Weaning from Mechanical ventilation

Assessment and comparison of available methods Dr. Alok Nath Senior Resident Department of Pulmonary Medicine PGIMER Chandigarh

Introduction
Processofabruptlyorgraduallywithdrawing ventilatory support

Discontinuationof mechanical ventilation

Removalof artificial Airway

Double edged sword !!

Unnecessary delays in this discontinuation process increase the complication rate from mechanical ventilation (eg, pneumonia, airway trauma) as well as the cost Premature discontinuation carries its own set of problems, including difficulty in reestablishing artificial airways and compromised gas exchange

Double edged sword !!

On an average 42% of the time that a medical patient spends on a mechanical ventilator is during the discontinuation process Up to 20% of patients experience difficulty in the process of weaning

Reasons for ventilator dependence

Neurologic issues Respiratory system muscle/load interactions Metabolic factors and ventilatory muscle function Gas exchange factors Cardiovascular factors Psychological factors

Is the patient ready for weaning ?

Numerous trials performed to develop criteria for success weaning, however, not useful to predict when to begin the weaning Physicians must rely on clinical judgment Consider when the reason for IPPV is stabilized and the patient is improving and haemodynamically stable Daily screening may reduce the duration of MV and ICU cost

Essentials to begin weaning

Patient parameters
Awake, alert and cooperative Haemodynamically stable RR < 30/min No effect of sedation/neuromuscular blockade Minimal secretions Nutritional status good
BurtonGG Respir Care1997,CarusoP1999Chest Girault C.1994 Monaldi ArchChest Dis, TobinMJ.1990 EurRespir J, YangKL.1991N Engl JMed

Essentials to begin weaning

Ventilator parameters
Spontaneous TV > 5 - 8 ml/kg , VC > 10 - 15 ml/kg , PEEP requirement < 5 mm of H2O Static compliance > 30 ml/mm of H2O MV < 10 L VD/VT < 60 %
BurtonGG Respir Care1997,CarusoP1999Chest Girault C.1994 Monaldi ArchChest Dis, TobinMJ.1990 EurRespir J, YangKL.1991N Engl JMed

Essentials to begin weaning

Oxygenationcriteria
PaCO2 <50mmofHgwithNormalpH PaO2 >60@FiO2 0.4orless SaO2 >90%@FiO2 0.4orless PaO2/FiO2 >200 Qs/QT <20% P(Aa)O2<350mmofHg@FiO2of1.0
Noneofthevariablesdemonstratemore thanmodestaccuracyinpredictingweaningoutcome
BurtonGG Respir Care1997,CarusoP1999Chest Girault C.1994 Monaldi ArchChest Dis, TobinMJ.1990 EurRespir J, YangKL.1991N Engl JMed

Combined indices
RSBI = Respiratory frequency/ Tidal volume

SWI =

f mv(PIP- PEEP) MIP

PaCO2 mv 40

CROP index =

[CDYN x MIP x PaO2/PAO2]

Predicting success !!
Rapid shallow breathing index Several studies have demonstrated that the rapid shallow breathing index (f/VT) is superior to conventional parameters in predicting the outcome of weaning
Chatila WAmJMed1996,JacobB Crit CareMed1997,KriegerBP,Chest1997

Inarecentrandomized,blindedcontrolledtrial304 patientsadmittedtointensivecareunitswereenrolled andRSBIwastakenasamajorweaningpredictor

Predicting success !!
Themediandurationforweaningtimewas significantlyshorterinthegroupwheretheweaningpredictor wasnotused(2.0vs.3.0days,p=0.04).Therewasnodifference withregardtothe extubation failure,inhospitalmortalityrate, tracheostomy,orunplanned extubation.
Crit CareMed2006;34:25302535

Inarecentstudyincluding900patients extubation failure occurredin121(13.4%)

Predicting success !!
Amongroutinelymeasuredclinicalvariables,RSBI,positive fluidbalance24hpriorto extubation,andpneumoniaatthe initiationofventilationwerethebestpredictorsof extubation failure
ButthethresholdforRSBIwaslower(>57)ascomparedto previouslyusedvalueof>100
Chest2006;130:16641671

Thedirectionandmagnitudeofthechangefrompretest toposttestprobabilityaredeterminedbythe likelihoodratio

Can we predict weaning success?

Inastudyby Jabour etalSWI<9/minhad93%predictionfora successfulweaningattemptandifSWI>11/mintherewas95%probability ofweaningfailure
AmRev RespisDis 1991;144:531537

ACROPindex>13ml/breaths/minwasapredictorof weaningsuccessinastudybyYang etal

N Engl JMed.1991;324:1445 1450

Thedecisiontousethesecriteriamustbeindividualized

Issues to be addressed
Gradual vs. sudden? Which mode to be used for weaning? Are newer modes useful for weaning? Is protocol driven weaning better? Is computer directed weaning better?

Gradual vs. sudden weaning?

No data available Most trials have used sudden weaning using Spontaneous breathing trial with T-piece, PSV or CPAP However if a patient fails recurrent weaning attempts gradual weaning strategy is advocated
Respir Care2002;47:6990

Available modes of weaning

CONVENTIONAL MODES

Spontaneous breathing trials Pressure support ventilation SIMV SIMV + PSV

NEWER MODES Automatic tube compensation Adaptive support ventilation Auto-mode ventilation Airway pressure release ventilation Volume assured pressure support Proportional assist ventilation Non invasive positive pressure ventilation

Spontaneous breathing trials

Two large randomized trials comparing SBT with other modalities
Estebanetalcompared2htrialsofunassistedbreathing usingPSof7cmH2O vs aTpiece

AsmallerproportionofpatientsinthePSgroup(14%) failedtotoleratetheweaningandtoachieve extubation attheendofthe2htrialthanintheTpiece Reintubation ratesweresimilar

Spontaneous breathing trials

Second study by same authors
Compareda30mintoa120minTpiecetrial

Noreporteddifferenceintherateofreintubation betweengroupspatientswhowererandomized ShorterTpiecetrialbenefitedfromstatistically significantreductionsinICUandhospitallengthsofstay (2daysand5daysshorter,respectively)

Spontaneous breathing trials

Various other trials small sample size
Analysisofpooleddataacrosstwostudiesthenumberofeventswasso lowthatthe95% CIs wereextremelywide (relativeriskfor nonextubation inCPAP vs Tpiecebreathing,1.66 [95%CI,0.60to4.64];relativeriskfor reintubation,1.61[95%CI, 0.39to6.59])

MeadeMChest2001;120:425S437S

Stepwise reduction
SIMV/PSVandT piecetrials

Five randomized controlled trials (RCTs) compared alternative methods of reducing ventilatory support in patients in whom clinicians thought that extubation was still several days away
Twostudiescomparedmultipledaily Tpiecebreathing;PS;andSIMV
EstebanA.N Engl JMed1995, Brochard L.AmJ RespirCrit CareMed1994

Stepwise reduction
Studydesignwasalmostsimilarinboththe studies
IncomparisonofTpiecebreathingtoPS,thepooledresults showednodifferenceinthedurationofventilation,the trendsgoinginoppositedirectionsinthetwostudies TheresultsofthetrialbyEstebanetalfavored weaningwithTpiecebreathing,andthoseofthetrialby BrochardetalfavoredPS

Stepwise reduction
In the comparison of T-piece breathing to SIMV, the two trials showed similar trends in favor of T-piece in the duration of ventilation InthecomparisonofPStoSIMVonthedurationof weaning,bothstudiesfoundtrendsinfavorofPS,although theeffectinthestudyby Brochard etalwas muchlarger

Stepwise reduction
Recent randomized prospective study including 260 patients who received mechanical ventilation for more than 48 h
Totallengthofadditionalmechanicalventilationandtotallength ofstayatICU significantlyshorterinpatientsundergoingPSV weaning ForthepatientswithweaningdifficultiesandAPACHEII score>20onadmission,PSVwasthesuperior
CMJ2004;45;162166

Stepwise reduction
Anotherstudy 19patientsrandomizedtoSIMVwith PS vs SIMVwithoutPS Thedurationoftheweaningprocesswas approximately1dayshorterinthegroupthatreceived PS,withthelowerboundaryofthe95%CIbeing approximately7h
TwopatientsintheSIMVgroup,andnoneinthegroup thatalsoreceivedPS,required reintubation
JounieauxV.Chest1994

Discussion
PooreroutcomewithSIMVingeneral!!

Designed to provide respiratory muscle rest during mandatory breaths and exercise during intervening breaths
Mainreasonforpooroutcomeswiththismodeisthatactually respiratorymusclesneverrest

Discussion
Hugediscrepancyinresultsofvarioustrials
Estebanandcolleaguesfoundthat22%of246patientsfailedaTpiece weaningtrial,andofthe192whowere extubated,19%required reintubation.Incontrast,Jonesandcoworkersreportedthatonly4%of 52patientsundergoingweaningwithTpiecebreathingwerenot extubated,andofthose extubated,only4%of50patientsrequired reintubation Thesediscrepanciessuggestthatinvestigatorsareusingquite differentcriteriawhenjudgingwhetherapatientisreadyfora trialofspontaneousbreathingandforjudgingwhenthetrialis a successand extubation isappropriate

Discussion
ThemeandurationofweaningintheTpiecebreathinggroup inthetrialby Brochard etalwas8.5days,andinthestudyby Estebanetal,3days Majorfocusofjudgmentmaybeissuesofpatient selectionandthejudgmentastowhentheweaning processbegins
EstebanA.N Engl JMed1995, Brochard L.AmJ RespirCrit CareMed1994

Discussion
Resultsoftwostudiesofweaningin48hprovidefurtherevidence thatSIMVmaybelessadvantageousthanothermethodsof decreasingmechanical ventilatory support. However,thesetrialscomparedparticularSIMVweaningregimens. OtherweaningregimensusingSIMVmayproducedifferentresults. Jounieaux etalofSIMVandPS vs SIMVsuggeststhesuperiorityof aregimenthatincludesPS Studyprovidesverylittleinformationabouttheeffectson outcomesof nonextubation or reintubation becauseofsmallsamplesize andlownumberofevents
JounieauxV.Chest1994

Discussion
Systemicreviewcomparingvariouspopularweaningmodes

Asuperiorweaningtechniqueamongthethree mostpopularmodes,Tpiece,pressuresupportventilation,or synchronizedintermittentmandatoryventilationcannotbe identified SIMVmayleadtoalongerdurationoftheweaningprocess thaneitherTpieceorPSV

Themosteffectivemodeofventilationforweaningstillneedsto bedeterminedandmoreworkisrequiredinthisarea.

Newer modes
Automode Availableon Siemens Servoventilators Combinesvolumesupport(VS)andpressureregulated volumecontrol(PRVC)intoonemode IfpatientparalyzedorapneicPressurelimitedtime cycledbreaths,withvariablepressuretoachieve desiredtidalvolume

Newer modes
After two spontaneously triggered breaths, the ventilator mode changes automatically from mandatory to spontaneous ventilation - If the patient does not continue to trigger the ventilator mode changes again automatically from spontaneous to mandatory Timeto extubation was2hshorterinpatientsassignedto automode ventilation(n=10)comparedtopatientsassigned toconventionalventilation(n=10)
Eur J CardiothoracSurg 2006;29:957963

Newer modes
AutomaticTubeCompensation
Continuous calculation of Ptrach using

Compensation for tube resistance by closed loop control of calculated Ptrach Resultsindecreaseinworkofinspiration Reductionof Rexp and PEEPi

Known resistive component of ET tube Measurement of flow

Newer modes
Comparision of Tp,PSVandorATC
Among all 90 patients (30 per group) no significant differences between the modes was observed. Twelve patients failed the initial weaning trial. Half of the patients who appeared to fail the spontaneous breathing trial on the T-tube, PSV, or both, were successfully extubated after a succeeding trial with ATC

ATCcanbeusedasanalternativemodeduringthefinal phaseofweaningfrommechanicalventilation
Haberthr C.ActaAnaesthesiolScand2002;46:973979

Newer modes
In a recent study, more patients in the ATC group underwent successful extubation (ATC, 42/51, vs. CPAP, 31/48; p < 0.04)
TheabsoluteriskreductioninfavorofATCof17.7%(95% confidenceinterval,0.6735%)andaNNTofsix
Crit CareMed2006;34:682686

Newer modes
Airway Pressure Release Ventilation (BIPAP/VPAP)
Partialsupportmode SomewhatsimilartoPCIRV Interspersedlong(moderatelyhigh)airwaypressureandshort deflationperiods unassistedbreathingduringbothperiods Progressivelower Ppeak

ProportionalAssistVentilation
Adjustsairwaypressureinproportiontopatienteffort Unlikeothermodes,amountofsupportchangeswithlevel ofpatienteffort Betterpatientventilatorsynchrony

Newer modes
Positivefeedbackcontrollerinwhichrespiratory elastance andresistancearethefeedbacksignal TypicallyPAVmust besetto~80%ofpatients elastance andresistance

Estimationofrespiratoryresistanceand elastance Temporalfluctuationinthesevalues(RUNAWAY) Limitedphysicianexperience

Newer modes
Adaptivesupportventilation
Dualcontrolbreathtobreathtimecycledandflowcycled breathsandallowstheventilatortochoosetheinitial ventilatorsettingsbasedoncliniciansinputofIBWand percentminutevolume0

Mostsophisticatedoftheclosedlooptechniquesavailable

Newer modes
Volume Support or Variable pressure support Allbreathsarepressuresupported Closedloopcontrol,withminutevolumeastarget Breathtobreathadjustmentofpressuresupportlevelto achievesetminutevolume Benefits Automatic weaning of pressure limit when patient effort or lung compliance improves Guaranteed minute ventilation

Newer modes
Disadvantages AutomaticincreaseinpressurelevelmayworsenautoPEEPin patientswithairflowobstruction In tachypneic patients,asnet ventilatory demandincreases, theventilatorsupportparadoxicallydecreases

Pressureregulatedvolumecontrol,APVor Autoflow
Notexactlyaweaningmode.Similartovolumesupport butusespressurelimitandisapressurecontrolmode Maintainsminimumpeakpressureandprovidesconstant settidalvolumeandautomaticweaningasthepatientimproves

Newer modes
Breathtriggered Ventilatorattemptstoreachpressuresupportlevel Microprocessormonitorsdeliveredvolume Minimumdesiredvolumecanbereached Yes Breathcontinuesasapressure supportedbreath No Flowdecreases&reachesthe setpeakflowlevel Additionalvolumedeliveredatthis constantflow,lengtheningthe inspiratorytime

VAPS

NIPPV for Weaning

In this method any patient tolerating SBT is extubated and put on non invasive ventilation All the studies have used mainly patients with chronic respiratory failure especially COPD and hence should only be used for this subgroup of patients
In a recent meta anlysis the duration of ICU stay, duration of hospitalization Occurrence of pneumonia and moratality decreased with the use of NIPPV for weaning

Protocol guided weaning

Has been compared to physician directed weaning in various trials But data sparse and conflicting
Manyofthestudieshaveshownbetteroutcomeswith protocolguidedweaning
Crit CareMed1997;25:567574,Arch Surg 1998;133:483488 Chest2000;118:459467,JTrauma2004;56:943951,JIntensiveCareMed.2004Sep Oct;19(5):27484.N Engl JMed1996Dec19;335(25):18649, AmJ Crit Care2003Sep;12(5):45460, Respir Care2001Aug;46(8):77282,1995Mar;40(3):21924

Protocol guided weaning

Proposed benefit of protocolized weaning are decrease in ventilation time and decreased cost Alsolessernumberofstaffrecruitmenthasbeen seeninthissubgroup Fewstudieshavealsodemonstratednegativeresultsin termsoflongerweaningtimes
AmJ RespirCrit CareMed2004;169:673678 Anaesthesia 2006;61:10791086, ArchSurg.2002Nov;137;11:12237

Protocol guided weaning

Resultsofprotocolguidedweaningstrategiesarelargely affectedbytheprevailingpracticesinaparticularICU

Anddifferentweaningprotocolswillresultindifferentresults soresultsof existingstudiescannotbeextrapolatedorgeneralized

MoreoverinwellequippedandstaffedICU protocolized weaning maynotberequiredatall

Computer driven weaning

In a two-center, prospective, open, clinical, pilot study in medical ICUs, 42 consecutive mechanically ventilated patients were evaluated Weaningwassuccessfulin25patientsandfailedin7; unplanned extubation occurredin1patient.Timeon computerdrivensystem(CDS)ventilationwas3 3days TheCDSdetectedweaningreadinessearlierthanthe intensivistsin17patients,and intensivists earlierthanthe CDSin4;in11patientsdetectiontimescoincided
BouadmaL.IntensiveCareMed2005;31:14461450

Computer driven weaning

144 patients were enrolled before weaning initiation - randomly allocated to computer-driven weaning (CDW, n=74) or to physician-controlled weaning (PCW, n=70)

WeaningdurationwasreducedintheCDWgroupfroma medianof5to3d(p=0.01)andtotaldurationof mechanicalventilationfrom12to7.5d(p=0.003). Reintubation ratedidnotdiffer(23vs.16%,p=0.40). CDWalsodecreasedmedianICUstaydurationfrom15.5 to12d(p=0.02)andcausednoadverseevents

Lellouche F.AmJ RespirCrit CareMed2006;174:894900

Miscellaneous interventions
Fluid balance Intensive euglycemia Composition of enteral nutrition Role of glucocorticoids Growth hormone Role of tracheostomy Oxymetry and capnography Relaxation biofeedback Acupuncture

Role of tracheostomy
Improvedpatientcomfort Moreeffectiveairwaysuctioning Decreasedairwayresistance Enhancedpatientmobility Increasedopportunitiesforarticulatedspeech Abilitytoeatorally,amoresecureairway Acceleratedweaningfrommechanicalventilation AbilitytotransferventilatordependentpatientsfromICU

Role of tracheostomy
Earlytracheotomyperformed withinthefirst7daysofmechanicalventilation decreasesthedurationofmechanicalventilation
RodriguezJL.Surgery1990;108:655659

Tracheotomyreducesthemechanicalworkload,workof breathing,andthemouthocclusionpressureat0.1safter inspiratoryeffortofventilatordependentpatients

DiehlJL.AmJ RespirCrit CareMed1999;159:383388, DavisKJr.Arch Surg 1999;134:5962

Role of tracheostomy
Earlyandlatetracheostomyhasbeencomparedinvarious studiesButhaveshownconflictingresultswithreferenceto durationofventilation,hospitalorICUstay
IncidenceofVAPhasalsobeenreportedtobelowerinthe tracheostoimsed insomestudiesbutnotinothers
Lesnik I.Am Surg 1992;58:346349 BlotF.SupportCareCancer1995;3:291296 Koh WY. Anaesth IntensiveCare1997;25:365368 DunhamMC.Trauma1984;24:120124 ElNaggar M. AnesthAnalg 1976;55:195201 Sugerman HJ.JTrauma1997;43:741747

Concluisons
Selectionofaparticularmodeshouldbedeterminedby availabilityandphysicianexperience OncedailyTpieceweaningorPSVsuperiortoSIMV Early extubation withbackupventilationofNIPPVisuseful especiallyinCOPD Roleofnewermodesunclear requiremorestudies Protocolandcomputerdirectedprotocolsmaybehelpfulin openandlessstaffedICUs

A reasonable strategy !