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Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, Mishra RC. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024; 28:S233-S248. [PMID: 39234223 PMCID: PMC11369923 DOI: 10.5005/jp-journals-10071-24716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 04/15/2024] [Indexed: 09/06/2024] Open
Abstract
Background and purpose Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists). Methods A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning. Result This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions). Conclusion This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards. How to cite this article Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.
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Affiliation(s)
- Anuj M Clerk
- Department of Intensive Care, Sunshine Global Hospital, Surat, Gujarat, India
| | - Ritesh J Shah
- Department of Critical Care Medicine, Sterling Hospital, Vadodara, Gujarat, India
| | - Jay Kothari
- Department of Critical Care Medicine, Apollo International Hospital, Ahmedabad, Gujarat, India
| | | | - Sonali Vadi
- Department of Intensive Care Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Fradkin M, Elyashiv M, Camel A, Agay N, Brik M, Singer P, Dankner R. A historical cohort study on predictors for successful weaning from prolonged mechanical ventilation and up to 3-year survival follow-up in a rehabilitation center. Respir Med 2024; 227:107636. [PMID: 38642907 DOI: 10.1016/j.rmed.2024.107636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/04/2024] [Accepted: 04/13/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND We followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival. METHODS This historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015-2018 and followed for survival according to weaning success up to 3 years or the end of 2021. RESULTS The study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts. The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33-1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42-1.39, p = 0.38. CONCLUSION Successful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings.
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Affiliation(s)
- Mila Fradkin
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Schoenbrun Academic Nursing School, Sourasky Medical Center, Tel Aviv, Israel
| | - Maya Elyashiv
- Intubation Unit, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Amasha Camel
- Intubation Unit, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Nirit Agay
- Center for Research of Public Health, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
| | - Michael Brik
- Research and Development Institute, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Pierre Singer
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; General Intensive Care Department, Beilinson Hospital, Rabin Medical Center, Petah Tikva, and ICU Herzliya Medical Center, Israel
| | - Rachel Dankner
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Center for Research of Public Health, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel; Research and Development Institute, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel.
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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [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: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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Oh J, Lim H, Jeong CW, Kim MS, Lee J, Kang WS, An UR, Park JU, Ahn Y, Kim YR, Park C. Clinical implication of thoracic skeletal muscle volume as a predictor of ventilation-weaning failure in brain-injured patients: A retrospective observational study. Medicine (Baltimore) 2023; 102:e35847. [PMID: 37904365 PMCID: PMC10615541 DOI: 10.1097/md.0000000000035847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 10/06/2023] [Indexed: 11/01/2023] Open
Abstract
Sarcopenia, a generalized loss of skeletal muscle mass that is primarily evident in the respiratory musculature, is associated with adverse outcomes in critically ill patients. However, the relationship between sarcopenia and ventilation-weaning outcomes has not yet been fully studied in patients with brain injuries. In this study, we examined the effect of reduced respiratory muscle mass on ventilation weaning in patients with brain injury. This observational study retrospectively reviewed the medical records of 73 patients with brain injury between January 2017 and December 2019. Thoracic skeletal muscle volumes were measured from thoracic CT images using the institute's three-dimensional modeling software program of our institute. The thoracic skeletal muscle volumes index (TSMVI) was normalized by dividing muscle volume by the square of patient height. Sarcopenia was defined as a TSMVI of less than the 50th sex-specific percentile. Among 73 patients with brain injury, 12 (16.5%) failed to wean from mechanical ventilation. The patients in the weaning-failure group had significantly higher sequential organ failure assessment scores [7.8 ± 2.7 vs 6.1 ± 2.2, P = .022] and lower thoracic skeletal muscle volume indexes [652.5 ± 252.4 vs 1000.4 ± 347.3, P = .002] compared with those in the weaning-success group. In multivariate analysis, sarcopenia was significantly associated with an increased risk of weaning failure (odds ratio 12.72, 95% confidence interval 2.87-70.48, P = .001). Our study showed a significant association between the TSMVI and ventilation weaning outcomes in patients with brain injury.
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Affiliation(s)
- Jimi Oh
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hyun Lim
- Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan-si, South Korea
| | - Chang Won Jeong
- Smart Health IT Center, Wonkwang University Hospital, Iksan-si, South Korea
| | - Min Su Kim
- Department of Rehabilitation Medicine, Soonchunhyang University, College of Medicine, Cheonan-si, South Korea
| | - Jinseok Lee
- Department of Biomedical Engineering, Kyung Hee University, Yongin-si, South Korea
| | - Wu Seong Kang
- Department of Trauma Surgery, Cheju Halla General Hospital, Jeju-si, South Korea
| | - Ui Ri An
- Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan-si, South Korea
| | - Joo Un Park
- Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan-si, South Korea
| | - Youngick Ahn
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Youe Ree Kim
- Department of Radiology, Wonkwang University School of Medicine, Iksan-si, South Korea
| | - Chul Park
- Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan-si, South Korea
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Michels JD, Trudzinski FC, Bornitz F, Ewert R, Müller M, Trinkmann F, Schellenberg M, Windisch W, Herth FJF. Costs of Weaning Failure: A Prospective, Multicentre, Controlled, Non-Randomised, Interventional Study on Economic Implications for the German Health Care System. Respiration 2023; 102:813-820. [PMID: 37619539 DOI: 10.1159/000533333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Intensive care patients with respiratory failure often need invasive mechanical ventilation (IMV). With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV rises as well. Up to 85% of these patients have no access to a certified weaning centre. Their medical care is associated with impaired quality of life and high costs for the German health care system. OBJECTIVES This study examined the weaning outcome of patients in certified weaning centres after a primarily unsuccessful weaning attempt in order to calculate saving expenses compared to patients on long-term IMV in an outpatient setting. METHODS In this multicentre, controlled, non-randomised, interventional, prospective study, 61 patients (16 from out-of-hospital long-term IMV, 49 from other hospitals) were referred to a certified weaning centre for a second weaning phase. The incurred costs after 1 year of the latter were compared to insurance claim data of patients who were discharged from an acute hospital stay to receive IMV in an outpatient setting. RESULTS In the intervention group, 50 patients (82%) could be completely weaned or partially weaned using non-invasive ventilation, thus not needing IMV any longer. The costs per patient for weaning and out-of-hospital care in the intervention group were EUR 114,877.08, and the costs in the comparison cohort were EUR 234,442.62. CONCLUSIONS Early transfer to a certified weaning centre can increase weaning success and reduce total costs by approximately EUR 120,000 per patient in the first year. Given the existing structural prerequisites in Germany, every patient should have access to a weaning centre before being transferred to long-term IMV, from a medical and health economical point of view.
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Affiliation(s)
- Julia D Michels
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franziska C Trudzinski
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Florian Bornitz
- Asklepios Hospital Barmbek, Pneumology and Internal Intensive Care Medicine, Hamburg, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, Cardiology, Pneumology, Weaning, Infectious Diseases, Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Michael Müller
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Frederik Trinkmann
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Mavi Schellenberg
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Witten/Herdecke University, Cologne, Germany
| | - Felix J F Herth
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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7
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Michels JD, Meis J, Sturm N, Bornitz F, von Schumann S, Weis A, Neetz B, Bentner M, Forstner J, Litke N, Wensing M, Erdmann S, Grobe T, Frerk T, Kempa A, Neurohr C, Schneider A, Müller M, Herth FJF, Szecsenyi J, Trudzinski FC. Prevention of invasive ventilation (PRiVENT)-a prospective, mixed-methods interventional, multicentre study with a parallel comparison group: study protocol. BMC Health Serv Res 2023; 23:305. [PMID: 36998047 PMCID: PMC10061400 DOI: 10.1186/s12913-023-09283-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/14/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) is a standard therapy for intensive care patients with respiratory failure. With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV increases, resulting in impaired quality of life and high costs. In addition, human resources are tied up in the care of these patients. METHODS The PRiVENT intervention is a prospective, mixed-methods interventional, multicentre study with a parallel comparison group selected from insurance claims data of the health insurer Allgemeine Ortskrankenkasse Baden-Württemberg (AOK-BW) conducted in Baden-Württemberg, Germany, over 24 months. Four weaning centres supervise 40 intensive care units (ICUs), that are responsible for patient recruitment. The primary outcome, successful weaning from IMV, will be evaluated using a mixed logistic regression model. Secondary outcomes will be evaluated using mixed regression models. DISCUSSION The overall objective of the PRiVENT project is the evaluation of strategies to prevent long-term IMV. Additional objectives aim to improve weaning expertise in and cooperation with the adjacent Intensive Care Units. TRIAL REGISTRATION This study is registered at ClinicalTrials.gov (NCT05260853).
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Affiliation(s)
- Julia D Michels
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany.
- Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Röntgenstrasse 1, Heidelberg, D-69126, Germany.
| | - Jan Meis
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Noemi Sturm
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Bornitz
- Asklepios Hospital Barmbek, Pneumology and Internal Intensive Care Medicine, Hamburg, Germany
| | - Selina von Schumann
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Aline Weis
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Martina Bentner
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Johanna Forstner
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Litke
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Stella Erdmann
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Thomas Grobe
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Timm Frerk
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Axel Kempa
- Department of Pneumology and Critical Care, SLK-Klinik Löwenstein, Löwenstein, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Gerlingen, Germany
| | - Armin Schneider
- Department of Anaesthesia and Intensive Care Medicine Waldburg-Zeil Kliniken, Wangen Im Allgäu, Germany
| | - Michael Müller
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Franziska C Trudzinski
- Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH, Heidelberg, Germany
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Escobar MA, Navarro E, Rositi ES, Obligado R, Morel Vulliez GG, De Vito EL. [Respiratory and physical recovery in cervical spinal cord injury. Seventeen years' experience in a weaning and rehabilitation center: An observational study]. Rehabilitacion (Madr) 2022; 56:125-132. [PMID: 33256992 DOI: 10.1016/j.rh.2020.10.009] [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: 05/23/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Spinal 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 METHOD Observational, 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. RESULTS Of 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. CONCLUSIONS The 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.
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Affiliation(s)
- M A Escobar
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Kinesiología y Fisiatría, Hospital Municipal de Vicente López Dr. B. Houssay, Ciudad Autónoma de Buenos Aires, Argentina
| | - E Navarro
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Unidad de Kinesiología, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina.
| | - E S Rositi
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Kinesiología, HIGA Petrona V. de Cordero, San Fernando, Buenos Aires, Argentina
| | - R Obligado
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina
| | - G G Morel Vulliez
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Rehabilitación, HIGA Eva Perón, San Martín, Buenos Aires, Argentina
| | - E L De Vito
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Instituto de Investigaciones Médicas Alfredo Lanari, UBA, Argentina
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9
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Rose L, Dvorani E, Homenauth E, Istanboulian L, Fraser I. Mortality, Health Care Use, and Costs of Weaning Center Survivors and Matched Prolonged ICU Stay Controls. Respir Care 2022; 67:291-300. [PMID: 35078929 PMCID: PMC9993494 DOI: 10.4187/respcare.09438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Quantification of long-term survival, health care utilization, and costs of prolonged ventilator dependence informs patient/family decision-making, health care policy, and understanding of specialized weaning centers (SWCs) as alternate care models. Our objective was to compare survival trajectory, health care utilization, and costs of SWC survivors with a matched cohort of ≥ 21-d-stay ICU patients. METHODS This was a retrospective longitudinal (12 y) case-control study linking to health administrative databases with matching on age, sex, Charlson comorbidity index, income quintiles, and days in ICU and hospital in preceding 12 months. RESULTS We matched 201 SWC subjects to 201 prolonged ICU survivors (402-subject cohort); 42% had a Charlson score of > 4. Risk of death at 12 months was lower in SWC subjects (hazard ratio [HR] 0.70 [95% CI 0.54-0.91]) adjusting for length of hospital admission (HR 1.02 [95% CI 1.00-1.04]) and number of care location transfers (HR 0.84 [95% CI 0.75-0.93]). By follow-up end, more SWC subjects died, 149 (73%) versus 127 (62%). We found no difference in discharge to home. At 12 months, acute health care utilization was comparable for the entire cohort, except hospital readmission rates (median interquartile range [IQR] 2 [1-3) vs 1 [1-2] d). Median (IQR) cost 12 months after unit discharge was CAD $68,165 ($19,894-$153,475). 12-month costs were higher in the SWC survivors (CAD $82,874 [$29,942-$224,965] vs CAD $55,574 [$6,572-$128,962], P < .001). SWC survivors had higher community health care utilization. Regression modeling demonstrated cost was associated with stay and care transfers but not SWC admission. Over 12-y follow-up, health care utilization and costs were higher in SWC survivors. CONCLUSIONS SWC admission may confer some medium-term survival advantage; however, this may be influenced by selection bias associated with admission criteria.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom; Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Hospital Trust, London, United Kingdom; and Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada.
| | - Erind Dvorani
- Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Esha Homenauth
- Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Laura Istanboulian
- Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada; and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ian Fraser
- Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada; and Faculty of Medicine, University of Toronto, Toronto, Canada
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10
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Löfroth M, Petersson JE, Uusijärvi J, Hårdemark Cedborg AI, Sundman E. Outcomes of prolonged intensive care and rehabilitation at a specialized multidisciplinary center in Sweden. Acta Anaesthesiol Scand 2022; 66:232-239. [PMID: 34778943 DOI: 10.1111/aas.13998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/12/2021] [Accepted: 10/29/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Specialized clinics may improve the outcome for patients with prolonged intensive care stays. Admission may depend on diagnosis, need of respiratory support and more. We report the results from a Swedish specialized center with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation regardless of patients' primary diagnosis or ventilator need. METHODS All patients admitted and discharged from 2015 to 2018 were included. Demographics, diagnoses, ventilatory support requirement, discharge destination and survival were retrieved from the center´s quality registry. RESULTS A total of 181 patients, mean age 61 ± 16 years, 64% men, were analyzed. A neurological diagnosis was the cause for hospitalization in 46% of patients. Of the 55 patients admitted to the center for weaning from mechanical ventilation, 89% were successfully weaned within a median of 25 (interquartile range (IQR) 16-45) days. Decannulation was intended in 117 patients of which 90% were successful within a median of 25 (IQR 13-43) days. Readmission to intensive care was 4%. Most patients were discharged to their home or to rehabilitation clinics with a lower level of care. In-clinic mortality was 3%. Survival beyond 1 and 2 years after discharge was 79% and 70%, respectively. CONCLUSION Patients with prolonged intensive care and complex medical needs treated at a specialized center in Sweden had weaning and decannulation rates comparable to or better than previously reported. Mortality was low, and most patients were discharged home or for further rehabilitation. This was achieved with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation.
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Affiliation(s)
- Mathias Löfroth
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - Jenny E. Petersson
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | | | | | - Eva Sundman
- The Remeo Clinic, Remeo Stockholm Sweden
- The Department of Medicine Solna Karolinska Institutet Stockholm Sweden
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11
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Ghiani A, Paderewska J, Walcher S, Neurohr C. Mechanical power normalized to lung-thorax compliance predicts prolonged ventilation weaning failure: a prospective study. BMC Pulm Med 2021; 21:202. [PMID: 34140018 PMCID: PMC8210735 DOI: 10.1186/s12890-021-01566-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/21/2021] [Indexed: 01/18/2023] Open
Abstract
Background Mechanical 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. Methods Prospective, 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]). Results Forty-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). Conclusions MP 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01566-8.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Schillerhoehe Lung Clinic (affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Solitudestrasse 18, 70839, Gerlingen, Germany.
| | - Joanna Paderewska
- Department of Pulmonology and Respiratory Medicine, Schillerhoehe Lung Clinic (affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Solitudestrasse 18, 70839, Gerlingen, Germany
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Schillerhoehe Lung Clinic (affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Solitudestrasse 18, 70839, Gerlingen, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Schillerhoehe Lung Clinic (affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Solitudestrasse 18, 70839, Gerlingen, Germany.,German Center for Lung Research (DZL), München, Germany
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12
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Langzeitbeatmung bei Kindern und Jugendlichen – ein Fall für die Rehabilitation? Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01112-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Sison SM, Sivakumar GK, Caufield-Noll C, Greenough WB, Oh ES, Galiatsatos P. Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review. Heliyon 2021; 7:e06230. [PMID: 33615014 PMCID: PMC7880845 DOI: 10.1016/j.heliyon.2021.e06230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/24/2021] [Accepted: 02/04/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives To determine the outcomes of chronically ventilated patients outside the setting of intensive care units. Design Systematic review. Setting and participants Studies evaluating patients on chronic invasive mechanical ventilation in different care settings. Methods A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion. Results Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death. Conclusions and implications Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.
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Affiliation(s)
- Stephanie M Sison
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Gayathri K Sivakumar
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | - William B Greenough
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature. Pulmonology 2020; 27:43-51. [PMID: 32723618 DOI: 10.1016/j.pulmoe.2020.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation. METHODS We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) "non-invasive ventilation", "tracheostomy" and "weaning". We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation. RESULTS In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge. CONCLUSIONS The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning.
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15
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Ghiani A, Paderewska J, Sainis A, Crispin A, Walcher S, Neurohr C. Variables predicting weaning outcome in prolonged mechanically ventilated tracheotomized patients: a retrospective study. J Intensive Care 2020; 8:19. [PMID: 32123565 PMCID: PMC7035768 DOI: 10.1186/s40560-020-00437-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background Several 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. Methods Retrospective, 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. Results A 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. Conclusions In 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.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Joanna Paderewska
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Alexandros Sainis
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany.,Athens, Greece
| | - Alexander Crispin
- 3IBE - Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Swenja Walcher
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
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Ghiani A, Sainis A, Sainis G, Neurohr C. Anemia and red blood cell transfusion practice in prolonged mechanically ventilated patients admitted to a specialized weaning center: an observational study. BMC Pulm Med 2019; 19:250. [PMID: 31852456 PMCID: PMC6921402 DOI: 10.1186/s12890-019-1009-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 11/25/2019] [Indexed: 01/28/2023] Open
Abstract
Background The 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. Methods Retrospective, 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. Results Ninety-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). Conclusions A 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.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH, Stuttgart), Solitudestr. 18, 70839, Gerlingen, Germany.
| | - Alexandros Sainis
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH, Stuttgart), Solitudestr. 18, 70839, Gerlingen, Germany.,, Athens, Greece
| | | | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH, Stuttgart), Solitudestr. 18, 70839, Gerlingen, Germany.,, Munich, Germany
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Kastrup M, Tittmann B, Sawatzki T, Gersch M, Vogt C, Rosenthal M, Rosseau S, Spies C. Transition from in-hospital ventilation to home ventilation: process description and quality indicators. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2017; 15:Doc18. [PMID: 29308061 PMCID: PMC5738500 DOI: 10.3205/000259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 10/16/2017] [Indexed: 12/14/2022]
Abstract
The current demographic development of our society results in an increasing number of elderly patients with chronic diseases being treated in the intensive care unit. A possible long-term consequence of such a treatment is that patients remain dependent on certain invasive organ support systems, such as long-term ventilator dependency. The main goal of this project is to define the transition process between in-hospital and out of hospital (ambulatory) ventilator support. A further goal is to identify evidence-based quality indicators to help define and describe this process. This project describes an ideal sequence of processes (process chain), based on the current evidence from the literature. Besides the process chain, key data and quality indicators were described in detail. Due to the limited project timeline, these indicators were not extensively tested in the clinical environment. The results of this project may serve as a solid basis for proof of feasibility and proof of concept investigations, optimize the transition process of ventilator-dependent patients from a clinical to an ambulatory setting, as well as reduce the rate of emergency re-admissions.
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Affiliation(s)
- Marc Kastrup
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Tittmann
- Department for Hematology, Oncology and Palliative Care - Sarcoma Centre Berlin-Brandenburg, Bad Saarow, Germany
| | - Tanja Sawatzki
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Gersch
- Freie Universität Berlin, School of Business & Economics, Department of Information Systems, Chair of Business Administration, Berlin, Germany
| | - Charlotte Vogt
- Freie Universität Berlin, School of Business & Economics, Department of Information Systems, Chair of Business Administration, Berlin, Germany
| | - Max Rosenthal
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Simone Rosseau
- Klinik Ernst von Bergmann Bad Belzig gGmbH, Bad Belzig, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Shin HJ, Chang JS, Ahn S, Kim TO, Park CK, Lim JH, Oh IJ, Kim YI, Lim SC, Kim YC, Kwon YS. Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation. J Thorac Dis 2017; 9:143-150. [PMID: 28203417 DOI: 10.21037/jtd.2017.01.14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For patients requiring prolonged mechanical ventilation (PMV), weaning is difficult and mortality is very high. PMV has been defined recently, by consensus, as constituting ≥21 consecutive days of mechanical ventilation (MV) for ≥6 hours per day. This study aimed to evaluate the clinical factors predicting weaning failure in patients undergoing PMV in medical intensive care unit (ICU). METHODS We retrospectively reviewed the clinical and laboratory characteristics of 127 patients who received MV for more than 21 days in the medical ICU at Chonnam National University Hospital in South Korea between January 2005 and December 2014. Patients who underwent surgery or experienced trauma were excluded from this study. RESULTS Among the 127 patients requiring PMV, 41 (32.3%) were successfully weaned from MV. The median age of the weaning failure group was higher than that of the weaning success group (74.0 vs. 70.0 years; P=0.003). The proportion of male patients was 58.5% in the weaning success group and 72.1% in the weaning failure group, respectively. The most common reasons for ICU admission were respiratory causes (66.1%) followed by cardiovascular causes (16.5%) in both groups. ICU mortality and in-hospital mortality rates were 55.1% and 55.9%, respectively. In the multivariate analysis, respiratory causes of ICU admission [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.29-12.30; P=0.016] and a high sequential organ failure assessment (SOFA) score on day 21 of MV (OR, 1.47; 95% CI, 1.17-1.85; P=0.001) were significantly associated with weaning failure in patients requiring PMV. The area under the receiver operating characteristic (ROC) curve of the SOFA score on day 21 of MV for predicting weaning failure was 0.77 (95% CI, 0.67-0.87; P=0.000). CONCLUSIONS Respiratory causes of ICU admission and a high SOFA score on day 21 of MV could be predictive of weaning failure in patients requiring PMV.
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Affiliation(s)
- Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jin-Sun Chang
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Seong Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Cheol-Kyu Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jung-Hwan Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Young-Chul Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
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