Weaning Center Research Articles

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Introduction: BRH is a 105-bed LTAC hospital network that serves as a regional weaning center, accepting chronically critically ill (CCI) patients transferred from the ICUs of hospitals in southern California. Herein we report updates to patient characteristics, weaning outcomes, and discharge dispo

S133 Observational cohort study of outcome of patients referred to a regional weaning centre

IntroductionData on outcome of the patients referred to weaning and rehabilitation centres are limited. In this observational cohort study, we report the outcomes of patients referred to a specialist complex...

S135 Long-term outcomes in patients referred to a specialised weaning centre; The impact of referral source, non-invasive ventilation and diagnosis

Introduction The expansion of specialised weaning centres serving networks of external ICUs has been recommended by the NHS commissioning board. However, data are limited for this proposed model of care. Papworth Hospital provides a multi-disciplinary weaning service in-line with these recommendations. Methods We analysed the records of patients transferred to our service for weaning from invasive ventilation (IMV) between 1992–2011 inclusive. Patients were categorised according to diagnosis (neuromuscular, COPD, post-surgical, non-COPD respiratory, chest-wall disorders and others). Results 458 patients receiving IMV (92% via tracheostomy) were transferred (mean age 61 years, 259 (57%) male, 421 (92%) from external ICUs with a median ICU stay of 33 days. On arrival, 422 (92%) were ventilator-dependent and 37 (8%) required nocturnal IMV. The median PaCO 2 was 10 kPa. Neuromuscular problems included Motor Neurone Disease (21%), Tetraplegia (12%), Muscular Dystrophies (11%), and Myotonic Dystrophy (9%). 417 (91%) patients survived to hospital discharge, with 330 (72%) weaned from IMV (median stay 24 days if decannulated, 37 days if IMV continued). Non-invasive ventilation (NIV) facilitated weaning in 79%. From the date of ICU admission, 63% of the whole cohort were alive at 1 year, 43% at 3 years, and 33% at 5 years. When adjusted for case-mix, survival was similar for external and in-house referrals. At least 343 (82%) survivors were discharged home. Further outcome data are summarised in Table 1. COPD patients had the lowest rate of death and/or failed decannulation (13%); further, long-term NIV was associated with a significant increase in survival (p = 0.01), despite normocapnia (5.9kPa) if completely weaned. 33% neuromuscular patients required long-term IMV, typically due to bulbar problems, although 65% were discharged home. Continued IMV in other groups conferred a very poor prognosis. Conclusions These data confirm high levels of survival and discharge home in patients referred to a specialised weaning service. Repatriation to the referring ICU was rarely necessary. NIV was important in the graded withdrawal of IMV and the provision of domiciliary care. In COPD, NIV use on discharge was associated with improved survival. Overall outcomes were favourable when compared to international data and are supportive of current national service plans.

Entwöhnung von der Langzeitbeatmung: Daten eines Weaningzentrums von 2007 bis 2011

Regional weaning centers play a more and more important role in the weaning process of long-term ventilated patients. The medical center Kloster Grafschaft is one of the oldest and largest centers in Germany. There is very little published data from larger weaning centers in Europe. From 2007 to 2011 all weaning patients were registered in a database. Additional information of the transferring hospitals was inquired. Prolonged weaning was defined by a period of at least 7 days of mechanical ventilation as well as three unsuccessful weaning trials. Data from 867 of 916 registered patients could be analyzed. 71.1% could be successfully weaned from mechanical ventilation. All patients were suffering from a hypercapnic insufficiency as well as a variety of secondary diagnoses, on average 15.1 per patient. The median of age was 70 years, 62 % were male. Prior to hospital transfer patients had been ventilated for a median of 41 days. Time to successful removal of the artificial airway was 8 days according to the DRG code directive and 13.4 days when non-invasive ventilation (NIV) time was included. Of the 616 patients who could be successfully weaned, 42 % were discharged on NIV. Out of the 251 patients who could not be weaned, 107 were discharged. The remaining 144 (16.7 %) patients died, 33 % due to the primary underlying disease or a complication. 66 % of the deceased patients received palliative care. Patients with successful and unsuccessful weaning did not differ by age, by duration of mechanical ventilation or time until tracheostomy. Postoperative patients could be weaned more often than medical patients (p < 0.05). Discrimination between patients with successful and unsuccessful weaning was not possible by the point in time of the first spontaneous breathing trial in regard to the duration of ventilation but only by the duration of this trial after transfer to our unit (150 vs. 60 min; p < 10-6). The TISS-28 and the SAPS-II-Score did not differ between the two groups. Patients with successful weaning had less agitation according to the RASS-Score (0.47 vs. 0.15; p < 0.005). It becomes apparent that in a specialized weaning center the majority of difficult to wean patients can be liberated in short time from mechanical ventilation.

Respiratorentwöhnung – Definition und klinischer Kontext aus Sicht der Pneumologie

Weaning from mechanical ventilation plays a key-role in modern intensive care medicine: about 40% of all ventilated patients suffer from difficult/prolonged weaning causing about 50% of the total stay on the intensive care unit (ICU). Severe chronic airway, lung and thoracic disorders, neuromuscular diseases and morbid obesity cause respiratory muscle insufficiency and result in respiratory failure with prolonged weaning. In Germany, pneumologists have a wide ranging expertise with this patient cohort and established weaning centers over the past 25 years. This article illustrates the classification, the most important therapeutical strategies and organizational aspects when caring for patients under (long-term) mechanical ventilation from the pneumologist's perspective.

Frequency and management of respiratory incidents in invasive home ventilation

There has been a rise in the number of patients requiring long-term ventilation, both in the in-hospital and the out-of-hospital setting. Despite this, little is known about the subsequent clinical course of these patients following hospital discharge. The purpose of this study was to determine the frequency and management of respiratory incidents in patients with invasive out-of-hospital ventilation living in a nursing home allied to a weaning centre. We evaluated retrospectively the protocols that are used to monitor the patients over a period of 2months. The average time from hospital discharge was 386±330days. Of the total 17 patients, 9 (53%) patients remained free from any respiratory incidents, while the remaining 8 (47%) patients were responsible for a total of 95 respiratory incidents. Patients that suffered respiratory incidents had been ventilated at home for an average of 194days, while the others were receiving out-of-hospital ventilation for an average of 557days. Desaturation (17), dyspnoea (17) and reduced general condition (10) were the most common respiratory incidents. Also, the use of an Ambu bag (bag valve mask; 17), request for a pneumologist review (12) and replacement of the tracheal cannula (7) were the most common interventions. Respiratory incidents are common in invasive home mechanical ventilation, and so home mechanical ventilation needed to be organized safely. Being allied to a weaning centre helps to organize invasive home mechanical ventilation in a safe manner over the long-term ventilation.

P228 Referral Patterns and Outcomes For Patients Treated in a National Centre Specialising in Weaning From Invasive Mechanical Ventilation

IntroductionWith increasing evidence for the use of non-invasive ventilation (NIV) for acute COPD1, a change in referral pattern to a national weaning unit was anticipated over time. We investigated the...

Patient Characteristics and Outcomes of a Provincial Prolonged‐Ventilation Weaning Centre: A Retrospective Cohort Study

Growing numbers of critically ill patients require prolonged mechanical ventilation and experience difficulty with weaning. Specialized centres may facilitate weaning through focused interprofessional expertise with an emphasis on rehabilitation. To characterize the population of a specialized prolonged-ventilation weaning centre (PWC) in Ontario, and to report weaning, mobility, discharge and survival outcomes. Data from consecutively admitted patients were retrospectively extracted from electronic and paper medical records by research staff and verified by the primary investigator. From January 2004 to March 2011, 144 patients were admitted: 115 (80%) required ventilator weaning, and 29 (20%) required tracheostomy weaning or noninvasive ventilation. Intensive care unit length of stay before admission was a median 51 days (interquartile range [IQR] 35 to 86 days). Of the patients admitted for ventilator weaning, 76 of 115 (66% [95% CI 55% to 75%]) achieved a 24 h tracheostomy mask trial in a median of 15 days (IQR eight to 25 days). Weaning success, defined as no further ventilation for seven consecutive days, was achieved by 61 patients (53% [95% CI 44% to 62%]) in a median duration of 62 days (IQR 46 to 95 days) of ventilation, and 14 days (IQR nine to 29 days) after PWC admission. Seventeen patients died during admission. Of the 91 patients discharged from the PWC for one year, 43 (47.3% [95% CI 37.3% to 57.4%]) survived; of the 78 discharged for two years, 27 (34.6% [95% CI 25.0% to 45.7%]) were alive; of the 53 discharged for three years, 19 (35.9% [95% CI 24.3% to 49.3%]) were alive; and seven of 22 (31.8% [95% CI 16.4% to 52.7%]) survived to five years. Weaning success was moderate despite a prolonged intensive care unit stay before admission, but was comparable with studies reporting weaning outcomes from centres in other countries. Few patients survived to five years.

Frustranes Weaning: Nachsorge durch das Weaningzentrum – Hausbesuche bei invasiv beatmeten Patienten

At present health-care at home for the majority of patients with invasive ventilation is mainly provided by nursing personnel. The reason for this unsatisfying condition is the lack of a basic medical supply for patients with invasive ventilation outside of hospitals. In contrast, current guidelines recommend a follow-up care by the weaning centres that applies for patients with invasive ventilation at home. In an case the practical implementation of the follow-up care is not specified. In this paper we attempt to balance the reasons for the need of follow-up care for ventilated patients by the weaning centre on the basis of 6 cases. Furthermore, we want to report our experience with a weekly visitation of these patients as a basic structure of the follow-up care. The necessity for a regular consultation by a pneumologist that can be established by weekly rounds has been demonstrated. In addition, it can be expected to reduce the costs of public health markedly if one takes data from ventilated patients living in specialised institutions into account. Nevertheless prospective studies are necessary to objectify the financial and medical benefits arising from this form of medical supply. These studies should be designed as multicentre studies because of the heterogenous population of ventilated patients and the fact that home ventilation is in general a seldom occurrence.

The role of non‐invasive home mechanical ventilation in patients with chronic obstructive pulmonary disease requiring prolonged weaning

Patients with COPD who require prolonged weaning from invasive mechanical ventilation show poor long-term survival. Whether non-invasive home mechanical ventilation (HMV) has a beneficial effect after prolonged weaning has not yet been clearly determined. Patients with COPD who required prolonged weaning and were admitted to a specialized weaning centre between January 2002 and February 2008 were enrolled in the study. Long-term survival and prognostic factors, including the role of non-invasive HMV, were evaluated. Of 117 patients (87 men, 30 women; mean age 69.5±9.5 years) included in the study, weaning from invasive ventilation was achieved in 82 patients (70.1%). Successful weaning was associated with better survival 1 year after discharge from hospital (hazard ratio (HR) 2.24, 95% CI: 1.16-4.31; P=0.016). Among the 82 patients who were successfully weaned, non-invasive HMV was initiated in 39 (47.6%) due to persistent chronic ventilatory failure. Initiation of HMV was associated with a higher rate of survival to 1 year as compared with patients who did not receive ventilatory support (84.2% vs 54.3%; HR 3.68, 95% CI: 1.43-9.43; P=0.007). In addition, younger age and higher PaO₂, haemoglobin concentration and haematocrit at discharge were associated with better survival. In an adjusted multivariate analysis, initiation of non-invasive HMV after successful weaning remained an independent prognostic factor for survival to 1 year (HR 3.63, 95% CI: 1.23-10.75; P=0.019). These findings suggest that based on the potential for improvement in long-term survival, non-invasive HMV should be considered in patients with severe COPD and persistent chronic hypercapnic respiratory failure after prolonged weaning.

Statuserhebung von Pflegediensten für außerklinische Beatmung

Homecare for mechanically ventilated patients is complex and challenging for homecare institutions. The framework conditions of homecare are regulated by a likewise complex social legislation. The German Respiratory Society (DGP) and the German Interdisciplinary Society for Home Care Ventilation (DIGAB) have published recommendations on the structure of homecare for ventilated patients in their recent guideline and recommended a certification of homecare nursing services. Prior to a certification process, the homecare task force of the DIGAB conducted a survey in order to compare the current structures with the guideline recommendations. Voluntary disclosure of information by means of a written questionnaire consisting of eleven items was requested. 37 homecare institutions with a total of 78 subsidiaries providing service all over Germany returned their questionnaires. While educational standards are mostly in line with the guideline recommendation, it was found that only 43 % of 812 recorded patients followed up with a specialised weaning centre or centre for ventilation. 84 % of these patients were ventilated invasively. In spite of the fact that all homecare institutions took care of invasively ventilated patients, there was a lack of company-owned standards for specific nursing measures. Homecare for ventilated patients in Germany has reached a decent degree of organisation, while follow-up with specialised centres for ventilation, and with that medical specialist care appears to be underserved. The certification process for homecare institutions should be pursued with emphasis in order to create uniform quality standards. The number of invasively ventilated patients in homecare settings is probably higher than previously estimated and could be the result of a lack of weaning capacity.

Functional Recovery Following Physical Training in Tracheotomized and Chronically Ventilated Patients

Rehabilitation is a non-pharmacologic therapy that can restore health and reverse the patient's disability, but the efficacy of rehabilitation in critically ill patients is not well documented. In a prospective cohort study, we assessed whether the degree of change in functional status after comprehensive rehabilitation influenced clinical outcomes in 77 tracheotomized patients (mean ± SD age 75 ± 7 y) admitted for difficult weaning to our regional weaning center. The care plan, including peripheral muscle training, was delivered daily. We recorded admission demographic, anthropometric, and functional characteristics. We measured the change in basic activities of daily living score (ΔBADL), survival, and weaning success rate as clinical outcomes. We performed the Pearson correlation analysis and linear regression, with ΔBADL as the dependent variable, to test the predictive power of the baseline measurements. Sixty-seven patients (87%) survived, and 55 of them (74%) succeeded in weaning during their stay in the weaning center. The mean ± SD ΔBADL improvement was 2.5 ± 2.0 points (median 2 points). Baseline performance of the latissimus dorsi predicted ΔBADL (β = 0.388, 95% CI 0.111-1,664, P = .03). The probability of remaining ventilator-free (P = .043) and survival (P = .001) differed across the 4 ΔBADL categories (0 = no change, 1-2 = least improvement, and > 2 = improvement above median change). Mortality rate and weaning success differ according to ΔBADL following active rehabilitation/training in tracheotomized, ventilated, difficult-to-wean patients. The performance of the latissimus dorsi was the only significant predictor of change.

A proposal of a new model for long-term weaning: Respiratory intensive care unit and weaning center

A proposal of a new model for long-term weaning: Respiratory intensive care unit and weaning center

The difficult-to-wean patient

Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients’ complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients’ autonomy and families’ preparation for home discharge with mechanical ventilation.

Protrahierte respiratorische Insuffizienz – Epidemiologie und Netzwerk zur Respiratorentwöhnung (Weaning) nach prolongierter Beatmung

The prevalence of difficult or prolonged weaning from the ventilator is increasing due to a growing number of multi-morbid, elderly and pulmonary deficient patients being mechanically ventilated. Intensive care units (ICU) tend to refer difficult to wean patients to specialised weaning facilities. A survey of 38 centres - performed in 2006 - included a total number of 2718 patients with difficult or prolonged weaning. Almost three quarters of the patients were transferred to a weaning centre from an external ICU. The weaning success rate was 66.3 %. After weaning in 31.9 % of the patients, home mechanical ventilation was started. The overall hospital mortality rate was 20.8 %. Recently the task force "WeanNet" - a network of weaning units - was founded under the auspices of the German Thoracic Society. The main aim of WeanNet is to improve cooperation among the weaning centres and the quality of patient management. Important tools of WeanNet are (i) the register of weaning patients and (ii) accreditation of the weaning centres. To develop the register an intensive cooperation between the task force and the Institute for Lung Research (ILF) was necessary. The finished register is now logistically run by ILF. In less than 1 year after the official start, already 70 weaning units with ca. 3000 patients are registered. In future "WeanNet", in particular in terms of the register and the accreditation, will stand for the quality of weaning centres in Germany.

A proposal of a new model for long-term weaning: Respiratory intensive care unit and weaning center

Respiratory intermediate care units (RICU) are hospital locations to treat acute and acute on chronic respiratory failure. Dedicated weaning centers (WC) are facilities for long-term weaning. We propose and describe the initial results of a long-term weaning model consisting of sequential activity of a RICU and a WC. We retrospectively analysed characteristics and outcome of tracheostomised difficult-to wean patients admitted to a RICU and, when necessary, to a dedicated WC along a 18-month period. Since February 2008 to November 2009, 49 tracheostomised difficult-to wean patients were transferred from ICUs to a University-Hospital RICU after a mean ICU length of stay (LOS) of 32.6 +/- 26.6 days. The weaning success rate in RICU was 67.3% with a mean LOS of 16.6 +/- 10.9 days. Five patients (10.2%) died either in the RICU or after being transferred to ICU, 10 (20.4%) failed weaning and were transferred to a dedicated WC where 6 of them (60%) were weaned. One of these patients was discharged from WC needing invasive mechanical ventilation for less than 12h, 2 died in the WC, 1 was transferred to a ICU. The overall weaning success rate of the model was 79.6%, with 16.3% and 4.8% in-hospital and 3-month mortality respectively. The model resulted in an overall 39 845 +/- 22 578 euro mean cost saving per patient compared to ICU. The sequential activity of a RICU and a WC resulted in additive weaning success rate of difficult-to wean patients. The cost-benefit ratio of the program warrants prospective investigations.

Admission pattern and outcome in a UK weaning centre

Although patients with weaning failure may be transferred to weaning centres, there are limited data on admission practice and clinical outcome.

Weaning from ventilation – current state of the science and art

Weaning from mechanical ventilation has attracted a growing interest recently in the medical and nursing press. Attempts have been made to determine a patient's readiness to wean, define criteria for successful weaning and enhance the weaning process through the developments of protocols. Key to this work is the role of the critical care nurse. Transferring the role and the responsibility of weaning from the traditional perspective of the intensivist to the nurse is not without challenges. Inherent is the need for skill and expertise and the willingness to accept this level of responsibility, not questioned in the medical role, but worthy of consideration when transferred to nurses. Key to successful weaning and weaning is redefined for the purposes of this paper, is continuity of care, knowing the patient and the development of patient-centred, individualized weaning plans. Critical care nurses have an important role to play. This is particularly so when the patient experience is to be understood. There is relatively little research conducted in this area, yet this is an important consideration if we are to fully understand and embrace the role of patients in their weaning. Weaning in the context of critical care can be challenging. To wean the difficult-to-wean or the long-term-weaning patient requires great skill and expertise. Expertise in this context has not been fully explored, yet research suggests that these patients are not allocated expert nurses to care for them because they are not seen as critically ill. It may be that this group of patients would benefit from a transfer to a weaning centre as suggested by the Modernisation Agency in 2002. This would greatly challenge the way we, as critical care nurses, perceive weaning in critical care.

Determinants of weaning success in patients with prolonged mechanical ventilation

IntroductionPhysiological determinants of weaning success and failure are usually studied in ventilator-supported patients, comparing those who failed a trial of spontaneous breathing with those who tolerated such a trial and were successfully extubated. A major limitation of these studies was that the two groups may be not comparable concerning the severity of the underlying disease and the presence of comorbidities. In this physiological study, we assessed the determinants of weaning success in patients acting as their own control, once they are eventually liberated from the ventilator.MethodsIn 30 stable tracheotomised ventilator-dependent patients admitted to a weaning center inside a respiratory intensive care unit, we recorded the breathing pattern, respiratory mechanics, inspiratory muscle function, and tension-time index of diaphragm (TTdi = Pdisw/Pdimax [that is, tidal transdiaphragmatic pressure over maximum transdiaphragmatic pressure] × Ti/Ttot [that is, the inspiratory time over the total breath duration]) at the time of weaning failure (T0). The measurements were repeated in all the patients (T1) either during a successful weaning trial (successful weaning [SW] group, n = 16) or 5 weeks later, in the case of repeated weaning failure (failed weaning [FW] group, n = 14).ResultsCompared to T0, in the FW group at T1, significant differences were observed only for a reduction in spontaneous breathing frequency and in TTdi (0.21 ± 0.122 versus 0.14 ± 0.054, P = 0.008). SW patients showed a significant increase in Pdimax (34.9 ± 18.9 cm H2O versus 43.0 ± 20.0, P = 0.02) and decrease in Pdisw/Pdimax (36.0% ± 15.8% versus 23.1% ± 7.9%, P = 0.004).ConclusionsThe recovery of an inadequate inspiratory muscle force could be the major determinant of 'late' weaning success, since this allows the patients to breathe far below the diaphragm fatigue threshold.

Betreuung von Patienten mit maschineller Beatmung unter häuslichen und heimpflegerischen Bedingungen

The advances in intensive and critical care medicine have not only improved the prognosis of patients with acute respiratory failure but have also increased the number of ventilator-dependent patients. The continuously increasing number of patients, the differentiation of care-giving institutions and the technical progress make it necessary to re-evaluate the quality of health care in weaning centres and outpatient care of patients on long-term ventilation. Therefore, the German medical associations of pneumology and ventilatory support, "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V." and the "Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e. V.", wish to present this actual position paper. However, scientific guidelines are in preparation.