require PMV postoperatively generally do significantly better than
patients with COPD

LTAC facilities
Scheinhorn et al.(2007) Large,
multicenter trial evaluating outcomes in
post-ICU PMV patients at 23 LTAC
facilities.

Scheinhorn et al (2007)

1,419 patients
23 sites from 3/2002-2/2003
Excluded: End-of-life care; terminal
weaning, or considered incapable of
weaning at the time of admission
One-Year Mortality: 52%

25% died in the weaning hospital

27% died after discharge

Survival to Discharge: 67%

Cost: $3968/day

References

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prediction of weaning outcome. Chest 2002. 122:980-4
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Eskanadar N, Apostolakos M.Weaning from mechanical ventilation.Crit Care Clin(2007) 23:263-274

Esteban A, Alia I, Gordo F. Weaning: what the recent studies have shown us. Clin Pulm Med 1996, 3:91-100

Esteban E, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue
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Scheinhom DJ, Artinian BM, Catlin JL et al. Weaning from prolonged mechanical ventilation. The experience at a
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