Use of Either Non-invasive Ventilation Immediately Post-extubation or Controlled Mechanical Ventilation for One Hour after Fulfilling Weaning Criteria Decreases Re-intubation of Patients with Post-traumatic ARDS

Mohamed Gaber Ibrahim Mostafa Allam

doi:10.2174/2589645802115010007

Abstract

Introduction: Re-intubation and re-ventilation after complete weaning of patients with prolonged ventilation are considered a major problem in ICU. The re-intubation in such patients associated with higher mortalities prolongs the duration of ICU stay. The mortality rate in those patients may exceed 40% in some studies. Aims: The study aimed to compare and evaluate the effect of use of two new maneuvers with control after fulfilling criteria of weaning from prolonged ventilation, either immediate use of NIV post-extubation and every 12 hours for 24 hours or MV for one hour on both re-intubation and ICU discharge of traumatic ARDS patients who ventilated for one week or more. Materials and Methods: It is a prospective double-blind study done on total 300 patients, admitted with respiratory failure ARDS due to severe lung contusion. All of them were selected to be ventilated for > one week. All of them fulfilled the criteria of weaning at the end of the studied period. Patients were randomly allocated in three groups; each group contained 100 patients. Group A was considered the control group. They extubated and followed our routine protocol; patients of group B used our first new maneuver and reconnected to mechanical ventilation before extubation for one hour, while patients of group C used our second new maneuver; patients of this group extubated and immediately connected to NIV with BIPAP mode for 1 hour every 12 hours for 24 hours. Results: There was a significant reduction in the number of patients who experienced deterioration in conscious level throughout the study in patients of both groups B and C compared to group A. Also, a significant reduction was seen in the number of patients who experienced deterioration in clinical parameters of respiration, of both groups B and C compared to group A with regard to high respiratory rate, desaturation and development of hyperdynamic circulation (tachycardia and hypertension). Also, a significant reduction was seen in the number of patients who had multiple quadrant parenchymatous infiltration throughout the study in patients of both groups B and C compared to group A. significant reduction in the number of patients marked limitation to FEV1, FVC and MVV in patients of both groups B and C compared to group A. Conclusion: Use of either immediate NIV every 12 hours for 24 hours or MV for one hour after fulfillment of weaning criteria reduced reintubation, re-ventilation and post-extubation respiratory failure and decreased the ICU stay in prolonged ventilated patients due to ARDS from severe lung trauma with no significant difference between them.

Highlights

Introduction5-30% of mechanically ventilated patients who completely weaned from the ventilator and extubated require re-intubation and re-ventilation [1]
Re-intubation and re-ventilation after complete weaning of patients with prolonged ventilation are considered a major problem in ICU
A significant reduction was seen in the number of patients who experienced deterioration in clinical parameters of respiration, of both groups B and C compared to group A with regard to high respiratory rate, desaturation and development of hyperdynamic circulation

Summary

Introduction

5-30% of mechanically ventilated patients who completely weaned from the ventilator and extubated require re-intubation and re-ventilation [1] Those who ventilated for more than one week, this prolongs the duration of ICU stay and starts a vicious circle again with high morbidity and mortality. Many ventilatory maneuvers have been introduced recently to decrease the percent of reintubation and re-ventilation after full weaning and extubation, break this vicious circle and save the patients who ventilated for a long time (> 1week) from being ventilator dependent Those maneuvers include the use of either invasive or noninvasive ways of assisted ventilation for certain periods until the patient can maintain oxygenation by his/her own respiratory muscles. Besides the careful clinical assessment, with attention to underlying medical conditions and co- morbidities of those patients [5], the main causes of re-intubation in such patients should be kept in mind, which may be diaphragmatic and respiratory muscle fatigue from myopathy which developed from a prolonged time of ventilation, hidden underlying significant respiratory impairment prior to hospitalization and significant comorbidity which might be acquired in the hospital e.g.(critical illness neuropathy, and/ or upper air way problems from prolonged intubation) or previously known systemic disease e.g.(diabetes, hypertension, renal and/or liver impairment...etc.) which accelerate and aggravate the development of critical illness neuropathy and myopathy [6]

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