Patients In Prolonged Weaning Research Articles

Diaphragm ultrasound in patients with prolonged weaning from mechanical ventilation.

Several publications have examined diaphragmatic ultrasound using two-dimensional (2D) parameters in the context of weaning from mechanical ventilation (MV) and extubation. However, the studied cohorts had rather short duration of ventilation. Examinations on patients with prolonged weaning after long-term ventilation were missing. It was the aim of this study to assess of the diaphragm and peripheral musculature of patients undergoing prolonged weaning creating a chronological sequence of ultrasonic parameters during the course of weaning. This study was carried out as a monocentric, prospective observational cross-sectional study. Patients in prolonged weaning who were transferred to a specialized weaning unit were eligible for inclusion if they were ventilated invasively by means of an endotracheal tube or tracheal cannula and if their expected treatment period was at least 5 days. Diaphragmatic function and one representative peripheral muscle were examined in 50 patients between March 2020 and April 2021. The 2D sonographic parameters of diaphragm and diaphragmatic function consisted of diaphragmatic thickness (Tdi) at the end of inspiration and expiration, the fractional thickening (FT) and the diaphragmatic excursion. Additionally, the M. quadriceps femoris was sonographically assessed at two locations. The difference of measurements between the first and the last measuring timepoint were examined using the Wilcoxon signed-rank test. For a longer chronological sequence, the Friedman's rank sum test with subsequent Wilcoxon-Nemenyi-McDonald-Thompson test for multiple comparisons was carried out. Fifty patients with prolonged weaning were included. The median duration of MV before transfer to the weaning unit was 11.5 [interquartile range (IQR) 10] days. Forty-one patients could be assessed over the full course of weaning, with 38 successfully weaned. Within these 41 patients, the sonographic parameters of the diaphragm slightly increased over the course of weaning indicating an increase in thickness and mobility. Especially parameters which represented an active movement reached statistical significance, i.e., inspiratory Tdi when assessed under spontaneous breathing [begin 3.41 (0.99) vs. end 3.43 (1.31) mm; P=0.01] and diaphragmatic excursion [begin 0.7 (0.8) vs. end 0.9 (0.6) cm; P=0.01]. The presence of positive end-expiratory pressure (PEEP) and pressure support did not influence the sonographic parameters significantly. The M. quadriceps femoris, in contrast, decreased slightly but constantly over the time [lower third: begin 1.36 (0.48) vs. end 1.28 (0.36) cm; P=0.054]. The present study is the first one to longitudinally analyse diaphragmatic ultrasound in patients with prolonged weaning. Sonographic assessment showed that Tdi and excursion increased over the course of prolonged weaning, while the diameter of a representative peripheral muscle decreased. However, the changes are rather small, and data show a wide dispersion. To allow a potential, standardized use of diaphragm ultrasound for diagnostic decision support in prolonged weaning, further studies in this specific patient group are required.

Effects of structured protocolized physical therapy on the duration of mechanical ventilation in patients with prolonged weaning

Purpose20% of patients with mechanical ventilation (MV) have a prolonged, complex weaning process, often experiencing a condition of ICU-acquired weakness (ICUAW), with a severe decrease in muscle function and restricted long-term prognosis. We aimed to analyze a protocolized, systematic approach of physiotherapy in prolonged weaning patients and hypothesized that the duration of weaning from MV would be shortened. MethodsICU patients with prolonged weaning were included before (group 1) and after (group 2) introduction of a quality control measure of a structured and protocolized physiotherapy program. Primary endpoint was the tested dynamometric handgrip strength and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). Secondary endpoints were weaning success rate, ventilator-free days, hospital mortality, the prevalence of ICUAW, infections and delirium. Results106 patients were included. Both the SOMS and the handgrip test were significantly improved after introducing the program. Despite no differences in weaning success rates at discharge, the total length of MV was significantly shorter in group 2, which also had lower prevalence of infection and higher probability of survival. ConclusionsProtocolized, systematic physiotherapy resulted in an improvement of the clinical outcome in patients with prolonged weaning. Results were objectifiable with the SOMS and the handgrip test.

Outcomes after Prolonged Weaning in Chronic Obstructive Pulmonary Disease Patients: Data from the German WeanNet Initiative

Background: The outcome of prolonged weaning in COPD patients is still unclear. Methods: A subgroup analysis of 2,937 COPD patients (median: age 69 years, 5 comorbidities, 43% female) from the entire WeanNet cohort of specialized German weaning centers previously published (N = 11,424) was performed. Results: Weaning outcomes were as follows: successful weaning without subsequent long-term noninvasive ventilation (NIV): N = 900; 30.6%; successful weaning with subsequent long-term NIV: N = 900; 30.6%; weaning failure with subsequent long-term invasive ventilation: N = 780; 26.6%; and death: N = 357; 12.2%. Most important predictors of mortality and weaning failure were advanced age and duration of mechanical ventilation in the transferring ICU, respectively. On discharge, the tracheostoma was closed in only 53% and 59% of patients with successful weaning not receiving and receiving long-term NIV, respectively. Unsuccessfully weaned patients were predominantly discharged home (20.5%) or to long-term care facilities (57.2%). Successfully weaned patients were predominantly discharged home (22.4%/35.9%: without/with NIV) and to rehabilitation (41.0%/43.1%: without/with NIV), respectively. Conclusion: COPD forms an important subgroup of prolonged weaning patients. Following transfer from the ICU to a specialized weaning center, weaning is successful more than 60%. Importantly, both tracheostomy status and initial destination following discharge are highly dependent on the weaning outcome.

WeanNet: The Network of Respiratory Weaning Centers

Invasive ventilation via endotracheal tube as access to the airways often is treatment of choice of acute respiratory failure. Multifactor-related increases the number of patients who are dependent on the ventilator for a longer period. The prolonged weaning (or "liberation") from mechanical ventilation therefore has an increasing importance.In Germany since the 90s of the last century, weaning units have been established in lung clinics. With the aim of achieving the highest possible quality of treatment in these weaning centers, the network "WeanNet" was founded in 2007 within the German Society of Pneumology and Respiratory Medicine (DGP). The structure, process and result quality of the weaning centers is reviewed as part of a certification process. By October 2018, 53 weaning centers had been certified.Important statements and recommendations on treatment strategies in prolonged weaning were published in 2014 in the sK2 guideline "Prolonged Weaning" under the leadership of DGP.In 2016, the WeanNet Study Group published data on the outcome of 6899 prolonged weaning patients from the WeanNet registry. The majority of patients (62 %) were successfully weaned from the respirator. Non-invasive ventilation after prolonged weaning was required in approximately 19 % of patients caused by chronic ventilatory insufficiency.Due to the increasing number of patients and the associated challenges in the field of intra- and ex-hospital respiratory medicine, "WeanNet" is available to the healthcare sector as a future-oriented discussion partner.

Impact of multidrug-resistant bacteria on outcome in patients with prolonged weaning

BackgroundPneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown.MethodsPatients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation.ResultsOf 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p < 0.05). Mortality rate on the weaning unit was 12.4% with no difference between the two patient groups. There were no significant differences between patient groups in secondary infections and ventilator-free days.ConclusionsIn patients with pneumonia or septic pneumonic shock undergoing prolonged weaning, infection with MDR bacteria may influence the weaning success rate but does not appear to impact on patient survival.

Monitoring of Electrical Activity of the Diaphragm Shows Failure of T-Piece Trial Earlier than Protocol-Based Parameters in Prolonged Weaning in Non-communicative Neurological Patients.

The weaning target in tracheotomised patients is not extubation, but spontaneous breathing without the support of a ventilator. Overloading the respiratory pump during such spontaneous breathing trials is unfavorable, prolongs weaning time, and increases morbidity and mortality. The goal of this study was to evaluate the electrical activity of the diaphragm during a t-piece trial in non-communicative neurological patients and the comparison to clinical parameters of exhaustion. During multiple t-piece trials, the electrical activity of the diaphragm was obtained before, during and after the end of the trial. T-piece trials were grouped based on the reason for stopping the trial (exhaustion or allotted time period). Twenty-nine tracheotomised patients in prolonged weaning (29±22days ventilated at the start of the study) were included in a prospective observational study. T-piece trials (n=152; 5±2 per patient) were grouped based on the reason for stopping the trial (n=91 because of exhaustion; n=61 because of the allotted time period). We found that the electrical activity of the diaphragm exhibits an earlier increase than protocol-based clinical parameters in patients who failed the trial due to exhaustion. The electrical activity of the diaphragm shows no relevant difference during the t-piece trial in patients in whom the trial was stopped due to the allotted time period per protocol. Monitoring the electrical activity of the diaphragm in non-communicative neurological patients in prolonged weaning allows earlier detection of exhaustion than protocol-based parameters.

Differences between prolonged weaning patients from medical and surgical intensive care units

It is not clear whether patients entering a specialized, interdisciplinary weaning unit from surgical or medical intensive care units (ICU) distinguish substantially. The purpose of the present study was to assess differences in patients with prolonged weaning being referred from surgical and medical ICU. Data collected from April 2013 to April 2014 was conducted for retrospective analysis. Mortality rates, demographic data, clinical, and microbial differences in 150 patients with prolonged weaning were assessed (80 surgical and 70 medical). Surgical ICU referrals tended to be older (70.7 ± 11.3 vs. 67.3 ± 12.3, P = 0.051) and had fewer underlying pulmonary diseases (45% vs. 60%, P = 0.067). Sodium values at the time of referral to the weaning unit were significantly higher in surgical (147.1 ± 9.6) vs. medical (141.3 ± 6.7 mmol/l) patients (P < 0.001). Each 10-unit increase in sodium at the time of referral to the weaning unit was associated with a 2.5-day (95% CI -0.4, 5.4; P = 0.09) prolongation of stay in the weaning unit. Although significant differences in microbiological agents from tracheal aspiration were seen, the infection rate on the weaning unit was similar in both groups. There was no difference in weaning unit mortality between surgical and medical ICU patients (18% vs. 23%; P = 0.41). Few differences were found between patients being referred to a specialized weaning unit from surgical vs. medical ICUs. Besides differences in microbiological characteristics of tracheal secretions, there were also differences in sodium levels, which appear to influence on treatment duration.

Timed Inspiratory Effort Index, a New Diagnostic Method to Assess Endurance and Inspiratory Muscle Strength in Patients under Mechanical Ventilation

Introduction: Mechanical ventilation is a critical component of modern intensive care medicine, but the process of discontinuing mechanical ventilation could be difficult in some cases. Several studies demonstrated that the combination of diaphragmatic inactivity and mechanical ventilation periods over than 18 hours is associated with atrophy of human diaphragm myofibers. Thus, the disuse atrophy of human diaphragm myofibers could be a major contributor for weaning failures. Indeed, its proper assessment of the respiratory muscle impairment depends on the use of appropriate tests. The predicting weaning indexes are still the most commonly used tests in clinical practice at ICUs around the world, because they are more widely known and easy to use in different diseases. Objective: The aim of the present article is to describe advantages, procedures, and clinical applicability of a new method called timed inspiratory effort index, or TIE index, to assess inspiratory muscle strength and specifically address the diagnosis of muscle fatigue in patients under mechanical ventilation. Methods: This short review about a new method to assess endurance and inspiratory muscle strength of patients with respiratory weakness and undergoing weaning from mechanical ventilation. Main recommendations: The analysis of respiratory muscle function through the TIE method translates a new feature to the intensive care fast, easy, accurate, reproducible and secure. In addition, to aid in the differential diagnosis of respiratory muscle fatigue directly predict weaning, may lead the most appropriate respiratory muscle training in prolonged weaning patients. Conclusion: In summary, nowadays, the TIE index can be considered one of the most appropriate methods to evaluate the various interactions in a critical patient under mechanical ventilation. Therefore, TIE index performance as a weaning predictor is among the best rates ever reported in literature.

A CASE SERIES OF A PAV+ WEANING PROTOCOL IN AN ACUTE CARE ENVIRONMENT DEMONSTRATING AN ABSENCE OF WEANING FAILURE

Most patients undergoing mechanical ventilation (MV) in critical care units are liberated from the ventilator within a median of 7 days. Unfortunately, some patients experience difficulty in liberation from MV during their ICU stays and require extended time on MV. It has been estimated that 40% of the patient's duration on the ventilator is spent weaning.[1] Moreover, although patients requiring prolonged mechanical ventilation represent approximately 6% of all ventilated patients, they consume 37% of intensive care unit resources.[2] Therefore, accelerating the liberation of prolonged weaning patients from MV improves patient care and could yield significant economic benefits.

What Are the Implications of Blunted Load Compensation Responses in Prolonged-Weaning Patients?

Removal of patients from mechanical ventilation can be classified into 3 categories: simple-weaning, comprising the majority of patients, who can be extubated without difficulty on the first spontaneous breathing trial (SBT); difficult-weaning, defined as requiring up to 3 SBTs or as many as 7 days

Respiratorentwöhnung – Definition und klinischer Kontext aus Sicht der Anästhesie

Independent from the mode of mechanical ventilation, particularly a quick termination of mechanical ventilation is essential for the weaning progress. Respirator-associated complications need to be early detected and treated. Thus it is important to know correspondent pathomechanisms as they have a crucial influence on the weaning process.To facilitate a holistic treatment approach for patients in prolonged weaning, a tight junction of intensive care within specialized units seems mandatory.

Comparison of Sleep Quality With Mechanical Versus Spontaneous Ventilation During Weaning of Critically Ill Tracheostomized Patients*

In mechanically ventilated patients under mechanical ventilation in the ICU, ventilatory mode or settings may influence sleep quality. The aim of this study was to evaluate the direct impact of mechanical ventilation per se on sleep quantity and quality in patients who were able to tolerate separation from mechanical ventilation over prolonged periods. Randomized crossover clinical trial in a medical ICU. Sixteen conscious patients, free of sedation and tracheostomized because of prolonged weaning from mechanical ventilation, were included in the study when able to tolerate at least 5 hours of spontaneous ventilation. Patients were randomized to receive either spontaneous ventilation or mechanical ventilation at low levels of pressure support for two crossover periods of 5-hour duration each, from 22:00 to 08:00. Polysomnography was performed throughout the study. Total sleep time was higher during mechanical ventilation than during spontaneous ventilation (183 min vs 132 min, p = 0.04). No significant differences between mechanical ventilation and spontaneous ventilation were observed in slow wave sleep time (45 min vs 28 min), rapid eye movement sleep time (11 min vs 3 min), or the fragmentation index (25 vs 23 arousals and awakenings per hr). In four patients, however, our analysis of patient-ventilator interaction suggested that the ventilatory settings were suboptimal and could have been improved to potentially improve sleep. In difficult-to-wean tracheostomized patients, sleep quality was similar with or without the ventilator. Sleep quantity was higher during mechanical ventilation. Reconnection to the ventilator during the night period may favor sleep efficiency in tracheostomized patients in prolonged weaning.