difficult weaning. indications for mechanical ventilation: a) global pathophysiological indications:...
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Difficult Weaning
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Indications for mechanical ventilation:
A) Global pathophysiological indications:
- Apnea- Acute ventilatory failure- impending failure- Refractory hypoxemia- Signs of respiratory failure
B) Common clinical conditions when need for ventilatory support is high:
- ARDS- Asthma- COPD- Chest trauma- Overdose- Post cardiac surgery- Pneumonia- Sepsis- Head Trauma
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-Preparing the Patient for Weaning:
- Electrolyte Disturbance- Volume Overload
- Altered Mental status- Fatigue of the diaphragm
- Adequacy of sleep and sleep deprivation- Malnutrition
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-Criteria to consider Patients for Weaning:
- Reversal of underlying pathology- Po2, PEEP, FiO2, PH- ABG- Vital Data- CXR
-Parameters Predicting successful Weaning:
- Respiratory rate- Tidal Volume- Minute Ventilation- Negative inspiratory force- Maximal Inspiratory pressure- RSBI- RSBI rate
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Algorithm for weaning Protocol
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New Advances in Ventilators to assist Weaning:
- Automated tube compensation (ATC)
- Proportional Assisted ventilation (PAV)
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Causes of Difficult Weaning
Imbalance
Respiratory muscle pump Respiratory muscle load
A) Increased Ventilatory Needs
Increased resistive load Increased chest Wall Load Increased parenchyma load
-Bronchospasm- Airway edema- Airway obstruction- Tube kinking- Sleep Apnea- Secretions- Circuit resistance
- Pleural effusion- Pnumothorax- Flail chest- Obesity - Ascites- Distension
-Hyperinflation- Inflammation- Atelectasis- Alveolar edema
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B) Decreased Neuromuscular compliance:
Decreased Drive Muscle Weakness Impaired Transmission
Drug overdose - Electrolyte derangement - Critical illness polyneuropathyBrain-stem lesion - Malnutrition - Neuromuscular blockersSleep deprivation - Myopathy - AminoglycosidesHypothyroidism - Hyperinflation - Guillain–Barré syndromeStarvation/malnutrition - Drugs, corticosteroids - Mysthenia gravisMetabolic alkalosis - Sepsis - Phrenic nerve injuryMyotonic dystrophy
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How to Wean Difficult to Wean Patients
Correction of Causes
Choice of appropriate mode
Tracheostomy
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Neuromuscular Weakness in Critically Ill
Critical illness polyneuropathy (CIP): Disorders of neuromuscular transmission: Myopathy:
Critical illness Polyneuropathy
DefinitionCourseCausesDiagnosis: - EPS: shows reduced compound motor and sensory nerve action potential amplitudes with normal conduction velocities. - Needle EMG reveals fibrillation potentials and positive sharp waves indicating denervation
Treatment
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Disorders of neuromuscular transmission:
- Prolonged use of neuromuscular blockers
- Decreased Metabolism
- Decremental Response
- Aminoglycosides, Polypeptide antibiotics
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Myopathy:
1. Critical illness myopathy:
- Histological Pattern
- Normal CPK levels
- Type II myofibres
- IL-1, TNF
2. Thick filament myopathy:
- Selective loss of myosin
- Absent neuropathy
- Increased steroid receptors
- Triggering factors: NMBA, Denervation
- Diagnosis: EPS, CPK , Muscle biopsy
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3. Necrotizing myopathy:
- Prominent muscle necrosis
- CPK elevated
- Correlated with NMBA, Steroids
- Diagnosis: - difficult to diagnose - Direct muscle stimulation and calculation of the ratio of nerve and muscle evoked compound muscle action potential amplitudes. - Muscle biopsy is of choice
-No specific treatment is available
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Prevention of neuromuscular weakness in ICU:
- Appropriate treatment of sepsis
- Minimize use of NMBA
- Check serum electrolytes
- Avoid Pharmacological agents causing weakness
- Early EPS
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Thank You