Prolonged Respiratory Insufficiency and Ventilator Dependence in the ICU

2014 ◽  
Author(s):  
Gaëtan Beduneau ◽  
Jean-Christophe M Richard ◽  
Laurent Brochard
Keyword(s):  
Mechanical Ventilation ◽  
Spontaneous Breathing ◽  
Prolonged Mechanical Ventilation ◽  
Early Mobilization ◽  
Economic Cost ◽  
Psychological Status ◽  
Difficult Weaning ◽  
Ventilation Modes ◽  
Controlled Mechanical Ventilation ◽  
Prolonged Immobilization

The process of separation or weaning from mechanical ventilation can be arbitrarily separated into three categories: (1) simple weaning when patients are separated from the ventilator after the first attempt of unsupported spontaneous breathing. This usually represents slightly more than half of the patients; (2) difficult weaning when up to three attempts or 1 week is necessary to successfully separate the patient from the ventilator; (3) prolonged weaning for the remaining patients. This last group represents between 6 and 20% of the ICU population arriving at the stage of weaning and carries a considerable human and economic cost. A global approach, including measures to optimize psychological status, nutritional support, and sleep, is essential in the management of these patients, and referral to specialized weaning centres may be helpful. Muscle weakness is a very frequent finding in patients undergoing prolonged mechanical ventilation and may be worsened by excessive sedation, prolonged immobilization, and the use of controlled mechanical ventilation modes. It follows that approaches that include sedation sparing, early mobilization, and the transition to spontaneous breathing are likely to be beneficial.

scholarly journals Noninvasive ventilation during the weaning process in chronically critically ill patients

2016 ◽  
Vol 2 (4) ◽  
pp. 00061-2016 ◽  
Author(s):  
Jesus Sancho ◽  
Emilio Servera ◽  
Luis Jara-Palomares ◽  
Emilia Barrot ◽  
Raquel Sanchez-Oro-Gómez ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Noninvasive Ventilation ◽  
Critically Ill Patients ◽  
Predictive Value ◽  
Spontaneous Breathing ◽  
Prolonged Mechanical Ventilation ◽  
Respiratory Care ◽  
Spontaneous Breathing Trials ◽  
Chronically Critically Ill

Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process.We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h.231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01–1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97).NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning.

Weaning failure in critical illness

2016 ◽  
Author(s):  
Annalisa Carlucci ◽  
Paolo Navalesi
Keyword(s):  
Mechanical Ventilation ◽  
Spontaneous Breathing ◽  
Respiratory Muscle ◽  
Prolonged Mechanical Ventilation ◽  
Spontaneous Breathing Trial ◽  
Extubation Failure ◽  
High Morbidity ◽  
Weaning Failure ◽  
Generating Capacity ◽  
The One

Weaning failure has been defined as failure to discontinue mechanical ventilation, as assessed by the spontaneous breathing trial, or need for re-intubation after extubation, so-called extubation failure. Both events represent major clinical and economic burdens, and are associated with high morbidity and mortality. The most important mechanism leading to discontinuation failure is an unfavourable balance between respiratory muscle capacity and the load they must face. Beyond specific diseases leading to loss of muscle force-generating capacity, other factors may impair respiratory muscle function, including prolonged mechanical ventilation, sedation, and ICU-acquired neuromuscular dysfunction, potentially consequent to multiple factors. The load depends on the mechanical properties of the respiratory system. An increased load is consequent to any condition leading to increased resistance, reduced compliance, and/or occurrence of intrinsic positive-end-expiratory pressure. Noteworthy, the load can significantly increase throughout the spontaneous breathing trial. Cardiac, cerebral, and neuropsychiatric disorders are also causes of discontinuation failure. Extubation failure may depend, on the one hand, on a deteriorated force-load balance occurring after removal of the endotracheal tube and, on the other hand, on specific problems. Careful patient evaluation, avoidance and treatment of all the potential determinants of failure are crucial to achieve successful discontinuation and extubation.

scholarly journals P1111MULTI ORGAN SUPPORT WITH EXTRACORPOREAL CARBON DIOXIDE REMOVAL (ECCO2R) AND CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) WITH CITRATE ANTICOAGULATION IN THE CLINICAL SETTING OF DIFFICULT WEANING FROM MECHANICAL VENTILATION

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Davide Ricci ◽  
Alessandra Sagliocchi ◽  
Antonio Siniscalchi ◽  
Marco Ranieri ◽  
Elena Mancini
Keyword(s):  
Mechanical Ventilation ◽  
Blood Flow ◽  
Prolonged Mechanical Ventilation ◽  
Respiratory Muscles ◽  
Bleeding Risk ◽  
Esophageal Pressure ◽  
Organ Support ◽  
Citrate Anticoagulation ◽  
Difficult Weaning ◽  
Simple Technology

Abstract Background and Aims Prolonged mechanical ventilation is associated with the risk of difficult weaning due to the onset of muscle weakness. A disproportion occurs between the respiratory workload and the muscular force, which leads to failure of the ventilatory pump and hypercapnia. Some early experiences suggest that ECCO2R facilitates weaning from the ventilator in patients with a high risk of failure. Method Clinical case: a 49 year-old man with a) recent orthotopic liver transplantation (cryptogenic cirrhosis), b) acute renal injury (AKI) on continuous veno-venous hemofiltration (CVVH) and c) acute respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation. After unsuccessful attempts at weaning from the ventilator, a lung membrane was inserted in series, before the hemofilter, on the CRRT circuit in order to remove CO2 and so reduce the workload of the respiratory muscles (Fig. 1). The patient was then extubated. We used citrate anticoagulation due to the presence of contraindications to systemic heparin (high bleeding risk, thrombocytopenia). Results ECCO2R + CRRT treatment requires a relatively high blood flow (300-350 ml / min) in order to extract a significant amount of CO2, but, the more the blood flow increases, the more citrate must be infused, and the more the metabolic load increases. The patient developed mild alkalosis as an initial sign of citrate accumulation (Table 1), but it was self-limiting. During ECCO2R we actually obtained the desired decrease in respiratory muscle effort (decrease in respiratory rate from 24 to 18 per minute and a maximum negative value of esophageal pressure from -8 to -4 cmH2O) and the treatment was interrupted after 36 hours. Mechanical ventilation was restored due to a complication independent of ECCO2R (massive pneumothorax). The patient tolerated the treatment for 36 hours. Conclusion ECCO2R proved an efficient and relatively simple technology helping respiratory function recovery. Due to the very frequent association of AKI and ARDS, leading to a high mortality rate, nephrological care in intensive care units should include this new treatment. Moreover, reduction of the inflammatory pathway secondary to mechanical ventilation could also benefit the evolution of AKI.

scholarly journals Ventilator-Induced Diaphragm Dysfunction (Review)

2018 ◽  
Vol 14 (3) ◽  
pp. 82-103
Author(s):  
M. A. Babaev ◽  
D. B. Bykov ◽  
Т. M. Birg ◽  
M. А. Vyzhigina ◽  
A. A. Eremenko
Keyword(s):  
Mechanical Ventilation ◽  
Spontaneous Breathing ◽  
Contractile Function ◽  
Clinical Manifestations ◽  
Lung Ventilation ◽  
Respiratory Support ◽  
Diaphragm Dysfunction ◽  
Mechanical Lung ◽  
Mechanical Lung Ventilation ◽  
Ventilation Modes

Mechanical ventilation is associated with a number of complications that increase the cost of treatment and the hospital mortality rate. In 2004, the term «ventilator-induced diaphragm dysfunction» (VIDD) was proposed to explain one of the reasons for the failure of respiratory support. At present, this term is understood as a combination of atrophy and weakness of the contractile function of the diaphragm caused directly by a long-term mechanical lung ventilation. Oxidative stress, proteolysis, mitochondrial dysfunction, as well as passive overdistension of the diaphragm fibers contribute greatly to the pathogenesis of VIDD. Since 30—80% of patients in the ICU require mechanical respiratory support and even 6—8 hours of mechanical lung ventilation can contribute to the development of a significant weakness of the diaphragm, it can be concluded that the VIDD is an extremely urgent problem in most patients. Its typical clinical presentation is characterized by impaired breathing mechanics and unsuccessful attempts to switch the patient to the spontaneous breathing in the absence of other valid reasons for respiratory disorders. The sonography is the most informative and accessible diagnostic method, and preservation of spontaneous breathing activity and the use of the latest mechanical ventilation modes are considered a promising approach to prevention and correction of the disorders. The search for an optimal strategy for lung ventilation, development of diagnostic and physiotherapeutic methods, as well as the consolidation of the work of a multidisciplinary team of specialists (anesthesiologists and intensive care specialists, neurologists, pulmonologists, surgeons, etc.) can help in solving this serious problem. A review of 122 sources about the VIDD presented data on the background of the issue, the definition of the problem, etiology and pathogenesis, clinical manifestations, methods of diagnosis, the effect of drugs, prevention and therapy. 

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