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New insights on tracheal extubation after difficult weaning
J. Mancebo, MD
COI (3yr)
-Covidien, and Maquet: Research grants
-Air Liquide: DMSB, Adv Board
-Faron and A-Lung: S Comm
-Covidien: Speaker at a mtg
-Braun: Consultancy
Beginning End
Screening SBT (<2h) Extubation
Extubation Reintubation NIV
Clinical approach
Predictors Techniques
Unplanned extubation
ERJ 2007
26/160 = 16%
13 10
15
0
7 10
19
9 5
16
33
24
0
10
20
30
40
FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.
Rate of re-intubation (%)
Rate of ICU Mortality (%)
Simple weaning Difficult weaning Prolonged weaning
37
13
017
11
2
22
13
42
18
0
10
20
30
40
50
FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.
1519
13 14 1510
16
50
27
33
43
35
26 28
0
10
20
30
40
50
60
Rate in % Reintubation rate
In-ICU mortality rate
Esteban 1997 [3] N=397
Esteban 1999 [4] N=453
Epstein 1997 [5] N=287
Vallverdú1998 [6] N=148
Thille 2011 [2] N=168
Frutos-Vivar 2011 [8] N=1142
Peñuelas2011 [7] N=2714
Thille AW, et al. COCC. 2013;19:57-64
Implications
De Jonghe B, et al. JAMA 2002;288:2859-67
Patients under MV for at least of 7 days were screened daily for awakening (D1). Cohort study March 1999-June 2000 (5 ICUs). ICU acquired paresis: severe muscle weakness on D7 after awakening. Results: 95 patients achieved awakening, and 25% had ICUAP. Duration of MV after D1 longer in ICUAP patients compared to those w/o (18.2 vs 7.6 days, p=.03). Independent predictors of ICUAP: female, # days with dysfuction of 2 or more organs, duration of MV, and administration of corticosteroids.
CCM 2007;35:2007-15
AJRCCM 2013;187:1294-302
Clinical tolerance: ACV: 100% PSV+PEEP: 11/14 (79%) PSV no PEEP: 8/14 (57%) T-piece: 0%
533 patients under mechanical ventilation (MV) over 18 months
Planned extubation without DNR order after at least 24h of MV: N = 225
Reintubation ≤ 7 days: N = 31 (14%)
All planned extubation: N = 310
66 patients ventilated less than 24h (1 reintubation)
19 patients died with a do-not-reintubate (DNR) order
175 patients died or transferred before meeting criteria for extubation
7 patients tracheotomized without prior extubation
25 terminal extubations
16 unplanned extubations (3% of intubated patients)
Thille AW, et al. CCM 2015;43:613-620
CCM 2015;43:613-620
1170 screened
855 Ventilated>48hrs
122 at risk*
25 excluded
97 randomised
48 NIV
49 Standard medical therapy
• Exclusion criteria (n.16). Not randomised (n.7). Refusal (n.2)
Nava S, et al. CCM 2005; 33:2465-70
*: hypercapnia, CHF, > 1 failed SBT, >1 comorbidity, upper aw obstr, weak cough
Nava S, et al. CCM 2005; 33:2465-70
- Reintubation: 4/48 (NIV) vs 12/49 (standard), P=0.027 - Reintubation was associated with higher mortality risk (P<0.01) - NIV use resulted in a reduced risk of ICU mortality (-10%, P<0.01) because of a reduction for the need of reintubation
Survival
n=27
n=22
n=83 n=79
n=61 n=52
AJRCCM 2006;173:164-70
Tolerance SBT and risk: age >65 yr, or CHF, or APACHE-II >12. Re IOT : 11% NIV vs 22% control p:NS
Ferrer M, et al. Lancet 2009
AJRCCM 2012;186:1256-63
ca 150h 210h 230h
Strategy-Proposal
-Simple: Screen often and as soon as possible. The pretest probability is not high. -Difficult: Understand the causes (respiratory/cardiovascular). Monitor respiratory muscle output, echocardiography, biomarkers, laringeal injuries. Ventilator settings: avoid the extremes. -Prolonged: Overall clinical practice and organization are probably relevant (sleep, sedatives, communication, nutrition, mobilization, …).
Conclusion
Extubation failure after weaning is a relevant clinical issue, but:
• We need to precisely understand the
pathophysiological mechanism/s explaining extubation failure.
• Unless much research is conducted in this field, the outcomes won’t improve much.