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Weiss N. Should We Assess Diaphragmatic Function During Mechanical Ventilation Weaning in Guillain-Barré Syndrome and Myasthenia Gravis Patients? Neurocrit Care 2021; 34:371-374. [PMID: 33420670 PMCID: PMC7794071 DOI: 10.1007/s12028-020-01159-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Nicolas Weiss
- Sorbonne University & Neurological Intensive Care Unit, Department of Neurology, AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75013, Paris, France.
- Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE), Sorbonne Université, Paris, France.
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their 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 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, 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 was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Hospital-level variation in the development of persistent critical illness. Intensive Care Med 2020; 46:1567-1575. [PMID: 32500182 DOI: 10.1007/s00134-020-06129-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness. METHODS This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness. RESULTS In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049-0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051-0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041-0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33-1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness. CONCLUSION Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness.
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Magnet FS, Bleichroth H, Huttmann SE, Callegari J, Schwarz SB, Schmoor C, Windisch W, Storre JH. Clinical evidence for respiratory insufficiency type II predicts weaning failure in long-term ventilated, tracheotomised patients: a retrospective analysis. J Intensive Care 2018; 6:67. [PMID: 30349727 PMCID: PMC6192318 DOI: 10.1186/s40560-018-0338-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/01/2018] [Indexed: 11/24/2022] Open
Abstract
Background Patients who require a prolonged weaning process comprise a highly heterogeneous group of patients amongst whom the outcome differs significantly. The present study aimed to identify the factors that predict whether the outcome for prolonged weaning will be successful or unsuccessful. Methods Data from tracheotomised patients who underwent prolonged weaning on a specialised weaning unit were assessed retrospectively via an electronic and paper-bound patient chart. Factors for weaning success were analysed by univariate and multivariate analyses. Results Out of the 124 patients examined, 48.4% were successfully weaned (n = 60). Univariate analysis revealed that long-term home mechanical ventilation prior to current weaning episode; time between intubation and the first spontaneous breathing trial (SBT); time between intubation and the first SBT of less than 30 days; lower PaCO2 prior to, and at the end of, the first SBT; and lower pH values at the end of the first SBT were predictors for successful weaning. Following multivariate analysis, the absence of home mechanical ventilation prior to admission, a maximum time period of 30 days between intubation and the first SBT, and a non-hypercapnic PaCO2 value at the end of the first SBT were predictive of successful weaning. Conclusions The current analysis demonstrates that the evidence for respiratory insufficiency type II provided by clinical findings serves as a predictor of weaning failure.
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Affiliation(s)
- Friederike Sophie Magnet
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany
| | - Hannah Bleichroth
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany.,Department of General, Visceral and Vascular Surgery, St.-Josefs-Hospital Freiburg, Freiburg im Breisgau, 79104 Germany
| | - Sophie Emilia Huttmann
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany
| | - Jens Callegari
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany
| | - Sarah Bettina Schwarz
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany
| | - Claudia Schmoor
- 3Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, 79106 Germany
| | - Wolfram Windisch
- 1Cologne Merheim Hospital, Department of Pneumology, Faculty of Health/School of Medicine, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Cologne, 51109 Germany
| | - Jan Hendrik Storre
- Department of Intensive Care, Sleep Medicine and Mechanical Ventilation, Asklepios Fachkliniken Munich-Gauting, Robert-Koch-Allee 2, 82131 Gauting, Germany.,Department of Pneumology, University Medical Hospital, Freiburg im Breisgau, 79106 Germany
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Tingsvik C, Hammarskjöld F, Mårtensson J, Henricson M. Patients’ lived experience of intensive care when being on mechanical ventilation during the weaning process: A hermeneutic phenomenological study. Intensive Crit Care Nurs 2018; 47:46-53. [DOI: 10.1016/j.iccn.2018.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/14/2018] [Accepted: 03/24/2018] [Indexed: 02/06/2023]
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Sánchez Solana L, Goñi Bilbao I, Ruiz García P, Díaz Agea JL, Leal Costa C. Acquired neuromuscular dysfunction in the intensive care unit. ENFERMERIA INTENSIVA 2018; 29:128-137. [PMID: 29958844 DOI: 10.1016/j.enfi.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Polyneuropathy and myopathy, grouped under the term «intensive care unit-acquired weakness» (ICUAW), are neuromuscular pathologies to which patients in the intensive care unit (ICU) are susceptible. They are multifactorial pathologies, prolonged connection to a ventilator is one of the most common. The objective of this review was to identify the efficacy of different rehabilitative treatments in patients with ICUAW, and the relationship between ICUAW and a series of indicators. METHODS A systematic review of the primary studies selected from the Medline, Scielo, Web of Science, Cochrane, Cuiden and Science Direct databases was carried out, following the guidelines of the PRISMA statement, by which the search protocol was established. RESULTS AND CONCLUSIONS Of 161 articles, only 10 were selected to be part of this review, in which a total of 717 patients admitted to the ICU were studied. A statistically significant relationship was observed between ICUAW and failure in ventilator disconnection, mortality, increase in ICU stay and the time that the patients required mechanical ventilation. Moreover, all this improved in this type of patients with the application of a rehabilitation therapy. The use of corticosteroids, was not shown to be related to neuromuscular alteration.
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Affiliation(s)
- L Sánchez Solana
- Facultad de Enfermería, Universidad Católica de Murcia (UCAM), Murcia, España.
| | - I Goñi Bilbao
- Facultad de Enfermería, Universidad Católica de Murcia (UCAM), Murcia, España
| | - P Ruiz García
- Facultad de Enfermería, Universidad Católica de Murcia (UCAM), Murcia, España
| | - J L Díaz Agea
- Facultad de Enfermería, Universidad Católica de Murcia (UCAM), Murcia, España
| | - C Leal Costa
- Facultad de Enfermería, Universidad Católica de Murcia (UCAM), Murcia, España
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Sanson G, Sartori M, Dreas L, Ciraolo R, Fabiani A. Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment. Eur J Cardiovasc Nurs 2018; 17:751-759. [PMID: 29879852 DOI: 10.1177/1474515118782103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched. AIM To identify variables that are predictive of ExtF and related outcomes. METHOD Prospective observational longitudinal study. Consecutively presenting patients ( n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU. RESULTS The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO2/FiO2 was <150 and 11 times when it was ≥450. Also, a reassuring PaO2/FiO2 value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function. CONCLUSION The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.
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Affiliation(s)
- Gianfranco Sanson
- 1 School of Nursing, University of Trieste, Italy
- 2 Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | | | - Lorella Dreas
- 3 Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | | | - Adam Fabiani
- 3 Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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Dres M, Demoule A. Les systèmes automatisés de sevrage de la ventilation mécanique ont-ils une place en pratique clinique ? MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/s13546-017-1323-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Du fait de la stagnation de l’offre démographique médicale et du vieillissement de la population, les besoins en ventilation mécanique vont croître dans les années à venir. Dans ce contexte, la conduite du sevrage de la ventilation mécanique par des systèmes automatisés est une perspective séduisante, permettant d’épargner du temps médical et infirmier. La gestion du sevrage par des systèmes automatisés repose sur l’utilisation de l’intelligence artificielle incorporée au sein de ventilateurs capables de détecter précocement la sevrabilité des patients puis d’entreprendre le cas échéant une épreuve de ventilation spontanée. Deux systèmes répondant à ce cahier des charges sont actuellement commercialisés. Bien que les données disponibles soient peu nombreuses, celles-ci semblent justifier l’intérêt pour ces systèmes en montrant au pire une équivalence, au mieux une réduction dans la durée du sevrage, lorsqu’ils sont comparés à une démarche de sevrage conventionnelle. Les défis de demain seront de tester la généralisation de ces systèmes dans la pratique clinique et de définir les caractéristiques des populations susceptibles d’en bénéficier le plus.
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Tonella RM, Ratti LDSR, Delazari LEB, Junior CF, Da Silva PL, Herran ARDS, Dos Santos Faez DC, Saad IAB, De Figueiredo LC, Moreno R, Dragosvac D, Falcao ALE. Inspiratory Muscle Training in the Intensive Care Unit: A New Perspective. J Clin Med Res 2017; 9:929-934. [PMID: 29038671 PMCID: PMC5633094 DOI: 10.14740/jocmr3169w] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background Prolonged use of mechanical ventilation (MV) leads to weakening of the respiratory muscles, especially in patients subjected to sedation, but this effect seems to be preventable or more quickly reversible using respiratory muscle training. The aims of the study were to assess variations in respiratory and hemodinamic parameters with electronic inspiratory muscle training (EIMT) in tracheostomized patients requiring MV and to compare these variations with those in a group of patients subjected to an intermittent nebulization program (INP). Methods This was a pilot, prospective, randomized study of tracheostomized patients requiring MV in one intensive care unit (ICU). Twenty-one patients were randomized: 11 into the INP group and 10 into the EIMT group. Two patients were excluded in experimental group because of hemodynamic instability. Results In the EIMT group, maximal inspiratory pressure (MIP) after training was significantly higher than that before (P = 0.017), there were no hemodynamic changes, and the total weaning time was shorter than in the INP group (P = 0.0192). Conclusion The EIMT device is safe, promotes an increase in MIP, and leads to a shorter ventilator weaning time than that seen in patients treated using INP.
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Affiliation(s)
- Rodrigo Marques Tonella
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Ligia Dos Santos Roceto Ratti
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | | | - Carlos Fontes Junior
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Paula Lima Da Silva
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Aline Ribeiro Da Silva Herran
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Daniela Cristina Dos Santos Faez
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Ivete Alonso Bredda Saad
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Luciana Castilho De Figueiredo
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Rui Moreno
- Neurological Intensive Care Unit, Sao Jose Hospital, Lisboa, Portugal
| | - Desanka Dragosvac
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, Department of Surgery, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Antonio Luis Eiras Falcao
- School of Medical Sciences, Intensive Care Unit of Clinical Hospital, Department of Surgery, State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
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Prevalence and Impact on Weaning of Pleural Effusion at the Time of Liberation from Mechanical Ventilation: A Multicenter Prospective Observational Study. Anesthesiology 2017; 126:1107-1115. [PMID: 28338483 DOI: 10.1097/aln.0000000000001621] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pleural effusion is frequent in intensive care unit patients, but its impact on the outcome of weaning remains unknown. METHODS In a prospective study performed in three intensive care units, pleural ultrasound was performed at the first spontaneous breathing trial to detect and quantify pleural effusion (small, moderate, and large). Weaning failure was defined by a failed spontaneous breathing trial and/or extubation requiring any form of ventilatory support within 48 h. The primary endpoint was the prevalence of pleural effusion according to weaning outcome. RESULTS Pleural effusion was detected in 51 of 136 (37%) patients and was quantified as moderate to large in 18 (13%) patients. As compared to patients with no or small pleural effusion, their counterparts were more likely to have chronic renal failure (39 vs. 7%; P = 0.01), shock as the primary reason for admission (44 vs. 19%; P = 0.02), and a greater weight gain (+4 [0 to 7] kg vs. 0 [-1 to 5] kg; P = 0.02). The prevalence of pleural effusion was similar in weaning success and weaning failure patients (odds ratio, 1.23; 95% CI, 0.61 to 2.49; P = 0.56), as was the prevalence of moderate to large pleural effusion (odds ratio, 0.89; 95% CI, 0.33 to 2.41; P = 1.00). Duration of mechanical ventilation and intensive care unit length of stay were similar between patients with no or small pleural effusion and those with moderate to large pleural effusion. CONCLUSIONS Significant pleural effusion was observed in 13% of patients at the time of liberation from mechanical ventilation and was not associated with an alteration of weaning outcome. (ANESTHESIOLOGY 2017; 126:1107-15).
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Dres M, Sklar M, Brochard L. Sevrage de la ventilation mécanique : quel test de sevrage utiliser chez les patients de réanimation ? MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Acute Respiratory Failure. SURGICAL INTENSIVE CARE MEDICINE 2016. [PMCID: PMC7153455 DOI: 10.1007/978-3-319-19668-8_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute respiratory failure accounts for 25–40 % of ICU admissions and carries a mortality rate of 30 % or more. In this chapter, we classify acute respiratory failure in two main types, based on their primary physiologic abnormality:Disorders of the airways, where increase of airway resistance to gas flow determines pharmacologic treatment and ventilatory strategies. These disorders are mainly asthma and chronic obstructive pulmonary disease. Disorders of the alveoli, where a decrease of lung compliance mandates the use of higher ventilatory pressures that can recruit but also damage the lung. These disorders include the acute respiratory distress syndrome, pneumonia, acute cardiogenic pulmonary edema, and influenza.
Additional types of acute respiratory failure are described elsewhere in this book: disorders that result from neuromuscular disease in Chap. 10.1007/978-3-319-19668-8_19 and pulmonary disorders of the circulation, including pulmonary thromboembolism, in Chap. 10.1007/978-3-319-19668-8_27. Finally, we provide a section on weaning from mechanical ventilation, which includes the pathophysiology of the ventilatory load imposed by the prolonged acute respiratory failure, the possible ways to support the weakened respiratory system, and the current process of screening and testing for readiness to remove the ventilator.
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Carrié C, Bonnardel E, Vally R, Revel P, Marthan R, Marthan R. Vital Capacity Impairment due to Neuromuscular Disease and its Correlation with Diaphragmatic Ultrasound: A Preliminary Study. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:143-149. [PMID: 26620221 DOI: 10.1016/j.ultrasmedbio.2015.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 09/07/2015] [Accepted: 09/21/2015] [Indexed: 06/05/2023]
Abstract
The purpose of this pilot study was to evaluate the correlation between diaphragmatic excursion measured by a right sub-costal ultrasound approach and forced vital capacity in patients with amyotrophic lateral sclerosis (ALS) or myotonic dystrophy (MD). All patients referred for pulmonary function testing underwent ultrasonic measurement of diaphragmatic excursion during quiet breathing, voluntary sniffing (Esniff) and forced breathing (EDEmax). Forty-five patients were included, mainly for amyotrophic lateral sclerosis or myotonic dystrophy. There was a significant correlation between EDEmax values and forced vital capacity (FVC) values (r = 0.68 [0.46–0.90], p < 0.0001) and between EDEmax values and percentage of predicted FVC values (r = 0.75 [0.55–0.95], p < 0.0001). At a threshold of EDEmax < 5.5 cm, the sensitivity and specificity of ultrasonic diaphragmatic excursion in predicting FVC ≤ 50% of theoretical values were 100% [66%–100%] and 69% [52%–84%] respectively, without any significant difference between males and females. There was no statistical correlation between maximal inspiratory pressure and Esniff.
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Affiliation(s)
- Cédric Carrié
- Emergency Department, CHU de Bordeaux, Bordeaux, France
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Silva MGBE, Borges DL, Costa MDAG, Baldez TEP, da Silva LN, Oliveira RL, Ferreira TDFR, Albuquerque RAM. Application of Mechanical Ventilation Weaning Predictors After Elective Cardiac Surgery. Braz J Cardiovasc Surg 2015; 30:605-9. [PMID: 26934398 PMCID: PMC4762550 DOI: 10.5935/1678-9741.20150076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/03/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To test several weaning predictors as determinants of successful extubation after elective cardiac surgery. METHODS The study was conducted at a tertiary hospital with 100 adult patients undergoing elective cardiac surgery from September to December 2014. We recorded demographic, clinical and surgical data, plus the following predictive indexes: static compliance (Cstat), tidal volume (Vt), respiratory rate (f), f/ Vt ratio, arterial partial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2), and the integrative weaning index (IWI). Extubation was considered successful when there was no need for reintubation within 48 hours. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were used to evaluate each index. RESULTS The majority of the patients were male (60%), with mean age of 55.4±14.9 years and low risk of death (62%), according to InsCor. All of the patients were successfully extubated. Tobin Index presented the highest SE (0.99) and LR+ (0.99), followed by IWI (SE=0.98; LR+ =0.98). Other scores, such as SP, NPV and LR-were nullified due to lack of extubation failure. CONCLUSION All of the weaning predictors tested in this sample of patients submitted to elective cardiac surgery showed high sensitivity, highlighting f/Vt and IWI.
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Affiliation(s)
| | - Daniel Lago Borges
- University Hospital of Universidade Federal do
Maranhão (HUUFMA), São Luís, MA, Brazil
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Friedrich O, Reid MB, Van den Berghe G, Vanhorebeek I, Hermans G, Rich MM, Larsson L. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill. Physiol Rev 2015; 95:1025-109. [PMID: 26133937 PMCID: PMC4491544 DOI: 10.1152/physrev.00028.2014] [Citation(s) in RCA: 224] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca(2+) dysregulation is present through altered Ca(2+) homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models.
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Affiliation(s)
- O Friedrich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M B Reid
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Van den Berghe
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - I Vanhorebeek
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Hermans
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M M Rich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - L Larsson
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
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Byrne PIBJ, Collins S, Mah CC, Smith B, Conlon T, Martin SD, Corti M, Cleaver B, Islam S, Lawson LA. Phase I/II trial of diaphragm delivery of recombinant adeno-associated virus acid alpha-glucosidase (rAAaV1-CMV-GAA) gene vector in patients with Pompe disease. HUM GENE THER CL DEV 2015; 25:134-63. [PMID: 25238277 DOI: 10.1089/humc.2014.2514] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Larraza S, Dey N, Karbing DS, Jensen JB, Nygaard M, Winding R, Rees SE. A mathematical model approach quantifying patients' response to changes in mechanical ventilation: evaluation in volume support. Med Eng Phys 2015; 37:341-9. [PMID: 25686673 DOI: 10.1016/j.medengphy.2014.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/14/2014] [Accepted: 12/28/2014] [Indexed: 11/17/2022]
Abstract
This paper presents a mathematical model-approach to describe and quantify patient-response to changes in ventilator support. The approach accounts for changes in metabolism (V̇O2, V̇CO2) and serial dead space (VD), and integrates six physiological models of: pulmonary gas-exchange; acid-base chemistry of blood, and cerebrospinal fluid; chemoreflex respiratory-drive; ventilation; and degree of patients' respiratory muscle-response. The approach was evaluated with data from 12 patients on volume support ventilation mode. The models were tuned to baseline measurements of respiratory gases, ventilation, arterial acid-base status, and metabolism. Clinical measurements and model simulated values were compared at five ventilator support levels. The models were shown to adequately describe data in all patients (χ(2), p > 0.2) accounting for changes in V̇CO2, VD and inadequate respiratory muscle-response. F-ratio tests showed that this approach provides a significantly better (p < 0.001) description of measured data than: (a) a similar model omitting the degree of respiratory muscle-response; and (b) a model of constant alveolar ventilation. The approach may help predict patients' response to changes in ventilator support at the bedside.
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Affiliation(s)
- S Larraza
- Respiratory and Critical Care Group (RCARE), Center for Model-based Medical Decision Support, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, E4-213, DK-9220 Aalborg, Denmark.
| | - N Dey
- Department of Anaesthesia and Intensive Care, Regions Hospital Herning, Herning, Denmark
| | - D S Karbing
- Respiratory and Critical Care Group (RCARE), Center for Model-based Medical Decision Support, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, E4-213, DK-9220 Aalborg, Denmark
| | | | - M Nygaard
- Department of Anaesthesia and Intensive Care, Regions Hospital Herning, Herning, Denmark
| | - R Winding
- Department of Anaesthesia and Intensive Care, Regions Hospital Herning, Herning, Denmark
| | - S E Rees
- Respiratory and Critical Care Group (RCARE), Center for Model-based Medical Decision Support, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, E4-213, DK-9220 Aalborg, Denmark
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Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory Muscle Dysfunction: A Multicausal Entity in the Critically Ill Patient Undergoing Mechanical Ventilation. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bernal T, Pardavila EV, Bonastre J, Jarque I, Borges M, Bargay J, Ayestarán JI, Insausti J, Marcos P, González-Sanz V, Martínez-Camblor P, Albaiceta GM. Survival of hematological patients after discharge from the intensive care unit: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R302. [PMID: 24377481 PMCID: PMC4056608 DOI: 10.1186/cc13172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/27/2013] [Indexed: 11/17/2022]
Abstract
Introduction Although the survival rates of hematological patients admitted to the ICU are improving, little is known about the long-term outcome. Our objective was to identify factors related to long-term outcome in hematological patients after ICU discharge. Methods A prospective, observational study was carried out in seven centers in Spain. From an initial sample of 161 hematological patients admitted to one of the participating ICUs during the study period, 62 were discharged alive and followed for a median time of 23 (1 to 54) months. Univariate and multivariate analysis were performed to identify the factors related to long term-survival. Finally, variables that influence the continuation of the scheduled therapy for the hematological disease were studied. Results Mortality after ICU discharge was 61%, with a median survival of 18 (1 to 54) months. In the multivariate analysis, an Eastern Cooperative Oncology Group score (ECOG) >2 at ICU discharge (Hazard ratio 11.15 (4.626 to 26.872)), relapse of the hematological disease (Hazard ratio 9.738 (3.804 to 24.93)) and discontinuation of the planned treatment for the hematological disease (Hazard ratio 4.349 (1.286 to 14.705)) were independently related to mortality. Absence of stem cell transplantation, high ECOG and high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores decreased the probability of receiving the planned therapy for the hematological malignancy. Conclusions Both ICU care and post-ICU management determine the long-term outcome of hematological patients who are discharged alive from the ICU.
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Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from mechanical ventilation. Intensive Care Med 2013; 39:1885-95. [DOI: 10.1007/s00134-013-3014-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/27/2013] [Indexed: 01/28/2023]
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Smith BK, Gabrielli A, Davenport PW, Martin AD. Effect of training on inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients. Respir Care 2013; 59:22-31. [PMID: 23764858 DOI: 10.4187/respcare.02053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND While inspiratory muscle weakness is common in prolonged mechanical ventilation, inspiratory muscle strength training (IMST) can facilitate strengthening and ventilator weaning. However, the inspiratory load compensation (ILC) responses to threshold loads are not well characterized in patients. We retrospectively compared ILC responses according to the clinical outcomes of IMST (ie, maximum inspiratory pressure [PImax], weaning outcome), in difficult-to-wean ICU patients. METHODS Sixteen tracheostomized subjects (10 weaned, 6 unweaned) from a previous clinical trial underwent IMST 5 days/week, at the highest tolerated load, in conjunction with daily, progressive spontaneous breathing trials. PImax and ILC with a 10 cm H2O load were compared in the subjects before and after IMST. Changes in ILC performance were further characterized (5, 10, 15 cm H2O loads) in the trained subjects who weaned. RESULTS Demographics, respiratory mechanics, and initial PImax (52 ± 26 cm H2O vs 42 ± 13 cm H2O) did not significantly differ between the groups. Upon enrollment, PImax significantly correlated with flow ILC responses with the 10 cm H2O load (r = 0.64, P = .008). After IMST, PImax significantly increased in the entire sample (P = .03). Both before and after IMST, subjects who weaned generated greater flow and volume ILC than subjects who failed to wean. Additionally, ILC flow, tidal volume, and duty cycle increased upon ventilator weaning, at loads of 5, 10, and 15 cm H2O. CONCLUSIONS Flow ILC at a threshold load of 10 cm H2O in ventilated, tracheostomized subjects positively correlated with PImax. Although PImax improved in both groups, the flow and volume ILC responses of the weaned subjects were more robust, both before and after IMST. The results suggest that ILC response is different in weaned and unweaned subjects, reflecting dynamic inspiratory muscular efforts that could be influential in weaning.
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22
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Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation. Arch Bronconeumol 2013; 50:73-7. [PMID: 23669061 DOI: 10.1016/j.arbres.2013.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 02/02/2013] [Accepted: 03/04/2013] [Indexed: 11/19/2022]
Abstract
Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.
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Affiliation(s)
- Magda C Díaz
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia; Departamento de Ciencias Fisiológicas, Facultad de Salud, Universidad del Valle, Cali, Colombia
| | - Gustavo A Ospina-Tascón
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia; Grupo de Investigación Biomédica de la Universidad ICESI, Cali, Colombia
| | - Blanca C Salazar C
- Departamento de Ciencias Fisiológicas, Facultad de Salud, Universidad del Valle, Cali, Colombia.
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Deye N, Lellouche F, Maggiore SM, Taillé S, Demoule A, L'Her E, Galia F, Harf A, Mancebo J, Brochard L. The semi-seated position slightly reduces the effort to breathe during difficult weaning. Intensive Care Med 2012; 39:85-92. [PMID: 23093247 DOI: 10.1007/s00134-012-2727-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The influence of posture on breathing effort in patients with difficult weaning is unknown. We hypothesized that posture could modulate the breathing effort in difficult-to-wean patients. METHODS A prospective, crossover, physiologic study was performed in 24 intubated patients breathing with pressure support who had already failed a spontaneous breathing trial or an extubation episode. Their median duration of mechanical ventilation before measurements was 25 days. Breathing pattern, occlusion pressure (P (0.1)), intrinsic PEEP (PEEP(i)), and inspiratory muscle effort evaluated by the pressure-time product of the respiratory muscles and the work of breathing were measured during three postures: the seated position in bed (90°LD), simulating the position in a chair, the semi-seated (45°), and the supine (0°) positions consecutively applied in a random order. A comfort score was obtained in 17 cooperative patients. The influence of position on chest wall compliance was measured in another group of 11 sedated patients. RESULTS The 45° position was associated with the lowest levels of effort (p ≤ 0.01) and occlusion pressure (p < 0.05), and tended to be more often comfortable. Respiratory effort was the lowest at 45° in 18/24 patients. PEEP(i) and PEEP(i)-related work were slightly higher in the supine position (p ≤ 0.01), whereas respiratory effort, heart rate, and P (0.1) values were increased in the seated position (p < 0.05). CONCLUSION A 45° position helps to unload the respiratory muscles, moderately reduces PEEP(i), and is often considered as comfortable. The semi-seated position may help the weaning process in ventilator-dependent patients.
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Affiliation(s)
- N Deye
- Medical Intensive Care Unit (ICU), Henri Mondor University Hospital, AP-HP, Créteil, France.
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Black CJ, Kuper M, Bellingan GJ, Batson S, Matejowsky C, Howell DCJ. A multidisciplinary team approach to weaning from prolonged mechanical ventilation. Br J Hosp Med (Lond) 2012; 73:462-6. [DOI: 10.12968/hmed.2012.73.8.462] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claire J Black
- UCL Hospitals NHS Foundation Trust, London NW1 2BU and NIHR Clinical Doctoral Research Fellow in Bloomsbury Institute of Intensive Care Medicine, University College London, London
| | | | | | | | | | - David CJ Howell
- UCL Hospitals NHS Foundation Trust, London and the Centre for Respiratory Research, Rayne Institute, University College London, London
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Pettersson S, Melaniuk-Bose M, Edell-Gustafsson U. Anaesthetists' perceptions of facilitative weaning strategies from mechanical ventilator in the intensive care unit (ICU): a qualitative interview study. Intensive Crit Care Nurs 2012; 28:168-75. [PMID: 22227354 DOI: 10.1016/j.iccn.2011.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 12/06/2011] [Accepted: 12/10/2011] [Indexed: 11/26/2022]
Abstract
AIM This study aimed to examine anaesthetists' perceptions of facilitative weaning from the mechanical ventilator in the intensive care unit (ICU). METHODS Explorative qualitative interviews in a phenomenographic reference frame with a purposive sample of 14 eligible anaesthetists from four different ICUs with at least one year of clinical experience of ICU and of ventilator weaning. FINDINGS Four categories of anaesthetists' perceptions of facilitative decision-making strategies for ventilator weaning were identified. These were the instrumental, the interacting, the process-oriented and the structural strategies" for ventilator weaning. The findings refer to a supportive multidisciplinary holistic ICU quality of care. Choice of strategy for ventilator weaning was flexible and individually tailored to the patients'. CONCLUSIONS Choice of strategy was flexible and individually adjustable. Introduction of evidence-based guidelines from ventilator weaning is necessary in the ICU. The guidelines should also cover the responsibilities of various professional groups. Regular evaluations of methods and strategies used in practice need to be implemented. This may facilitate decision-making strategies for ventilator weaning in practice at the ICU. Greater attention needs to focus on family members' experiences. The strategies should be an integral part of continuous staff training.
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Affiliation(s)
- Sara Pettersson
- Department of Medicine and Health, Division of Nursing Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Haugdahl HS, Storli SL. 'In a way, you have to pull the patient out of that state …': the competency of ventilator weaning. Nurs Inq 2011; 19:238-46. [PMID: 22882506 DOI: 10.1111/j.1440-1800.2011.00567.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The introduction of the weaning protocol has reduced weaning time and improved results in patients. However, the evidence is inconsistent. This may reflect that the use of a protocol should not exclude individual considerations and clinical judgement. However, the significant aspects of the context and the competency important in the nurse-patient relationship in weaning have not yet been sufficiently described. This study aimed at exploring these aspects of weaning. Qualitative data from six in-depth interviews and field observations of three experienced intensive care nurses in weaning situations were analysed through systematic text condensation within a hermeneutic-phenomenological approach. Competency appeared to be based on thorough knowledge of physiology and ventilator skills, but also on knowing the patient, helping the nurse connect the meaningless to the meaningful for the patient. Behaving competently involves a continuous dialogue with the situation, observation of the patient's body language and symptoms over a period of time and the ability to see the interrelationships of all these elements. Competency in ventilator weaning may thus be linked to personal qualifications, while it is simultaneously dependent on a professional community that both confirms and acknowledges this competency.
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Affiliation(s)
- Hege S Haugdahl
- Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway.
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Doherty N, Steen CD. Critical illness polyneuromyopathy (CIPNM); rehabilitation during critical illness. Therapeutic options in nursing to promote recovery: a review of the literature. Intensive Crit Care Nurs 2011; 26:353-62. [PMID: 20971010 DOI: 10.1016/j.iccn.2010.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 07/17/2010] [Accepted: 08/24/2010] [Indexed: 12/13/2022]
Abstract
Following critical illness requiring prolonged mechanical ventilation and sedation, intensive care patients often present with neuromuscular weakness. This results from critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). A lack of diagnostic criteria for each syndrome complicates prevention and treatment. Consequently the term critical illness polyneuromyopathy (CIPNM) has emerged and is characterised by severe weakness, reduced or absent limb reflexes and marked muscle wasting. Although clinical trials report a high incidence of CIPNM, in clinical practice it often remains undetected. The pathophysiological mechanisms that lead to neuromuscular weakness are not entirely clear, however several risk factors have been identified and will be discussed. To date, there are no specific treatments or interventions available to reduce the onset or impact of CIPNM. This paper will review the strategies employed that are supportive and aimed at controlling the associated risk factors.
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Affiliation(s)
- Nicola Doherty
- Critical Care Sister, Lancashire Teaching Trust, Preston, United Kingdom.
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