Difficult Weaning. Indications for mechanical ventilation: A) Global pathophysiological indications: - Apnea - Acute ventilatory failure - impending failure.

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Presentation transcript:

Difficult Weaning

Indications for mechanical ventilation: A) Global pathophysiological indications: - Apnea - Acute ventilatory failure - impending failure - Refractory hypoxemia - Signs of respiratory failure B) Common clinical conditions when need for ventilatory support is high: - ARDS - Asthma - COPD - Chest trauma - Overdose - Post cardiac surgery - Pneumonia - Sepsis - Head Trauma

-Preparing the Patient for Weaning: - Electrolyte Disturbance - Volume Overload - Altered Mental status - Fatigue of the diaphragm - Adequacy of sleep and sleep deprivation - Malnutrition

-Criteria to consider Patients for Weaning: - Reversal of underlying pathology - Po2, PEEP, FiO2, PH - ABG - Vital Data - CXR -Parameters Predicting successful Weaning: - Respiratory rate - Tidal Volume - Minute Ventilation - Negative inspiratory force - Maximal Inspiratory pressure - RSBI - RSBI rate

Algorithm for weaning Protocol

New Advances in Ventilators to assist Weaning: - Automated tube compensation (ATC) - Proportional Assisted ventilation (PAV)

Causes of Difficult Weaning Imbalance Respiratory muscle pumpRespiratory muscle load A) Increased Ventilatory Needs Increased resistive loadIncreased chest Wall LoadIncreased parenchyma load -Bronchospasm - Airway edema - Airway obstruction - Tube kinking - Sleep Apnea - Secretions - Circuit resistance - Pleural effusion - Pnumothorax - Flail chest - Obesity - Ascites - Distension -Hyperinflation - Inflammation - Atelectasis - Alveolar edema

B) Decreased Neuromuscular compliance: Decreased Drive Muscle WeaknessImpaired Transmission Drug overdose - Electrolyte derangement - Critical illness polyneuropathy Brain-stem lesion - Malnutrition - Neuromuscular blockers Sleep deprivation - Myopathy - Aminoglycosides Hypothyroidism - Hyperinflation - Guillain–Barré syndrome Starvation/malnutrition - Drugs, corticosteroids - Mysthenia gravis Metabolic alkalosis - Sepsis - Phrenic nerve injury Myotonic dystrophy

How to Wean Difficult to Wean Patients Correction of Causes Choice of appropriate mode Tracheostomy

Neuromuscular Weakness in Critically Ill Critical illness polyneuropathy (CIP):Disorders of neuromuscular transmission: Myopathy: Critical illness Polyneuropathy Definition Course Causes Diagnosis: - EPS: shows reduced compound motor and sensory nerve action potential amplitudes with normal conduction velocities. - Needle EMG reveals fibrillation potentials and positive sharp waves indicating denervation Treatment

Disorders of neuromuscular transmission: - Prolonged use of neuromuscular blockers - Decreased Metabolism - Decremental Response - Aminoglycosides, Polypeptide antibiotics

Myopathy : 1. Critical illness myopathy: - Histological Pattern - Normal CPK levels - Type II myofibres - IL-1, TNF 2. Thick filament myopathy: - Selective loss of myosin - Absent neuropathy - Increased steroid receptors - Triggering factors: NMBA, Denervation - Diagnosis: EPS, CPK, Muscle biopsy

3. Necrotizing myopathy: - Prominent muscle necrosis - CPK elevated - Correlated with NMBA, Steroids - Diagnosis: - difficult to diagnose - Direct muscle stimulation and calculation of the ratio of nerve and muscle evoked compound muscle action potential amplitudes. - Muscle biopsy is of choice -No specific treatment is available

Prevention of neuromuscular weakness in ICU: - Appropriate treatment of sepsis - Minimize use of NMBA - Check serum electrolytes - Avoid Pharmacological agents causing weakness - Early EPS

Thank You