NExCOB en pathofysiologie ontwenning van de beademing

NExCOB en pathofysiologie ontwenning van de beademing Leo Heunks Longarts - intensivist Afdeling intensive care

Regionaal refereren november 2012 donderdag 29 november 12

Ontwennen van beademing • 40% van tijd aan beademing • Simpel • Moeilijk (tot 3 SBT of < 8 dagen) • Langdurig (> 3 SBT of > 1 week)

donderdag 29 november 12

Mortaliteit en ontwenduur

Penuelas, AJRCCM, 2011 donderdag 29 november 12

Ontwennen in NL • Beperkte epidemiologische data • Geen LTWF • Geen respiratory care units • Geen gespecialiseerde IC’s • Wel centra voor thuisbeademing



Missie Een bijdrage leveren aan snelle ontwenning van kunstmatige beademing door gebruik te maken van geavanceerde diagnostische technieken en specifieke kennis. In bredere zin wordt een bijdrage geleverd aan snellere ontwenning van de beademing door topklinische patiëntenzorg, uitvoeren van wetenschappelijk onderzoek en overdragen van kennis op dit vakgebied. donderdag 29 november 12

Diagnostiek Behandeladvies


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2692

Review

Clinical review: The ABC of weaning failure - a structured approach Leo M Heunks, Johannes G van der Hoeven Critical Care 2010, 14:245 (8 December 2010) [Abstract] [Full text] [PDF] [PubMed] [Related articles]

2. Accesses

2689


Research

Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group

Rinaldo Bellomo, Claudio Ronco, John A Kellum, Ravindra L Mehta, Paul Palevsky, the ADQI workgroup Critical Care 2004, 8:R204-R212 (24 May 2004) [Abstract] [Full text] [PDF] [PubMed] [Related articles] [F1000 Medicine] [Cited on BioMed Central] [1 comment]

Critical Care BioMed Central Current Controlled Trials PubMed PubMed Central

ABC moeilijke ontwenning


Technisch geneeskundige

Logopedist

intensivist

Fysiotherapeut

verpleegkundig specialist

consulenten donderdag 29 november 12

• Start voorjaar 2012 • ± 15 externe patiënten • Gelderland • Brabant • Limburg • Noord Holland donderdag 29 november 12

• ± 15 externe patiënten • Diastolisch hartfalen • IC verworven spierzwakte (ipv M. Steinert) • ALS • Depressie / angst donderdag 29 november 12

• ± 15 externe patiënten • Veelal verandering in beleid • Medicamenteus • Training • Stoppen / intensiveren • Psychiater donderdag 29 november 12

Falende trial spontaan ademen



Falende ontwenningtrial 1. Cognitieve functie 2. Centrale drive 3. Spierkracht 4. Zuurstof transport 5. Systolische functie 6. Diastolische functie 7. Metabool / endocriene functie

Capaciteit


1. Respiratoire weerstand 2. Respiratoire elasticiteit 3. PEEPi 4. Gaswisseling

Last



Ademweg / long Centrale luchtwegen (los van beademing) Ademmechanica Gaswisseling


Tracheostoma malpositie 40 / 403 patiënten in LTWF

Langdurige ontwenning: 25 vs. 15 dagen Schmidt, Chest, 2008 donderdag 29 november 12

Inspiratie


Expiratie

Ademmechanica

Compliantie Weerstand Ademarbeid


Compliance

Change in volume divided by change in pressure


Transpulmonary pressure = Distending pressure (Palv - Ppl)


Compliance ∆V

CLung =

Ccw =

∆Ptp ∆V ∆Ptt

ml / cmH2O

ml / cmH2O

Ptp Ptt

1

1

CRS = CL


1 + Ccw

Compliance ∆V

CLung =

Ccw =

∆Ptp ∆V ∆Ptt

1

1

CRS = CL

ml / cmH2O

150 - 200 ml / cmH2O

ml / cmH2O

200 ml / cmH2O

1 + Ccw Alleen meten bij flow = 0


Compliantie meting 1000 Flow (l/min)

Flow (l/min)

1000 500 0 -500

500 0 -500 -1000

-1000 0

2

4

6

8

10

0

2

4

6

8

10

12

0

2

4

6

8

10

12

0

2

4

6 time (s)

8

10

12

12

40 Pinsp (cmH2O)

Pinsp (cmH2O)

40 30 20 10 0

0

2

4

6

8

10

10

12

25 Pes (cmH2O)

Pes (cmH2O)

20

0

25

20

15

10

30

0

2


4

6 time (s)

8

10

12

20

15

10

Lung and chestwall compliance Compliance lung =

TV (PL,es EIO - PL,es EEO)

TV

Compliance lung = (P,aw EIO - Pes EIO) - (P,aw EEO - Pes EEO)

Compliance chestwall = donderdag 29 november 12

TV (P,es EIO - P,es EEO)

Ademmechanica

R,rs = 11,5 cmH2O/L/s Compl,rs = 41 ml/cmH2O


Altered compliance

11/ 23 donderdag 29 november 12

Respiratoire weerstand

Flow = ∆P / R


Respiratoire weerstand

R,rs = donderdag 29 november 12

P,peak - P,plat Flow,i

Ademarbeid Lung volume TLC ac9ve infla9on (lung elas9c recoil)

passive infla9on (relaxed chestwall)

Vt

resis9ve inspiratory WOB

Vt

elas9c inspiratory WOB PEEPi inspiratory WOB

PEEPi

expiratory WOB

FRC FRC 0

-‐


Ppl / Pes

+

Ademarbeid


Respiratoire compliantie Failure

• N 35, COPD

Success

C,dyn, lung ml/cmH2O

120

• Median 11 (2-150) days ventilation

100 80

*

60

• Pi, max: ± 45 cmH2O (P>0.05)

40

*

20 0

• Ready to wean

• ABG not different between groups • SBT 45 min

0

33%

Edema Atelectasis Hyperinflation donderdag 29 november 12

66%

End

Jubran, AJRCCM (155)906

Respiratoire weerstand • N ± 35; COPD Pre SBT

Post SBT

• Median 11 (2-150) days ventilation • Ready to wean

R,aw (cmH2O/L/s)

20

• Pi, max: ± 45 cmH2O (P>0.05)

15

• ABG not different between groups

10

• SBT 45 min

5 0

Wean sucess

Jubran, AJRCCM (155)906 donderdag 29 november 12

Wean failure

Respiratoire weerstand • N ± 35; COPD Pre SBT

R,aw (cmH2O/L/s)

20

Post SBT

*

15

• Ready to wean • Pi, max: ± 45 cmH2O (P>0.05)

10 5 0


• ABG not different between groups Wean sucess

Jubran, AJRCCM (155)906 donderdag 29 november 12

Wean failure

• SBT 45 min

Intrinsieke PEEP • N ± 35; COPD Failure

Success

• Ready to wean

4 PEEPi (cmH2O)


3 2

• Pi, max: ± 45 cmH2O (P>0.05)

1 0 Start

• ABG not different between groups 33%

66%

End

• SBT 45 min Jubran, AJRCCM (155)906


Arbeid tijdens ontwennen Failure

Success

PTP (min/cmH2O.s/min)

400 300 200 100 0 Start


25%

75%

End

Ademweg / long: Gaswisseling • (A-a)D,o2

• Shunt fractie (PAC)


Interim conclusie “A” • Verandering ademmechanica belangrijke rol moeilijke ontwenning (COPD en niet COPD)




Brein disfunctie Cognitive impairement Delirium Anxiety / depression Sleep disturbances


Depression and weaning

• Weaning associated mental stress • machine dependency • difficult communication • loss of control ➡ Coping overwhelmed: “desire to die” donderdag 29 november 12

Depression and weaning Doel: 1. Depressive disorders associated with weaning failure? 2. Depressive disorders associated with mortality?

Baugh, Chicago (IL). ATS 2010 donderdag 29 november 12

Psychiatric Evaluation

• Psychologist examined for depression (DSM IV) • Delirious (DSM IV) • Comatous and delirious rescreened daily • Patients weaned daily with PSV or SBT


Baugh, ATS 2010 donderdag 29 november 12

Prevalence of depressive disorders 60 48%

Patients, %

42% 40

12% major depression 20 4% dysthmic disorder 84% depressive disorder, not otherwise specified 6%

4%

0 De


pre

ssiv e

Ad Dis

jus

ord

tme

er

nt D

Oth er

s

iso

rde

r

No

ne

Effect of depressive disorder on outcome No depressive disorder Depressive disorder

30

80 p = 0.007

p = 0.0001

60

20

40 p = 0.0008

10

0

20

Duration MV at LTWF (days)


0

Weaning failure (%)

Mortality (%)

Interim conclusions 1. In difficult to wean patients 42% depressive disorder 2. Depressive disorders associated with increased duration of weaning and mortality




Cardiaal Ischemie Systolische functie Diastolische functie


Hartfalen en moeilijke ontwenning



Weaning success Weaning failure

Cardiac index

4,0

*

3,5

• N = 10 / groep, heterogeen • ± 6 dagen MV • WF = 39 min

3,0 2,5 2,0

MV

end SBT Jubran, Am J Respir Crit Care Med (158)1763



Weaning success Weaning failure

1. Contractiliteit ↓: afterload LV ↑

4,0

Cardiac index

Oorzaak niet verhogen CI:

*

3,5

2. Contractiliteit ↓: hypoxemia, hypercapnia 3. Contractiliteit ↓: ischemie

3,0 2,5 2,0

MV



Hartfalen en moeilijke ontwenning Weaning success Weaning failure 30

*

PCWP

25 20

• N ± 10 / group, heterogeen • ± 6 dagen MV

15 10 5 0

MV



Diastolisch hartfalen bij ontwennen “Noncardiac patients” SBT (50) Success (54%)

Fail (46%) Failures: 63% cardiogenic edema

Extubation Success (44%)

Extubation Failure (10%) Papanikolauo, ICM, 201


Diastolisch hartfalen bij ontwennen Baseline echocardiography

12% higher grade diastolic dysfunction with SBT Papanikolauo, ICM, 201 donderdag 29 november 12

Conventionele doppler markers WS 1,5 1,2

WF 250

1,26

1,24

200

0,9

150

0,6

100

0,3

50

0

0

E/A

Papanikolauo, ICM, 201 donderdag 29 november 12

205

194

DTE

Advanced doppler markers WS 15 12

WF 2

P< 0.001 10,83

9 6

P< 0.001 1,79

1,6 1,2

1,32

0,8 5,35

3

0,4

0

0

Lateral E/Em

Papanikolauo, ICM, 201 donderdag 29 november 12

E/Vp

Septal Ea Lateral Ea LA volume

Septal Ea ≥ 8 Lateral Ea ≥ 10 LA < 34 mL/m2

Normal function

Septal Ea ≥ 8 Lateral Ea ≥ 10 LA ≥ 34 mL/m2

Septal Ea < 8 Lateral Ea < 10 LA ≥ 34 mL/m2

E/A < 0.8 DT > 200 ms E/Ea ≤ 8 Ar - A < 0 ms Val ∆ E/A < 0.5

E/A 0.8-1.5 DT 160-200 ms E/Ea 9-12 Ar - A ≥ 30 ms Val ∆ E/A ≥ 0.5

E/A ≥ 2.0 DT < 160 ms E/Ea ≥ 13 Ar - A ≥ 30 ms Val ∆ E/A ≥ 0.5

Grade 1

Grade 2

Grade 3

Normal function Athlete’s heart Constriction

Nagueh SF. Eur J Echocardiogr 2009;10:165-193 donderdag 29 november 12

Conclusie • Diastolische disfunctie frequent ontwenfalen • Voorspeller ontwen falen • verminderde LVEF • Advanced doppler markers diastolische disfunctie


BNP en ontwenning

N=100 > 48 h beademing Zapata, ICM, 2011 donderdag 29 november 12

BNP en ontwenning

Zapata, ICM, 2011 donderdag 29 november 12

Interim conclusie “C” • Cardiale origine falen SBT frequent • Let op diastolisch en systolich falen • Sluit ischemie uit




Diafragma Bewegelijkheid Kracht Uithoudingsvermogen


Mechanical ventilation induces diaphragm atrophy

Levine, NEJM, 2008 donderdag 29 november 12

Mechanical ventilation reduces diaphragm strength

Jaber, AJRCCM, 2010 donderdag 29 november 12

Inspiratory muscle weakness and weaning

Multicenter, n = 116 > 7 d mechanical ventilation Sepsis: 50% de Jonghe Crit Care Med, 2007 donderdag 29 november 12

Pdi, tw

Diaphragm fatigue in ICU patients

Laghi, Am J Respir Crit Care Med donderdag 29 november 12

Respiratory drive

6

4

*

2

*

WS - Card Surg WF - Card Surg

0 P0.1 (cmH2O)


WS - COPD WF - COPD

Diafragma echo

Diam disfunctie < 10 mm bij rustig ademen


Diam disfunctie en ontwenen Diam disunctie

Non- diam Disfunctie

N

24 (29%)

58 (71%)

Tijd tot SBT, d

4 (2,5 - 7,5)

4 (3,0 - 6,0)

0,55

Totale ontwentijd, h

576 (374 - 850)

203 (109 - 408)

<0,01

Primair falen, %

83

59

<0,01

Bekende diafragma disfunctie geexcludeerd donderdag 29 november 12

P


Neuroventilatory efficiency

Neuroventilatory efficiency =

Neuroventilatory efficiency =


TV Edi TV Edi

=

=

400 20 400 10

= 20

= 40

Neuro-Ventilatory Efficiency TV NVE = Edi


Neuroventilatoire efficientie

Success


Failure

Interim conclusie “D” • Diafragma disfunctie belangrijke rol moeilijke ontwenning

• Evalueer hele traject van CZS of sarcomeer




Bijnierschors insufficientie en ontwennen Placebo Hydrocortisone 7 5

*

4

N = 70 Inadequate ACTH response Ready to wean Beademing ±5 dagen Hydrocortisone 4 dd 50 mg

2 0

Duration weaning

Huang, Am J Respir Crit Care Med (173)276 donderdag 29 november 12

Interim conclusie Pathofysiologie van moeilijke ontwenning is complex


www.NExCOB.NL

• Algemene informatie ontwenning • professionals • patienten • Literatuur • Journalclub donderdag 29 november 12

• Uitstekende mogelijkheden voor research • Sterven naar research netwerk


Onderzoek 1. Medicamenteuze ondersteuning ademspieren 2. Vroege voorspeller succesvolle extubatie 3. Patiënt - ventilator asynchronie 4. Beademing geïnduceerde ademspierzwakte


Take home messages 1. Falende ontwenningstrial = diagnostiek 2. NExCOB voor advies 3. Website (wordt) informatiebron ontwenning

NExCOB( Nijmegen(Expertisecentrum(voor(Ontwenning(van(de(Beademing(


De onderste steen boven Regionale refereeravond IC 28 november 2012

A: B: C: D: E:

Airway and lung dysfunction Brain dysfunction Cardiac dysfunction Diaphragm dysfunction Endocrine dysfunction

CASUS

Male 68 year Hypertension COPD gold IV Alcohol & nicotine abusus Admission AE-COPD

CASUS

Difficult weaning from mechanical ventialtion Muscle weakness / ALS / Myasthenia gravis ?

A: AIRWAY AND LUNG FUNCTION

1.  Airway mechanics (resistance / compliance) 2.  Work of breathing 3.  Gas exchange 4.  Upper airway

NORMAL BREATHING

æ

COMPLIANCE (1)

Change in volume divided by change in pressure Compliance total respiratory system: - Lung - Chest wall STATIC CONDITIONS!!!

COMPLIANCE (2)

∆V CLung = ml / cmH2O ∆Ptp ∆V Ccw = ml / cmH2O ∆Ptt

(normal 150 - 200 ml / cmH2O)

Ptp

(normal 200 ml / cmH2O)

Ptt

1

1

1

CRS = CL + Ccw

(normal 50- 100 ml / cmH2O)

MEASURING COMPLIANCE IN PRACTICE

EIO

500 0 -500 -1000 2

4

0 -500

6

8

10

12

0

P,peak

40 30 20

P,plat

10

0

2

4

6

2

4

6

8

10

12

8

10

12

40 Pinsp (cmH2O)

Pinsp (cmH2O)

500

-1000 0

0

EEO

1000 Flow (l/min)

Flow (l/min)

1000

8

10

30 20 10

PEEP,tot 0

12

25

0

2

4

6

25

Pes (cmH2O)

Pes (cmH2O)

550 ∆V ∆V PEEP,tot = PEEP,e += PEEP,i Crs = = = 50 ml / cmH2O 21 - 10 ∆P,plat – PEEP,tot ∆P 20

15

10

0

2

4

6 time (s)

8

10

12

20

15

10

0

2

4

6 time (s)

8

10

12

∆V CLung = ml / cmH2O = 78 ml / cmH2O ∆Ptp ∆V = = Ptp,EIO – Ptp,EEO (Paw,EIO – Pes,EIO) - (Paw,EEO – Pes,EEO) ∆V

∆V Ccw = ∆Ptt =

= 138 ml / cmH2O

∆V Ptt,EIO – Ptt,EEO

∆V = (Pes,EIO) – (Pes,EEO)

ALTERED COMPLIANCE

11/ 23

RESISTANCE

Flow = ∆P / R normal < 5 cmH2O/l/s

EIO

Flow (l/min)

1000 500 0 -500 -1000 0

2

4

8

10

12

P,peak

40 Pinsp (cmH2O)

6

30

R= P,plat

10 0

0

2

4

6

8

10

Flow

=

= 17 cmH2O/l/s

20

à bronchodilation

15

10

0.775

12

25 Pes (cmH2O)

34 - 21

Ppeak - Pplat

20

0

2

4

6 time (s)

8

10

12

WORK OF BREATHING (1) Lung volume TLC ac9ve infla9on (lung elas9c recoil)

passive infla9on (relaxed chestwall)

Vt

resis9ve inspiratory WOB

Vt

elas9c inspiratory WOB PEEPi inspiratory WOB

PEEPi

expiratory WOB

FRC FRC

-‐

0 Ppl / Pes

+

WORK OF BREATHING (2)

GAS EXCHANGE

Time

resp. freq.

Tidal volume

pH

(ml)

PaO2

PaCO2

HCO3-

(kPa)

(kPa)

(mmol/L)

Base Excess (mmol/L)

SpO2

Aa-gradient

DO2

(%)

(mmHg)

(L/min)

PS

25

339

7.45

10.9

6.6

33.9

8.7

100

142

0.53

10 min

22

354

7.44

19.1

6.8

34.1

8.7

98

150

0.64

12 hour

23

374

7.41

15.5

7.3

34.1

8.2

99

172

0.73

18 hour

22

382

7.40

14.2

7.7

34.9

8.6

99

178

0.91

UPPER AIRWAY

A: CONCLUSION

1.  Decreased compliance / increased resistance 2.  Increased work of breathing 3.  Increasing Aa-gradient during SBT 4.  Granulation tissue canula

B: BRAIN FUNCTION

Cognitive impairment Delirium Depression Anxiety +

C: CARDIAC FUNCTION

Ischemia Systolic function Diastolic function

SWAN GANZ / PA CATHETER

SPONTANEOUS BREATHING TRIAL

Time

PS 10 min 12 hour 18 hour

SvO2

PCWP

PAP

ABP

CVD

HR

SpO2

PaO2

CO

BNP

Lactate

(%)

(mmHg)

(mmHg)

(mmHg)

(mmHg)

(bpm)

(%)

(kPa)

(L/min)

(pg/mL)

(mmol/L)

69

5

39/24

150/70

5

79

100

10.9

5.7

74

0.9

74

7

42/24

139/83

7

70

98

19.1

6.2

-

-

73

12

45/27

171/68

8

84

99

15.5

7.3

-

1.1

79

17

49/28

169/68

4

89

99

14.2

8.4

2113

0.7

TRANSTHORACIC ECHOCARDIOGRAPHY

EF 40% Diastolic dysfunction grade III Most likely PHT

ECG %jdens rust aan de beademing

ECG na 18 uur spontaan ademen

C: CONCLUSION

1.  Good systolic function 2.  Severe diastolic dysfunction

D: DIAPHRAGM

Respiratory muscle force RAPID DISUSE ATROPHY

Levine NEJM 2008

Respiratory muscle force DECREASED STRENGTH DURING MV

Jaber AJRCCM 2010

Respiratory muscle force PATHOPHYSIOLOGY

Doorduin AJRCCM 2012

Respiratory muscle force

DECREASED STRENGTH DURING MV

MAXIMAL INSPIRATORY/EXPIRATORY STRENGHT

MEP

20

150

0

100

20

-40 -60

cmh2o

cmh2o

MIP

50 0

DIAPHRAGM EMG AND PRESSURES (1)

DIAPHRAGM EMG AND PRESSURES (2)

Insp Exp Pes (cmH2O)

20

latex balloon (Pes)

0 -20 -40

Pga (cmH2O) Pdi (cmH2O) EMGdi (mV)

Insp Exp Insp

Pdi = Pga – Pes

50

0

Pga = gastric pressure Pes = esophageal pressure Pdi = transdiaphragmatic pressure

50

9 electrodes

0 0.1 0 -0.1

latex balloon (Pga) 0

5 time (s)

10

EMG


resp.

Tidal volume

freq.

(ml)

(uV)

(%)

(kPa)

(kPa)

PS

25

339

13

100

10.9

6.6

7.45

10 min

22

354

23

98

19.1

6.8

7.44

12 hour

23

374

35

99

15.5

7.3

7.41

18 hour

22

382

39

99

14.2

7.7

7.40

Time

Edi peak

SpO2

PaO2

PaCO2 pH


PEEPi

P,gastric

P,oesophagus

P,trans-diaphr.

NVE

(cmH2O)

(cmH2O)

(cmH2O)

(cmH2O)

(TV / Edi)

PS

1.7

1

- 4

5

26

10 min

2.0

1

-8

9

15

12 hour

3.1

1

-12

13

11

18 hour

3.5

1

-14

15

10

Time

MAGNETIC STIMULATION

CMAP (uV)

uV

0.7 stimulus 0.7 stimulus 0.6 0.6 0.5 0.5 0.4 0.4 0.3 0.3

response

diaphragm response

0.2 0.2 0.1 0.1

00 -0.1 - 0.1 -0.2 - 0.2 0

25

25

50

50 time (ms) tijd (ms)

75

75

100 100

D: CONCLUSION

1.  Mild respiratory muscle weakness 2.  No neuro-mechanical uncoupling during SBT

E: ENDOCRINE adrenal insufficiency and weaning

no indication of adrenal insufficiency with synacthen test

Huang AJRCCM 2006

FINAL CONCLUSION

1. Diastolic dysfunction 2. Anxious 3. No pulmonary/ respiratory muscle dysfunction

ADVISE

1.  Weaningtrial with NTG (SBP < 140 mmHg) 2.  Consultation psychiatrist 3.  Prednison instead of dexamethason

à SUCCES

TAKE HOME MESSAGE

Difficult weaning: - complex pathophysiology - structured approach

How can we improve weaning? J.G. van der Hoeven Radboud University Nijmegen Medical Centre

Recognise those at risk N = 2714 60

55

Severity at admission Duration of MV before first attempt Chronic pulmonary disease Pneumonia PEEP before weaning

45

%

39 30

15

Extubation > 7 days from first attempt of withdrawal

6 0

Simple weaning

Difficult weaning

Prolonged weaning

Peñuelas O. Am J Respir Crit Care Med 2011;184:430-437

Consequences Simple weaning

Difficult weaning

Prolonged weaning

P-value

Reintubation (%)

10

10

16

0.08

Tracheostomy (%)

6

6

10

0.15

LOS ICU (median - IQR)

6 (3, 10)

9 (6, 15)

18 (14, 25)

< 0.001

ICU mortality (%)

7

7

13

0.01


Consequences


Prevent excessive support

Blackwood B. BMJ 2011;342:c7237

Sedation - SLEAP trial • Does daily sedation interruption improve outcome when protocolised sedation is already implemented?

• Multicenter RCT: Protocolised sedation ± daily sedation interruption (N = 423)

• Primary outcome - time to successful extubation

Mehta S. JAMA 2012;308:1985-1992

Protocol

Protocol + Daily interruption

P-value

Successful extubation (D)

7 (3 - 12)

7 (4 - 13)

0.52

Days in ICU (D)

10 (6 - 20)

10 (5 - 17)

0.36

ICU mortality (%)

24.9

23.4

0.72

Hospital mortality (%)

30.1

29.6

0.89

Higher nursing workload with daily interruption More sedatives/opiates with daily interruption

Mehta S. JAMA 2012;308:1985-1992

Load reduction • Decrease airway resistance (major/minor airways)

• Treat pulmonary edema / atelectasis • Remove pleural fluid

Remove pleural fluid Retrospective study

P = 0.03 8 Duration of MV (Days)

N = 168

6

4

2

0

Control

PF drainage

Kupfer Y. Chest 2011;139:519-523

Pleura effusion drainage in MV patients PaO2/FiO2

↑ 18% (95 CI 5 - 33%)

Pneumothorax

3.4% (95 CI 1.7 - 6.5%)

Hemothorax

1.6% (95 CI 0.8 - 3.3%)

Pneumothorax with ECHO

OR 0.32 (0.08 - 1.19)

19 observational studies (N = 1124)

Goligher EC. Crit Care 2011;15:R46

Cardiac function

Improve cardiac function • Careful evaluation • Prevention of cardiac ischemia • Treatment of diastolic dysfunction • Treatment of systolic dysfunction

Consider nitrates COPD - N = 12 35" 30"

200" 150" Controle" Nitroglycerine"

100" 50"

Wiggedruk)(mm)Hg))

Systolische+bloeddruk+(mm+Hg)+

250"

25" 20"

Controle"

15"

Nitroglycerine"

10" 5"

0"

0" MV"

Start"trial"

Einde"trial"

MV"

Start"trial"

Einde"trial"

After failure SBT (control) 90% successful with NTG Routsi C. Crit Care 2010;14:R204

Other inotropic agents Dobutamine/Levosimendan in 10 COPD patients with large increase in PAOP during spontaneous breathing

Ouanes-Besbes L. J Crit Care 2011;26:15-21

If the diaphragm is weak • Early mobilisation • Electrical muscle stimulation • Respiratory muscle training • Medication

Early mobilisation N = 104

Control

Protocol

P-value

59%

35%

0.02

ICU delirium (D)

4 (2-7

2 (0-6)

0.03

ICU paresis at HD

49%

31%

0.09

Ventilator-free days

21

23.5

0.05

LOS ICU

7.9

5.9

0.08

Independent at HD

Schweickert WD. Lancet 2009;373:1874-1882

Electrical stimulation N = 140 - only 52 evaluated

EMS 60

P = 0.04

Control P = 0.04

45

•

Daily sessions of 55 minutes

•

Bilateral vastus lateralis/ medialis and peroneus longus

•

Biphasic, 45 Hz, 0.4 ms pulse duration, 12 seconds on and 6 seconds off

30 15 0

CIPNP (%)

MRC score

MV significantly shorter in EMS group (1 [0-10] vs 3 [0 - 44], p 0.003) Routsi C. Crit Care 2010;14:R74

Muscle training 4 sets of 6 - 10 breaths per day (5 days/week) IMT

%

71

40 20 0

N = 69

P = 0.039

80 60

Sham

47

Weaned D 28

Threshold® PEP Threshold® IMT Respironics Respironics

PFlex® IMT Respironics

Inspiring through exhalation port

MIP (cmH2O)

-20

-40

-60

P < 0.0001 -80

Efficacy trial

Pre

Post

IMT

Sham

Martin AD. Crit Care 2011;15:R84

Inspiratory muscle strength

Weaning success

Weaning duration (hours)

Survival

Muscle damage in COPD patients? - Optimal program? Moodie L. J Physiother 2011;57:213-221

Myosin heavy Chain Slow Non-COPD

COPD

van Hees HWH. Am J Respir Crit Care Med 2009;179:41-47

Levosimendan improves neuromechanical efficiency Doorduin J. Am J Respir Crit Care Med 2012;185:90-95

Other medication • Growth hormone? • Anti-oxidants?

Conclusions • Prevention extremely important • Weaning protocol - diagnostic scheme • Remove pleural fluid • Remember and treat diastolic dysfunction • Early mobilisation • IMT

NExCOB en pathofysiologie ontwenning van de beademing

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