Download - Discontinuing Mechanical Ventilation in ICU
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Discontinuing MV in ICU Up
to Date
Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases , Assiut University
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• Simple weaning” (group 1) includes
patients who succeed the first weaning trial
and are extubated without difficulty
, “Difficult weaning” (group 2) includes patients who fail the first weaning
trial and require up to 3 spontaneous
breathing trials or 7 days to achieve
successful weaning, and
“prolonged weaning” (group 3) includes patients who require more than 7
days of weaning after the first weaning trial.
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• Several indexes have been employed to assess the
patient's ability to recover spontaneous breathing.
• Variables such as minute ventilation (Ve), maximum
inspiratory pressure (PImax), breathing frequency,
rapid shallow breathing index (RSBI, i.e., respiratory
frequency/tidal volume), tracheal airway occlusion
pressure 0.1 s (P 0.1), P0.1/ PImax >0.3,
P0.1Xf/VT<300 , a combined index named CROP
(compliance, rate, O2, pressure index) >13, IWI>25
and CORE >8 have been used in common clinical
practice
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• P0.1/PImax > 0.3
— P0.1 is pressure at the airway opening
0.1 s after start of inspiratory flow
— Correlates with central respiratory drive
• P0.1 x f/VT <300
• CROP index (dynamic compliance,
respiratory rate, oxygenation, maximum
inspiratory pressure index) >13
— Cdyn x PImax x (PaO2/PAO2)/f
— >13 good
— Cdyn = dynamic compliance
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• IWI (integrative weaning index) >25
— (CRS x SaO2)/(f/VT)
— CRS = static compliance of the
respiratory system
• CORE index (dynamic compliance,
oxygenation, rate, effort) >8
— Cdyn x (PImax/P0.1) x (PaO2/PAO2)/f
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• Among the numerous parameters used
in clinical practice, the rapid shallow
breathing index is one of the most
accurate.
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First Recommendation
For acutely hospitalized patients
ventilated more than 24 h, we suggest
that the initial SBT be conducted with
inspiratory pressure augmentation (5-
8 cm H2O) rather than without (T-piece
or CPAP)
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Second Recommendation
For acutely hospitalized patients
ventilated for more than 24 h, we
suggest protocols attempting to
minimize sedation
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Third Recommendation
For patients at high risk for extubation
failure who have been receiving
mechanical ventilation for more than
24 h and who have passed an SBT, we
recommend extubation to preventive
NIV
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Third Recommendation
Patients at high risk for failure of
extubation may include those
patients with hypercapnia, COPD,
congestive heart failure, or other
serious comorbidities
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Noninvasive ventilation as a weaning strategy for
mechanical ventilation in adults with respiratory
failure: a Cochrane systematic review Karen E.A. Burns et al CMAJ 2014. DOI:10.1503
Noninvasive weaning reduces rates of
death and pneumonia without increasing
the risk of weaning failure or reintubation.
In subgroup analyses, mortality benefits
were significantly greater in patients with
COPD
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Fourth Recommendation
For acutely hospitalized adults who have
been mechanically ventilated for > 24 h,
we suggest protocolized rehabilitation
directed toward early mobilization
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Fifth Recommendation
We suggest managing acutely
hospitalized adults who have been
mechanically ventilated for > 24 h with a
ventilator liberation protocol
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Sixth Recommendation
We suggest performing a CLT in
mechanically ventilated adults who meet
extubation criteria and are deemed high
risk for PES
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Seventh Recommendation
For adults who have failed a CLT but are
otherwise ready for extubation, we
suggest administering systemic steroids
at least 4 h before extubation; a repeated
CLT is not required
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Diaphragm Ultrasound as a
Novel Guide of Weaning from
Invasive Ventilation
Gamal Agmy , MD , FCCP Professor of Chest Diseases and respiratory ICU,
Assiut University, Assiut , Egypt
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Diaphragm Ultrasound as a
Novel Guide of Weaning from
Invasive Ventilation
Gamal Agmy , MD , FCCP Professor of Chest Diseases and respiratory ICU,
Assiut University, Assiut , Egypt
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• DT was calculated as percentage
from the following formula:
T end-inspiration − T end-expiration
T end-expiration
• It was recorded at total lung
capacity (TLC) and residual volume
(RV).
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• DT was significantly different between
patients who failed and patients who
succeeded SBT.
• A cutoff value of a DT >40% was
associated with a successful SBT with a
sensitivity of 88%, a specificity of 92%, a
positive predictive value (PPV) of 95%,
and a negative predictive value (NPV) of
82%.
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