Weaning Center Research Articles

Mechanical power normalized to lung-thorax compliance predicts prolonged ventilation weaning failure: a prospective study

BackgroundMechanical power (MP) of artificial ventilation, the energy transferred to the respiratory system, is a chief determinant of adequate oxygenation and decarboxylation. Calculated MP, the product of applied airway pressure and minute ventilation, may serve as an estimate of respiratory muscle workload when switching to spontaneous breathing. The aim of the study was to assess MP’s discriminatory performance in predicting successful weaning from prolonged tracheostomy ventilation.MethodsProspective, observational study in 130 prolonged mechanically ventilated, tracheotomized patients in a specialized weaning center. Predictive weaning outcome ability of arterial blood gas analyses and indices derived from calculated MP at beginning and end of weaning was determined in terms of area under receiver operating characteristic curve (AUROC) and measures derived from k-fold cross-validation (likelihood ratios, diagnostic odds ratio, F1 score, and Matthews correlation coefficient [MCC]).ResultsForty-four (33.8%) patients experienced weaning failure. Absolute MP showed poor discrimination in predicting outcome; whereas specific MP (MP normalized to dynamic lung-thorax compliance, LTCdyn-MP) had moderate diagnostic accuracy (MCC 0.38; AUROC 0.79, 95%CI [0.71‒0.86], p < 0.001), further improved by correction for corresponding mechanical ventilation PaCO2 (termed the power index of the respiratory system [PIrs]: MCC 0.52; AUROC 0.86 [0.79‒0.92], p < 0.001). Diagnostic performance of MP indices increased over the course of weaning, with maximum accuracy immediately before completion (LTCdyn-MP: MCC 0.49; AUROC 0.86 [0.78‒0.91], p < 0.001; PIrs: MCC 0.68; AUROC 0.92 [0.86‒0.96], p < 0.001).ConclusionsMP normalized to dynamic lung-thorax compliance, a surrogate for applied power per unit of ventilated lung volume, accurately discriminated between low and high risk for weaning failure following prolonged mechanical ventilation.

Evaluation of Weaning Success in Long-Term Invasively Ventilated Patients at a Weaning Center

Despite the use of enormous personnel and other resources in German weaning centers, approximately 20 % of patients currently fail to get weaned from mechanical ventilation (MV) and need out-of-hospital ventilation.Between 03/2015 and 11/2019, we carried out a pilot project with 33 patients (48 % female, mean age 68 ± 11 years at hospital admission) in order to re-evaluate their options of a possible weaning from MV. At this stage the patients had been invasively ventilated for 475 ± 775 days. The mean stay in our weaning center was 26 ± 19 days. 24/33 (73.53 %) patients were successfully weaned from MV. Of those, 11/24 (44 %) were discharged with non-invasive out-of-hospital ventilation. The completely weaned patients had a survival period of 3 or 12 months (92 % and 77 %), respectively. In those discharged with non-invasive ventilation, the survival period of 3 or months was 91 % and 81 %, respectively. In those discharged with invasive ventilation, this was 86 % and 71 %, respectively.The current results demonstrate that even those undergoing long-term out-of-hospital invasive ventilation can be successfully weaned from MV. Therefore, we suggest regular re-evaluations of weaning opportunities in invasively ventilated ambulatory patients.

Ventilation Patients between Acute Care and Long-term Out-of-Hospital Ventilation - Routine Documentation based Analysis of the Care Situation

The number of invasive and non-invasive long-term out-of-hospital ventilations has been increasing rapidly for years. At the same time, there is poor information on the quality of care of out-of-hospital ventilated patients. The present investigation was conducted as part of the OVER-BEAS study. The aim of this study was to describe the care situation of weaning patients from admission to discharge from the weaning center using existing routine documentation. In our retrospective analysis, we included all patients admitted in 2018 via the weaning ward of the Thorax Center Münnerstadt. Descriptive analysis of routine data collected as part of quality management was performed. Data sources were the WeanNet database, the discharge letter of the weaning center, and the transfer report of the referring hospital. In the studied weaning center, 50.8 % of the patients (n = 31) could be completely weaned from the respirator and extubated or decannulated (category 3aI). If complete weaning was not successful, 75.0 % (n = 21) required the constant presence of specially trained staff or a specialist nurse in the further course. In this case, further care was mostly provided in inpatient care facilities (e. g., ventilator shared living community). Based on routine documentation, the care situation of weaning patients can be presented and compared with known data. In this way, the outcome quality of a weaning center can be made comparable.

Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

Weaning in a Pandemic Situation - A Position Paper

ZusammenfassungDie logistischen und infektiologischen Besonderheiten und Erfordernisse in der Pandemie stellen die intensivmedizinischen Behandlungsteams vor außerordentliche Herausforderungen, die eine erfolgreiche Liberation von Patienten im prolongierten Weaning erschweren können. Gerade in der Pandemie gilt es daher, alle Potenziale zur Beatmungsentwöhnung und Dekanülierung von Patienten im prolongierten Weaning oder in der Langzeitbeatmung auszuschöpfen.Weaning-Zentren stellen Einheiten der intensivmedizinischen Betreuung mit besonderer Spezialisierung auf prolongiertes Weaning dar und sind integraler Bestandteil eines kontinuierlichen Versorgungskonzeptes dieser Patienten. Ein systematisches Weaning-Konzept in der Pandemie setzt strukturelle, personelle, apparative, infektiologische und hygienische Aspekte voraus.Im Mittelpunkt dieses Positionspapiers stehen als Ergänzung zur S2k-Leitlinie „Prolongiertes Weaning“ eine neue Klassifikation im prolongierten Weaning und zukünftig erforderliche Organisationsstrukturen für die Pandemie-Situation.Patienten der Kategorie A mit hohem Weaning-Potenzial bedürfen der strukturierten Respiratorentwöhnung in spezialisierten Weaning-Einheiten, um so die größtmögliche Chance auf erfolgreiches Weaning zu realisieren. Patienten der Kategorie B mit geringem oder aktuell nicht vorhandenem Weaning-Potenzial sollten verzögert nach einer Zwischenphase der weiteren Stabilsierung in einer außerklinischen Beatmungseinrichtung einen Weaning-Versuch erhalten. Patienten der Kategorie C ohne Weaning-Potenzial benötigen eine dauerhafte außerklinische Versorgung, alternativ eine palliativmedizinisch begleitete Beendigung der Beatmung. Die sich aus den 3 Kategorien ergebenden Aufgaben für die Weaning-Zentren werden im Positionspapier vertieft.Schließlich werden unter perspektivischer Betrachtung im Positionspapier folgende zukünftig denkbare Netzwerke und Register benannt: 1. lokal organisierte regionale Netzwerke von zertifizierten Weaning-Zentren, 2. ein zentrales, bundesweites Register der Weaning-Kapazitäten entsprechend dem DIVI-Register und 3. eine Registrierung der Patienten im schwierigen oder prolongierten Weaning.

Evolución respiratoria y motora en lesión medular cervical. Diecisiete años de experiencia en un centro de desvinculación de asistencia ventilatoria mecánica: un estudio observacional

Introduction and objectivesSpinal cord injury (SCI) is a devastating entity that generates substantial disability. The outcome of respiratory and motor features has an impact in human and social well-being. We analyzed demographic characteristics, motor and respiratory outcomes, and determined equipment needs at discharge in a weaning and rehabilitation center. Material and methodObservational, descriptive and retrospective study of medical records between January 2002 and December 2018. Tracheostomised cervical SCI patients with invasive mechanical ventilation were included. Forced vital capacity (upright and supine), maximal inspiratory and expiratory pressures, ASIA and Spinal Cord Independence MeasureIII (SCIMIII) were obtained. ResultsOf 1603 patients, 3.5% had SCI, and 28 met the inclusion criteria. The most frequent level of injury was C4-C5 (17/28), 21/28 had ASIAA classification, and 19 showed no change in either the ASIA or the SCIM score. In all, 22/28 patients were weaned, while 15/28 were decannulated. Twenty four patients were discharged to home. The most relevant change in SCIMIII was in the 5th component of respiration and sphincter subscale, related to weaning and tracheostomy. At discharge, 23/24 patients needed both respiratory and motor aids. ConclusionsThe admission rate of SCI patients was low in our weaning and rehabilitation center, with almost all being admitted for traumatic causes. Severity remained unchanged in most ASIAA patients. Respiratory recovery was more clinically significant than recovery of motor function. Upon discharge, most of our patients had to be equipped with both respiratory and motor aids.

Out-of-hospital ventilation after prolonged weaning

Die Zahl der Patienten im prolongierten Weaning steigt infolge des zunehmenden Alters und der Komorbidität der Patienten sowie des technischen Fortschrittes in der Chirurgie und der Intensivmedizin kontinuierlich an. Die Daten des WeanNet-Registers zeigen, dass über die Hälfte (64 %) der von der Intensivstation in ein spezialisiertes Weaningzentrum verlegten Patienten vom Respirator definitiv entwöhnt werden konnte. Mit einem Weaningversagen waren eine längere Beatmungsdauer vor Verlegung auf die Weaningstation, gefolgt von einem niedrigen Body-Mass-Index, vorbestehende neuromuskuläre Erkrankungen und ein fortgeschrittenes Alter assoziiert. Die Zahl der Patienten mit außerklinischer Beatmung, die wegen der Kontrolle der Beatmung oder eines Notfalls rehospitalisiert werden mussten, hat sich in Deutschland zwischen 2006 und 2016 vervierfacht. Die außerklinische invasive Beatmung bzw. Langzeit-NIV (nichtinvasive Beatmung) geht häufig mit einem deutlichen Autonomieverlust und geringer Lebensqualität einher, sodass deren Beginn in Zusammenschau mit der Komorbidität des Patienten und dem Patientenwillen sorgfältig geprüft, die Indikation regelmäßig reevaluiert und ggf. eine Entscheidung zur Therapiezieländerung getroffen werden sollte. Die Einstellung auf eine außerklinische Beatmung nach erfolglosem prolongiertem Weaning sollte in einem spezialisierten Weaningzentrum durchgeführt werden. Für das Behandlungskonzept von Patienten mit invasiver außerklinischer Beatmung bzw. NIV ist ein Weaningzentrum verantwortlich. Abhängig von der Infrastruktur und Vernetzung des jeweiligen Weaningzentrums ist es grundsätzlich auch möglich, die ambulante Betreuung klinisch stabiler Patienten im Rahmen eines Kooperationsmodells gemeinsam mit in der Beatmungsmedizin erfahrenen niedergelassenen Pneumologen durchzuführen.

Contract of the German Health Insurance AOK Hessen Concerning Prolonged Weaning-Methods and First Experiences

Zusammenfassung Hintergrund Die Zahl der Patienten, die im Verlauf einer intensivmedizinischen Behandlung von einer invasiven Beatmung entwöhnt werden müssen, hat in den vergangenen Jahren stetig zugenommen. Ein Teil hiervon bleibt dauerhaft beatmet und muss im ambulanten Bereich betreut werden. Das Gros dieser Patienten ist allerdings nicht in einem erfahrenen Weaningzentrum behandelt worden. Es ist daher wahrscheinlich, dass noch „Weaningpotenzial“ bei einem Teil der Patienten besteht. Methoden Die AOK Hessen hat nach umfangreicher Analyse Ansatzpunkte zur Verbesserung dieser Situation entwickelt, die hier erstmalig vorgestellt werden. Als wesentlich wurden die fachliche Expertise der das Potenzial einschätzenden Ärzte (Weanigerfahrung bzw. Weaningzentrum), die Option der temporären Unterbringung der Patienten in den neu zu schaffenden Therapiezentren für außerklinische Beatmung (TAB) und die strukturierte ambulante Nachsorge erkannt. Ergebnisse Bei den TAB handelt es sich um extrastationäre Einheiten, welche einem Weaningzentrum angeschlossen sind. Hier sollen Patienten in wohnlicher Atmosphäre betreut werden, bei denen es bisher nicht gelang, sie von der Invasivbeatmung zu entwöhnen. Der Fokus liegt dabei auf der täglichen physiotherapeutischen und logopädischen Arbeit. Hierfür wird ein Zeitraum von bis zu 6 Monaten ermöglicht, in dem sich die muskuläre und kognitive Situation verbessern soll. Im Anschluss wird dann je nach Verlauf ein erneuter Weaningversuch im Weaningzentrum unternommen. Diskussion Das Konzept wird im folgenden Artikel ausführlich beschrieben. Erste Erfahrungen zeigen den relevanten Stellenwert der TAB in der Entwöhnung von der Beatmung.

Predictors of survival after prolonged weaning from mechanical ventilation.

Weaning from mechanical ventilation is a key component of intensive care treatment; however, this process may be prolonged as some patients require care at specialised centres. Current data indicate that weaning from invasive mechanical ventilation is successful in approximately 65% of patients; however, data on long-term survival after discharge from a weaning centre are limited. We analysed predictors of survival among 597 patients (392 men, mean age 68±11) post-discharge from a specialised German weaning centre. Complete weaning from mechanical ventilation was achieved in 407 (57.8%) patients, and 106 patients (15.1%) were discharged with non-invasive ventilation; thus, prolonged weaning was successful in 72.9% of the patients. The one-year and five-year survival rates post-discharge were 66.5% and 37.1%, respectively. Age, duration of mechanical ventilation, certain clusters of comorbidities, and discharged with mechanical ventilation significantly influenced survival (p<.001). Completely weaned patients who were discharged with a tracheostomy had a significantly reduced survival rate than did those who were completely weaned and discharged with a closed tracheostomy (p=.004). The identified predictors of survival after prolonged weaning could support therapeutic strategies during patients' intensive care unit stay. Patients should be closely monitored after discharge from a weaning centre.

Weaning from Invasive Ventilation in Specialist Centers Following Primary Weaning Failure.

Ever more patients are being treated with invasive ventilation in the outpatient setting. Most have no access to a structured weaning process in a specialized weaning center. The personal burden on the patients is heavy, and the costs for the health care system are high. 61 patients who had been considered unfit for weaning were admitted to a weaning center. The primary endpoint was the number of patients who had been successfully weaned from the ventilator at six months. The comparison group consisted of health-insurance datasets derived from patients who were discharged from an acute hospital stay to receive invasive ventilation in the outpatient setting. 50 patients (82%; 95% confidence interval [70.5; 89.6]) were successfully weaned off of invasive ventilation in the weaning centers, 21 of them (34% [23.8; 47]) with the aid of non-invasive ventilation. The survival rate at 1 year was higher than in the group without invasive ventilation (45/50, or 90%, versus 6/11,or 55%); non-invasive ventilation was comparable in this respect to no ventilation at all. The identified risk factors for weaning failure included the presence of more than five comorbidities and a longer duration of invasive ventilation before transfer to a weaning center. If patients with prolonged weaning are cared for in a certified weaning center before being discharged to receive invasive ventilation in the outpatient setting, the number of persons being invasively ventilated outside the hospital will be reduced and the affected persons will enjoy a higher survival rate. This would also spare nursing costs.

Prolonged Weaning from Mechanical Ventilation.

To accommodate the increasing number of patients requiring prolonged weaning from mechanical ventilation, specialized weaning centers have been established for patients in whom weaning on the intensive care unit (ICU) was unsuccessful. This study aimed to determine both the outcome of treatment and the factors associated with prolonged weaning in patients who were transferred from the ICU to specialized weaning centers in Germany during the period 2011 to 2015, based on a nationwide registry covering all specialized weaning centers currently going through the process of accreditation by the German Respiratory Society. Of 11 424 patients, 7346 (64.3%) were successfully weaned, of whom 2236 were switched to long-term non-invasive ventilation; 1658 (14.5%) died in the weaning unit; and 2420 (21.2%) could not be weaned. The duration of weaning decreased significantly from 22 to 18 days between 2011 and 2015 (p <0.0001). Multivariate analysis revealed that the factor most strongly associated with in-hospital mortality was advanced age (odds ratio [OR] 11.07, 95% confidence interval [6.51; 18.82], p <0.0001). The need to continue with invasive ventilation was most strongly associated with the duration mechanical ventilation prior to transfer from the ICU (OR 4.73 [3.25; 6.89]), followed by a low body mass index (OR 0.38 [0.26; 0.58]), pre-existing neuromuscular disorders (OR 2.98 [1.88; 4.73]), and advanced age (OR 2.96 [1.87; 4.69]) (each p <0.0001). Weaning duration has decreased over time, but prolonged weaning is still unsuccessful in one third of patients.Overall, the results warrant the establishment of specialized weaning centers. Variables associated with death and weaningfailure can be integrated into ICU decision-making processes.

Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study

ObjectivesFamily caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre. Research methodology/designA longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis. SettingA 6-bed specialised weaning centre in Toronto, Canada. FindingsEighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight. ConclusionsDeficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.

Variables predicting weaning outcome in prolonged mechanically ventilated tracheotomized patients: a retrospective study

BackgroundSeveral studies have assessed predictors of weaning and extubation outcome in short-term mechanically ventilated patients, but there are only few studies on predictors of weaning from prolonged mechanical ventilation.MethodsRetrospective, single-center, observational study at a specialized national weaning center in Germany. Patients’ medical records were reviewed to obtain data on demographics, comorbidities, respiratory indices, and the result of a prospectively documented, standardized spontaneous breathing trial (SBT) upon admission to the weaning center. Respiratory indices assessed were the ventilatory ratio (VR) and parameters derived from calculated mechanical power (MP). Predictors associated with failure of prolonged weaning and failure of the SBT were assessed using a binary logistic regression model.ResultsA total of 263 prolonged mechanically ventilated, tracheotomized patients, treated over a 5-year period were analyzed. After 3 weeks of mechanical ventilation, patients with unsuccessful weaning failed a SBT more frequently and showed significantly increased values for inspiratory positive airway pressure, driving pressure, VR, absolute MP, and MP normalized to predicted body weight and dynamic lung-thorax compliance (LTC-MP). In the logistic regression analyses, variables independently correlated with weaning failure were female gender (adjusted odds ratio 0.532 [95% CI 0.291–0.973]; p = 0.040), obesity (body mass index ≥ 30 kg/m2) (2.595 [1.210–5.562]; p = 0.014), COPD (3.209 [1.563–6.589]; p = 0.002), LTC-MP (3.470 [1.067–11.284]; p = 0.039), PaCO2 on mechanical ventilation (1.101 [95% CI 1.034–1.173]; p = 0.003), and failure of the SBT (4.702 [2.250–9.825]; p < 0.001). In addition, female gender (0.401 [0.216–0.745]; p = 0.004), LTC-MP (3.017 [1.027–8.862]; p = 0.046), and PaCO2 on mechanical ventilation (1.157 [1.083–1.235]; p < 0.001) were independent risk factors for an unsuccessful SBT.ConclusionsIn the present study, the derived predictors of weaning point to a crucial role of the workload imposed on respiratory muscles during spontaneous breathing. Mechanical power normalized to lung-thorax compliance was independently correlated with weaning outcome and may identify patients at high risk for weaning failure.

Weaning İçin Pulmoner Rehabilitasyon Programı içeren Yeni Bir Model

INTRODUCTION: Our chronic respiratory failure service where we manage the patients with acute /chronic respiratory failure, is a hospital unit with multidisciplinary team with structured integrated pulmonary rehabilitation (PR) and home care unit. The aim of the study was to present our weaning experiences of inpatient hospital service in patients with prolonged mechanical ventilation (MV) and whether multidisciplinary structured inpatient service model could be an alternative method for weaning. METHODS: Twenty-three patients with home invasive mechanical ventilation (IMV) who underwent multidisciplinary inpatient PR program and weaning trials were analyzed. Dyspnea scores, body composition, respiratory muscle strength, physicological status, echocardiagraphic measurements before PR and weaning process, duration of IMV (since the opening of the tracheostomy), ABG levels before and 24 hours after weaning were recorded. RESULTS: One patient was with pneumonia, 13 with COPD, 5 with bronchiectasis, 2 with kyphoscoliosis, and 2 with congestive heart failure. The median value of duration of IMV was 126 days. The weaning trial was performed on 15 of 21 patients. Six patients were not found to be appropriate for weaning. 12 of 15 patients were decannulated with 80% weaning success. Four patients were discharged with long term oxygen therapy (LTOT), nocturnal non-IMV, 7 with LTOT, and 1 without device. The patients with weaning failure had higher anxiety depression scores, systolic pulmonary arterial pressures, lower maximum inspiratory, expiratory pressures, and shorter duration of IMV. DISCUSSION AND CONCLUSION: This study showed that chronic respiratory failure inpatients services consisting of multidisciplinary team and integrating PR into patients’ managements could serve as weaning centers in case of absence of specialized centers in prolonged MV.

Prolonged Ventilatory Support for Patients Recovering From Guillain-Barré Syndrome.

Recovery from Guillain-Barré syndrome (GBS) may be protracted, and patients may need prolonged ventilatory support. We present clinical data from a tertiary referral weaning center managing patients with GBS requiring prolonged ventilatory support. A retrospective review of patients managed in a 34-bed specialist ventilator weaning facility in London, United Kingdom, between 2006 and 2017. Data including demographics, initial presentation, and ventilatory support were collected. Functional recovery and outcome data were collected between 12 months and 3 years following disease onset. Twenty-nine patients with severe GBS requiring prolonged ventilation were included. In several patients, coexisting conditions or complications affected the course. Seventy-six percent (n = 22) were successfully weaned from invasive ventilation with a median time to tracheostomy decannulation of 193 days (range: 49-527 days). Use of noninvasive ventilation (NIV), as part of the weaning program, was applied in 59% (13/22), with 14% (3/22) requiring long-term nocturnal NIV. Twenty-four percent (7/29) were not decannulated, with 14% (4/29) supported on long-term invasive ventilation. Forty-five percent (10/22) weaned from invasive ventilation were able to achieve short distance-assisted ambulation. Mortality at 36 months was 17% (5/29), with 3 of these deaths occurring in patients invasively ventilated during their acute admission. GBS with severe respiratory muscle weakness and bulbar dysfunction may require prolonged invasive ventilation. However, there is potential for complete weaning from invasive mechanical ventilatory support with associated function recovery. These data highlight the importance of maintaining ongoing support and rehabilitation for patients with GBS requiring prolonged ventilation.

Anemia and red blood cell transfusion practice in prolonged mechanically ventilated patients admitted to a specialized weaning center: an observational study

BackgroundThe impact of anemia and red blood cell (RBC) transfusion on weaning from mechanical ventilation is not known. In theory, transfusions could facilitate liberation from the ventilator by improving oxygen transport capacity. In contrast, retrospective studies of critically ill patients showed a positive correlation of transfusions with prolonged mechanical ventilation, increased mortality rates, and increased risk of nosocomial infections, which in turn could adversely affect weaning outcome.MethodsRetrospective, observational study on prolonged mechanically ventilated, tracheotomized patients (n = 378), admitted to a national weaning center over a 5 year period. Medical records were reviewed to obtain data on patients’ demographics, comorbidities, blood counts, transfusions, weaning outcome, and nosocomial infections, defined according to the criteria of the U.S. Centers for Disease Control and Prevention. The impact of RBC transfusion on outcome measures was assessed using regression models.ResultsNinety-eight percent of all patients showed anemia on admission to the weaning center. Transfused and non-transfused patients differed significantly regarding disease severity and comorbidities. In multivariate analyses, RBC transfusion, but not mean hemoglobin concentration in the course of weaning, was independently correlated with weaning duration (adjusted β 12.386, 95% CI 9.335–15.436; p < 0.001) and hospital length of stay (adjusted β 16.116, 95% CI 8.925–23.306; p < 0.001); there was also a trend toward increased hospital mortality (adjusted odds ratio [OR] 2.050, 95% CI 0.995–4.224; p = 0.052), but there was no independent correlation with weaning outcome or nosocomial infections. In contrast, hemoglobin level on the day of admission to the weaning center was independently associated with hospital mortality (adjusted OR 0.956, 95% CI 0.924–0.989; p = 0.010), appearing significantly elevated at values below 8.5 g/dl (AUC 0.670, 95% CI 0.593–0.747; p < 0.001).ConclusionsA high percentage of prolonged mechanically ventilated patients showed anemia on admission to the weaning center. RBC transfusion was independently correlated with worse outcomes. Since transfused patients differed significantly regarding their clinical characteristics and comorbidities, RBC transfusion might be an indicator of disease severity rather than directly impacting patient prognosis.

Prolonged Weaning - S2k-Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of respiratory muscles and/or lung parenchymal disease when/after other treatments, (i. e. medication, oxygen, secretion management, continuous positive airway pressure or nasal highflow) have failed.MV is required to maintain gas exchange and to buy time for curative therapy of the underlying cause of respiratory failure. In the majority of patients weaning from MV is routine and causes no special problems. However, about 20 % of patients need ongoing MV despite resolution of the conditions which precipitated the need for MV. Approximately 40 - 50 % of time spent on MV is required to liberate the patient from the ventilator, a process called "weaning."There are numberous factors besides the acute respiratory failure that have an impact on duration and success rate of the weaning process such as age, comorbidities and conditions and complications acquired in the ICU. According to an international consensus conference "prolonged weaning" is defined as weaning process of patients who have failed at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Prolonged weaning is a challenge, therefore, an inter- and multi-disciplinary approach is essential for a weaning success.In specialised weaning centers about 50 % of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, heterogeneity of patients with prolonged weaning precludes direct comparisons of individual centers. Patients with persistant weaning failure either die during the weaning process or are discharged home or to a long term care facility with ongoing MV.Urged by the growing importance of prolonged weaning, this Sk2-guideline was first published in 2014 on the initiative of the German Respiratory Society (DGP) together with other scientific societies involved in prolonged weaning. Current research and study results, registry data and experience in daily practice made the revision of this guideline necessary.The following topics are dealt with in the guideline: Definitions, epidemiology, weaning categories, the underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions.Special emphasis in the revision of the guideline was laid on the following topics:- A new classification of subgroups of patients in prolonged weaning- Important aspects of pneumological rehabilitation and neurorehabilitation in prolonged weaning- Infrastructure and process organization in the care of patients in prolonged weaning in the sense of a continuous treatment concept- Therapeutic goal change and communication with relativesAspects of pediatric weaning are given separately within the individual chapters.The main aim of the revised guideline is to summarize current evidence and also expert based- knowledge on the topic of "prolonged weaning" and, based on the evidence and the experience of experts, make recommendations with regard to "prolonged weaning" not only in the field of acute medicine but also for chronic critical care.Important addressees of this guideline are Intensivists, Pneumologists, Anesthesiologists, Internists, Cardiologists, Surgeons, Neurologists, Pediatricians, Geriatricians, Palliative care clinicians, Rehabilitation physicians, Nurses in intensive and chronic care, Physiotherapists, Respiratory therapists, Speech therapists, Medical service of health insurance and associated ventilator manufacturers.

Clinical features and outcomes of prolonged mechanical ventilation: a single-center retrospective observational study

BackgroundInformation on epidemiology of prolonged mechanical ventilation (PMV) patients in the acute care setting in Japan is totally lacking. We aimed to investigate clinical features, impact, and long-term outcomes of PMV patients.MethodsThis was a retrospective observational study conducted in a tertiary care hospital. Adult patients who were admitted to our intensive care unit (ICU) from April 2009 to March 2014 and required mechanical ventilation (MV) for ≥ 2 days were included. PMV was defined as having MV for ≥ 21 consecutive days.ResultsAmong 1282 MV patients, 93 (7.3%) required PMV, and median duration of MV was 37.0 days. Compared with the non-PMV patients, PMV patients had longer total ICU and high care unit (HCU) stay (34.0 vs. 7.0 days, p < 0.001), longer hospital stay (74.0 vs. 35.0 days, p < 0.001), and higher hospital mortality (54.8 vs. 21.4%, p < 0.001). In multivariable logistic regression analysis, emergency ICU admission and steroid use during MV were associated with PMV. The Kaplan–Meier curves for MV withdrawal and ICU/HCU discharge were almost identical. Among PMV patients, 52 (55.9%) died, 29 (31.2%) were successfully liberated from MV during hospitalization, and 12 (12.9%) still required MV at discharge.ConclusionIn this investigation, 7.3% of the patients with MV required PMV. Most PMV patients were liberated from MV during hospitalization, while occupying critical care beds for an extended period. A nationwide survey is required to further elucidate the overall picture of PMV patients and to discuss whether specialized weaning centers to treat PMV patients are required in Japan.

Prevalence of and Risk Factors for Mechanical Ventilation Reinstitution in Patients Weaned From Prolonged Mechanical Ventilation.

Prolonged mechanical ventilation is increasingly common in ICUs. Although a consensus conference defined weaning success in this patient population, few studies have used this definition. A clear definition of successful weaning is useful to assess clinical and epidemiological outcomes, facilitate clinical decision making, and set goals of care. The aims of our study were to describe the prevalence of reinstitution of mechanical ventilation within 28 d in patients successfully weaned according to our institution criterion (ie, weaning success as per consensus guidelines), to describe reasons to reestablish mechanical ventilation, and to identify associated factors. An observational, analytical, cross-sectional study was conducted at a weaning and rehabilitation center. All patients liberated from mechanical ventilation (ie, no ventilatory support for 7 d) were included as subjects. Requirement of and reasons for reinstitution of mechanical ventilation within 28 d of weaning were recorded. A total of 639 tracheostomized subjects were analyzed. Of these, 219 (34%) were weaned, and 15 were eliminated due to lack of data. Of the remaining 204 subjects, 42 (21%) were reconnected to mechanical ventilation within 28 d. Sepsis accounted for 64% of reconnections. In the multivariate analysis, neurological comorbidity (adjusted odds ratio 5.1 [95% CI 2.3-11.1]) and delayed weaning (> 7 d after admission) (adjusted odds ratio 2.37 [95% CI 1.1-5.3]) were independently associated with reinstitution of mechanical ventilation within 28 d of weaning. The synergistic effect of both variables showed an adjusted odds ratio of 5.35 (95% CI 2.4-11.4). Reinstitution of mechanical ventilation within 28 d is a common event in patients considered to be weaned: 1 in 5 of such patients requires reconnection to mechanical ventilation, with sepsis being the most prevalent cause. Neurological comorbidity and delayed weaning are risk factors associated with reestablishment of mechanical ventilation. The presence of more than one risk factor increases the association with reinstitution of mechanical ventilation within 28 d of weaning.

Tremendous Increase of Home Care in Ventilated and Tracheostomized Patients - Reasons, Consequences, Solutions

Seit 2005 gibt es in Deutschland eine deutliche Steigerung der invasiven häuslichen Langzeitbeatmung von ca. 1000 auf mittlerweile ca.20 000 Patienten. Die häusliche Krankenpflege ist aufwendig und teuer: ca. 4 Mrd. Euro jährlich zahlt die Solidargemeinschaft dafür. Zudem werden in den letzten 2 – 3 Jahren auch zunehmend tracheotomierte Patienten (meist nach Apoplex) ohne Beatmung nach Hause entlassen.