WEANING FROM THE VENTILATOR AND …...spontaneous breathing trial (SBT) (T-tube) not predict well...
Transcript of WEANING FROM THE VENTILATOR AND …...spontaneous breathing trial (SBT) (T-tube) not predict well...
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WEANING FROM THE
VENTILATOR AND
EXTUBATION IN ICU
R黃心治
Curr Opin Crit Care. 2013 Feb;19(1):57-64.
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Purpose of review
� Both extubation delay and especially the need for reintubation are associated with poor outcomes.
� Review the recent literature on weaning and to clarify the role of certain interventions intending to help in this process.
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Recent findings
� Cardiac dysfunction is probably one of the most common causes of weaning failure.
� Several studies have evaluated the ability of B-natriuretic peptides and echocardiographictools to predict weaning outcome due to cardiac origin, attempting to prevent its failure.
� Noninvasive ventilation may have a potential benefit in preventing respiratory failure after extubation of hypercapnic patients, although more studies are needed to define a target population.
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1. Failure of planned extubation: 10–20%
2. patients who fail extubation have a high mortality: 25–50%.
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� Multicentre trial
� Use of noninvasive ventilation (NIV) to treat post-extubation respiratory distress,
� Mortality was found higher in the group using NIV
� Due to the delay in reintubation: around 2 h in the standard group versus more than 12 h in the NIV group
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� THE FIRST STEP: TO BREATHE ON ONE’S OWN WITHOUT THE VENTILATOR
� SECOND STEP: TO BREATHE WITHOUT THE ENDOTRACHEAL TUBE
� UPPER AIRWAY OBSTRUCTION AFTER EXTUBATION
� NONINVASIVE VENTILATION IN THE POSTEXTUBATION PERIOD
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FIRST STEP
� Resolution of disease for which the patient was intubated
� Cardiovascular stability with no need or minimal vasopressors
� No continuous sedation
� Adequate oxygenation defined as paO2/FiO2 of at least 150 mmHg with PEEP up to 8cmH2O.
� Earilier study: paO2/FiO2 was above 200 mmHg with PEEP 5 cmH2O or less.
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Three group of weaning
� Simple weaning: succeed the first weaning trial and extubated without difficulty
� Difficult weaning: fail the first weaning trial and require up to three trials or 7 days to achieve successful weaning
� Prolonged weaning: includes patients who require more than 7 days of weaning after the first weaning trial
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About BNP
� High basal levels or an increase in B-type natriuretic peptides measured at the end of spontaneous breath-ing trial
� Related to weaning failure due to cardiac origin
� Predict postextubation respiratory distress/
extubation failure
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About BNP
� A multi-centre study
� Diuretics guided by brain natriuretic peptide (BNP) measurements
� shortening duration of weaning suggesting that negative fluid balance using diuretics could hasten extubation.
� a large randomized controlled trial
� use of a conservative fluid strategy shortened the duration of mechanical ventilation in patients with acute lung injury
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About Echocardiographic
indices
� Several studies suggest that patients who have diastolic dysfunction, as indicated by an increase in E/Ea ratio with normal systolic function, could be at a high risk of weaning failure
� Interestingly, a recent innovative study found that the loss of lung aeration measured using pulmonary echography may be more helpful in predicting postextubation respiratory distress than BNP measurement or echo-cardiography.
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SECOND STEP
� spontaneous breathing trial (SBT) (T-tube)
� not predict well the consequences of the tube removal in terms of upper airway patency and
lower airway protection, removal of secretions and, ultimately, the ability to sustain spontaneous
breathing.
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Factors associated with extubation
failure
age, primary reason for intubation, neurological dysfunction, cough
efficacy and amount of secretions
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UPPER AIRWAY OBSTRUCTION
AFTER EXTUBATION
� Postextubation laryngeal oedema is due to the pres-sure exerted by the endotracheal tube and is favoured by the conditions of intubation and the duration of mechanical ventilation
� occurs in about 5–15% of the patients
� more often in women
� low patient’s height /tube diameter ratio
� The presence of detectable leak does not rule out the occurrence of upper airway obstruction
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UPPER AIRWAY OBSTRUCTION
AFTER EXTUBATION
� Upper airway obstruction was found to be the cause of extubation failure in 7–20% of the cases
� reached 38% in a large multicentric study focusing on postextubation stridor
� methylprednisolone prior to extubationreduced the incidence of stridor and the rate of reintubation due to laryngeal oedema
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UPPER AIRWAY OBSTRUCTION
AFTER EXTUBATION
� reintubation is purely linked to transient laryngeal oedema, it does not seem to be associated with a poor prognosis
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NONINVASIVE VENTILATION(NIV)
IN THE POSTEXTUBATION
PERIOD� prophylactic NIV after extubation may be
useful to prevent acute respiratory failure in selected populations
� NIV employed for treating postextubationacute respiratory failure has no proven benefit and can even increase mortality by delaying reintubation
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NONINVASIVE VENTILATION(NIV)
IN THE POSTEXTUBATION
PERIOD� NIV was found to be effective in preventing
postextubation respiratory failure in patients having hypercapnia at the end of the SBT
� NIV could reduce the risk of reintubation in postoperative patients after major elective abdominal surgery or lung resection, and could even reduce mortality in this latter group.
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Conclusion
� The results of large randomized controlled trials give an overall incidence of extubationfailure relatively‘low’ (10–20%) for the general ICU population.
� However, the individual risk of reintubation can become unacceptably high in some at-risk populations with an extremely high mortality in case of extubation failure.
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