separation from laurent brochard mechanical ventilation toronto · 2016. 9. 27. · laurent...

Laurent Brochard

Toronto

Laurent Brochard

Toronto

Separation fromMechanical Ventilation

Conflicts of interest

• Our clinical research laboratory has received research grantsand/or equipment for clinical research projects from the following companies: – Covidien (PAV+)

– Dräger (SmartCare)

– General Electric (FRC)

– Philips (NIV-sleep)

– Fisher Paykel (High flow)

– Maquet (NAVA)

Weaning from mechanical ventilation.

Three groups

• 1) Simple Weaning (first trial)

– Early detection

• 2) Difficult Weaning (more than 1 attempt, up to one

week)

– Reasons for failure

• 3) Prolonged Weaning (more than 1 week or than

three attemps)

– Global managementBoles JM. ERJ 2007

5955

43

3026

39 39 40

14

6

18

30

0

20

40

60

80

FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.

Proportion of patients in

each group (%)

Re-intubation rate (%)

ICU Mortality (%)

Simple weaning Difficult weaning Prolonged weaning

37

13

01

711

2

22

13

42

18

0

10

20

30

40

50

FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.

1310

1 0

710

19

95

16

33

24

0

10

20

30

40

50

FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.

WIND new classification

Beduneau G et al AJRCCM 2016

WIND new classification /

Mortality

6%

17% 29%

Beduneau G et al AJRCCM 2016

Beduneau G et al AJRCCM 2016

Ely E.W. et coll. N Engl J Med 1996; 335: 1864-9

• Intervention Group

1) A daily screening of respiratory function (by the respiratory therapists of the unit)

PaO2/FIO2 > 200

PEEP< 5 cm H2O

Adequate cough

f/VT < 105 c/min

No vasopressor agents or sedatives

2) A 2-hour trial of spontaneous breathing

3) Notification of the physician of the successful results

Identifying patients capable of breathing spontaneously

and duration of mechanical ventilation

Pa

tien

ts R

ecei

vin

g M

ech

an

ical

Ven

tila

tion

(%

)

Days after Succesful Screening

SIMV

Imsand et al. Anesthesiology 1994

Imsand et al. Anesthesiology 1994

Weaning with Pressure Support Ventilation

Brochard AJRCCM 1994 Esteban NEJM 1995

Weaning with Pressure Support Ventilation

Good ? Bad ?

•RR < 35 breaths/min•RR ≤ 25 breaths/min

Brochard AJRCCM 1994 Esteban NEJM 1995

0

2

4

6

8

10

12

14

16

18

0:00 0:28 0:57 1:26 1:55 2:24 2:52

PS

level cm

H2O

)

Time (h:min)

ObservationMaintain

Adaptation

PS min

« Epreuve de VS automatisée»

EXTUBATION

Reduction of ¨PSV

Message: « separation from ventilator »

PEEP 5 cmH2O

Weaning with «SmartCare »

2014

Weaning…

…Screening & Tests

Tobin M J et al. Am Rev Respir Dis 1986;134:1111-8

A place forf/Vt?

The «Spontaneous Breathing Trial»:

T-piece, Low PS, CPAP…

Screening Test or Diagnostic

Tool?

Straus C, et al. AJRCCM 1998;157:23-30

Total

E

R

n Failure,

2hr

Ext Reint Succ Ext,

48hr

2 hr

T-piece

246 22%

(54/246)

192 36 63%

(156/246)

2 hr

PSV 7

238 14%

(33/238)

205 38 70%

(167/238)

P 0.03 ns ns ns

Esteban A, et al. AJRCCM 1997;156:459-65

TEST: T-piece or PSV?

Mahul et al Crit Care AJRCCM 2016

Spontaneous breathing trial and post-extubation work of breathing in

morbidly obese critically ill patients

Physiological Measures of Patient Respiratory Effort Among

Different Spontaneous Breathing Trial Techniques: A Systematic

Review and Physiological Meta-Analysis

Sklar M et al submitted

0.4

0.6

0.8

1.0

1.2

1.4

PSV vs. E

xtub

ation

PSV vs. T

-Piece

PSV vs. P

SV/C

PAP0

PSV vs. C

PAP

CPAP vs. E

xtub

ation

CPAP vs. T

-Piece

CPAP vs. P

SV/C

PAP0

PSV0/

CPAP0

vs. E

xtub

ation

PSV0/

CPAP0

vs. T

-Piece

T-Piece

vs. E

xtub

ation

Ratio

of

me

an

s (

95

% C

I)

Measurement

WOB

PTP

RSBI

n=239

Weaning difficulties…

…Medical issues

Kress, JP. et al. N Engl J Med 2000; 342:1471-1477

Sedation

Daily interruption of sedation

Girard et al. Lancet 2008

Sedation

Patient with COPD repeatedly failing weaning

Lemaire et al, Anesthesiology 1988

Weaning-induced Pulmonary Edema

Succès Echec

0

500

1000

1500

2000

2500

BN

P,

pg

/mL

Mekontso Dessap et al, ICM 2007

BNP & WEANING PREDICTION

Success Failure

FLUID BALANCE AND EXTUBATION FAILURE

Frutos-Vivar F, Chest 2006

%

AJRCCM 2012

□ Usual

■ BNP

*p<0.05 between usual weaning and BNP-guided weaning

**p<0.01 between usual weaning and BNP-guided weaning

ICU-acquired

paresis

no ICUAP

Duration

of MV after

awakening

1.0

.80

.60

.40

.20

0.0

03

69

1215

1821

2427

30

Dependent variable

Independent variables (multivariate analysis)

Duration of MV after awakening

ICU-acquired paresis OR 2.4 (1.4 - 4.2)

COPD OR 2.6 (1.5 - 4.5)

P = 0.01

De Jonghe et al., Intensive Care Med 2004

Levine S et al. N Engl J Med 2008;358:1327-1335

Comparison of Representative Case and Control Diaphragm-Biopsy Specimens with Respect to Fiber Size

47

47

41

3934

30

27

21

4744

3228

22

18 15 1313

13

11

11

11

11

11

10

-30%

-20%

-10%

0%

+10%

+20%

+30%

1 2 3 4 5 6 7 8

Day of Study

Cha

nge

in

dia

ph

ragm

th

ickne

ss o

ve

r tim

e (

% o

f b

ase

line

)

Group: Diaphragm Thickness Change

>10% loss on or before day 8

<10% change on or before day 8

>10% gain on or before day 8

Goligher E et al. 2015 Am J Respir Crit Care Med

0

10

20

30

40

50

60

0 5 10 15 20 25 30 35

MR

C s

core

Ptr,stim (cm H2O)

Dres M et al AJRCCM 2016

76 patients at their first weaning attempt:

63% had diaphragm dysfunction, 34% had limb muscle weakness and 21% had both

DiehlDiehl J-L, et al.J-L, et al.AmAm JJ Respir Crit Care MedRespir Crit Care Med 1999; 159:383-3881999; 159:383-388

Effects of tracheostomy on work of breathing

Weaning…

…and the decision to

extubate

0 10 20 30 40 50

Daley

Demling-T

Rady

Engoren

Demling-GS

Tahvanainen

Epstein

Lee

Esteban

Esteban

Esteban

Vallverdú

Failure

Success

% Mortality for Extubation Failure Patients

0

2

4

6

8

10

12

J-1 J0 J1 J2 J3

SOFA score

Success

FailurePlanned extubation

‡

§§

§

‡ §

‡ ‡

NS

Day-1 Day0 Day1 Day2 Day3

Thille AW et al CCM

Weaning winning strategies

• Systematic screening

• Weaning test (safety) T-piece, low PS,

no PEEP

• Sedation management

• Fluid overload (BNP), weakness

(prevention)

• Automated weaning