Factors Contributing to Prolonged Mechanical Ventilation Support

Ahmed Al Gahtani, BSRC, RRT Associate Director, Clinical EducationChairman, RTS Scheduling CommitteeDept. of Respiratory TherapyInaya Medical College Central Chapter Member, Saudi Society for Respiratory Care

Difficult-to-wean patients are those requiring more than 7 days of weaning after the first spontaneous breathing trial.

ERS Task ForceRepresent up to 14% of patients admitted to the ICU for intubation and MV

The National Association for Medical Direction of Respiratory Care Consensus Conference defined prolonged MV as the need for more than 21

consecutive days of MV for more than 6 h a day.

There is evidence that 3–7% of patients fulfill this definition.

Some authors suggest that placement of a tracheotomy after at least 10 days of MV defines the onset of prolonged weaning because this definition involves the concept that the patient is not expected to die or to wean from

the ventilator in the immediate future.Nelson JE, Cox CE, Hope AA, Carson SS. Concise clinical review: chronic critical illness. Am. J. Respir. Crit. Care Med.

182(4), 446–454 (2010)

Facts

• 4% to 13% • 7250 and 11,400 patients undergoing

PMV at any one time• PMV is associated with increased health

care cost, morbidity, and mortality

Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit. Crit Care 2011; 15:R102.

PMV Weaning UnitsLTCH

Predictors• ICU admission due to pneumonia, acute respiratory distress syndrome (ARDS),

neuromuscular disease, head trauma, or postoperative intracerebral hemorrhage (44.3%).

• Elevated Acute Physiology Score (APS) of the Acute Physiologic and Chronic Health Evaluation III (APACHE III) on the first day in the ICU (25%).

• Admission to the ICU from another ICU, another hospital, or the medical ward (6.1%).• Abnormal arterial carbon dioxide (PaCO2), serum blood urea nitrogen (BUN), serum

creatinine, arterial pH, white blood cell count (WBC), or body temperature (4.8%) on the first day in the ICU.

• Extended inpatient length of stay prior to ICU admission (4.3%).• Elevated respiratory rate on the first day in the ICU (3.5%).• Admission to a large teaching hospital (3.4%).• Low serum albumin on the first day in the ICU (2.9%).• History of obstructive or restrictive lung disease (2.4%).• Decreased PaO2/FiO2 on the first day in the ICU (2%).• Advanced age (1.1%).

Outcomes

• Mortality Observational study that followed 1419 mechanically ventilated

patients admitted to a ventilator weaning hospital for one year. One-year mortality was 52 percent. Among these patients, 25

percent died in the weaning hospital and 27 percent died after discharge.

Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest 2007; 131:85.

Outcomes

Quality of Life

Survivors of critical illness have a lower quality-of-life (QOL) than age- and gender-matched controls, particularly patients who require PMV or survive ARDS, trauma, or sepsis (Fifty-three articles (10 multicenters) were included)

Mechanisms Associated With VentilatorDependence

• Systemic factors• Mechanical factors• Iatrogenic factors• Complications of long-term hospital care• Psychological factors• Process of care factors

Management of Patients Requiring Prolonged Mechanical Ventilation, CHEST / 128/6/ DECEMBER, 2005

Intensive Crit Care Nurs, [2002, 18(4):219-229]

Factors influencing the patient during weaning from mechanical ventilation: a national survey.

Family bedside presence during weaning from LTMV represents an important and potentially beneficial interaction that may be influenced by coaching and instruction from nurses, respiratory therapists, andphysicians.

Case Report

• 70 years old male arrived to ER on 21/8/2012 conscious, and alert with history of fall at home. GCS 15, RR 18, HR 82, BP 171/ 96 SpO2 99%, in pain & unable to walk.

• Found to have left femoral neck fracture.• PMH: HTN, Chronic Anemia. COPD ?• No Allergies

Case Report

• 24/8/2012:• Pt underwent open reduction internal

fixation surgery.• Procedure done with no complication.• Pt spent short time in recovery then

transferred to surgical wards stable• HR 93, BP 167/89, RR16, SpO2 99% NC

2 L.

Case Report

• After number of episodes of mild respiratory distress

• On 3/9/2102 patient deteriorated showing signs of sever respiratory distress. Chest Infection ?

• NIV trail failed to stabilize the pt condition• Pt admitted to SICU intubated and

ventilated same day

Case Report

• Caring team was able to wean the Pt to PSV over 12 days, 3 days later Pt was extubated on 19/9/2012

• Pt failed extubation and re-intubated on 22/9/2012

• Pt was given another trial of extubation on 29/9/2012, again failed and re-intubated on 1/10/2012

Case Report

• Percutaneous Tracheostomy was done for the Pt on 2/10/2012.

• Pt was ventilated over two months. With repeated weaning trials.

• Pt was weaned to PSV 10/8.• Liberation of ventiltory support failed.

Case Report

• Up to 19/12/2012• Investigations• Procedures

Case Report

• Through the previous course of care up to 22/12/2012 weaning and liberation plan was controlled assessed and modified by SICU physicians.

• On 24/12/2012 Head of Critical Care requested a consultation of a the senior RT of RCS in the hospital.

Case Report

• CNS: GCS 11, fully conscious• CVS: HR 88 regular, BP 160/75, MAP 92, CVP 2 cmH2O.

No antihypertensive medication • Respiratory: trached (7) on PSV 10/8 FiO2 50% RR 28,

alternating with ATM tolerating up to 1 hour only each time. C 42, Raw 14, VC 2.5 to 3 L, NIF -32 by the machine. ABG: 7.48/47.6/99.6/34.8/95%. Minimul use of accessory muscles.

• Abdomen: Soft • Renal: normal urine output 40 t0 60 ml/h

Respiratory assessment of the patient was done on the same day

Case Report

• Nutritional Assessment • Social/Psychological Assessment• Physical Assessment• Meeting with the family

Initial Recommendation By RCS

Case Report

• Nutritional Assessment: Hyponatremia• Physical Assessment: Pt is only receiving

minimal extremities muscle exercises. Pt need lots of encouragement.

• Social/Psychological Assessment: Pt is depressed & anxious.

Case report

Meeting the Family

Case Report

• Respiratory • Physiotherapy • Social Worker• Nutritional

Plan of Care

Case Report

• Pt was successfully decannualted on 3/1/2013.

Pt failed and was re-intubated on 5/1/2103 the surgical tracheostomy on 30/1/2013

Ventilated until 20/6/2013Out of the ICU on 27/6/2013

Discharged Home on 9/7/2013

On 26/9/2013 Patient was Decannulated Successfully

Way

Mechanisms Associated With VentilatorDependence

• Systemic factors• Mechanical factors• Iatrogenic factors• Complications of long-term hospital care• Psychological factors• Process of care factors

Management of Patients Requiring Prolonged Mechanical Ventilation, CHEST / 128/6/ DECEMBER, 2005

Intensive Crit Care Nurs, [2002, 18(4):219-229]

Factors influencing the patient during weaning from mechanical ventilation: a national survey.

Crit Care. 2008; 12(4): 221.

Family bedside presence during weaning from LTMV represents an important and potentially beneficial interaction that may be influenced by coaching and instruction from nurses, respiratory therapists, andphysicians.

Conclusion

•In appropriate commutation •Underestimating the impact of the psychological factor initially in the case.

REFERENCES1.MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest 2005; 128:3937.2.Nevins ML, Epstein SK. Weaning from prolonged mechanical ventilation. Clin Chest Med 2001; 22:13.3.Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit. Crit Care 2011; 15:R102.4.Seneff MG, Zimmerman JE, Knaus WA, et al. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest 1996; 110:469.5.Garnacho-Montero J, Amaya-Villar R, García-Garmendía JL, et al. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients. Crit Care Med 2005; 33:349.6.De Jonghe B, Bastuji-Garin S, Durand MC, et al. Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med 2007; 35:2007.

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