Mechanical Ventilation PROBLEMS

Although life-saving, PPV may be associated with many complications, including: Consequences of PPV Aspects of volutrauma Adverse effects of intubation and tracheostomy

Optimal Ventilatory Care Requires Attention to minimizing adverse hemodynamic effects Averting volutrauma Effecting freedom from PPV as early as possible

Common Scenarios New development of hypotension Acute respiratory distress (fighting) Repeated sounding of High pressure alarm Hypoxemia Blood from the endotracheal tube Problem of diagnosing VAP

BarotraumaVolutrauma Barotrauma or Volutrauma High Paw alone insufficient to cause alveolar rupture Excessive alveolar volume the likely factor leading to alveolar rupture and air dissection More frequent in younger age group May be difficult to detect if small in CXR “Stretch-induced” Acute lung injury

Patient-ventilator Synchrony Flow-targeted breath requires careful adjustment Constant flow of lpm not always adequate Monitor: patient response, airway pressure/flow graphics Using decelerating flow pattern may be helpful

Patient-ventilator Synchrony Pressure-targeted breath is better? Rapid pressurisation of the airway with high initial gas flow Match Ppl change quicker than flow pattern (difficult to assess Ppl) Flow is continuously adjusted by the ventilator to maintain a constant airway pressure

Patient-ventilator Synchrony Any problems from pressure breaths? Max initial flow may not be optimal in all patients depending on drive Adjustment of the rate of rise may be beneficial (rise time, sensitivity) Pressure of what? Proximal airway vs Ppl by muscular effort So! brain(NAVA) or pleural triggering helpful with a variable minute ventilation!

Weaning from Mechanical Ventilation

Definition of Weaning The transition process from total ventilatory support to spontaneous breathing. This period may take many forms ranging from abrupt withdrawal to gradual withdrawal from ventilatory support.

Weaning  Discontinuation of PPV is achieved in most patients without difficulty  up to 20% of patients experience difficulty  requires more gradual process so that they can progressively assume spont. respiration  the cost of care, discontinue PPV should proceed as soon as possible

Reversible reasons for prolonged mechanical ventilation Inadequate respiratory drive Inability of the lungs to carry out gas exchange effectively Psychological dependency Inspiratory fatigue

Weaning Patients who fail attempts at weaning constitute a unique problem in critical care It is necessary to understand the mechanisms of ventilatory failure in order to address weaning in this population

Why patients are unable to sustain spontaneous breathing Concept of Load exceeding Capacity to breathe Load on respiratory system Capacity of respiratory system

Balance Load vs Capacity Most patients fail the transition from ventilator support to sustain spont. breathing because of failure of the respiratory muscle pump They typically have a resp muscle load the exceeds the resp neuromuscular capacity

Load on Respiratory System Need for increase ventilation increased carbon dioxide production increased dead space ventilation increased respiratory drive Increased work of breathing

Causes of Inspiratory respiratory muscle fatigue Nutrition and metabolic deficiencies: K, Mg, Ca, Phosphate and thyroid hormone Corticosteroids Chronic renal failure Systemic disceases; protein synthesis, degradation, glycogen stores Hypoxemia and hypercapnia Excessive sedation

Capacity of respiratory system Central drive to breathe Transmission of CNS signal via Phrenic nerve Impairment of resp muscles to generate effective pressure gradients Impairment of normal muscle force generation

Evidence based medicine When to start weaning process? When to start weaning process? Decision making, any guideline? How long it will take? Decision making, any guideline? How long it will take?

When to begin the weaning process? Numerous trials performed to develop criteria for success weaning, however, not useful to predict when to begin the weaning Physicians must rely on clinical judgement Consider when the reason for IPPV is stabilised and the patient is improving and haemodynamically stable Daily screening may reduce the duration of MV and ICU cost

Evidence-based medicine Recommendation: Search for all the causes that may contribute to ventilator dependence in all patients with longer than 24 h of MV support, particularly who has fail attempts. Reversing all possible causes should be an integral part of discontinuation process.

Daily Screening Resolution/improvement of patient’s underlying problem OFF potent sedation Adequate gas exchange (SaO 2 > 90%, PaO 2 /FiO 2 >200) Respiratory rate < 35/ min Absence of fever, temperature < 38C Adequate haemoglobin concentration, > 8-10 g/dl Stable cardiovascular function: heart rate SBP>90

Daily Screening (cont.) Indices suggesting an adequate capacity of the ventilatory pump: respiratory rate of less than 30/ min, Maximum inspiratory pressure < -20 to - 30 cmH 2 O Correction of metabolic and electrolyte disorders Normal state of consciousness

Evidence-based medicine Recommendation 2. Patients receiving MV for respiratory failure should undergo a formal assessment of discontinuation potential if the criteria are satisfied. Reversal of cause, adequate oxygenation, haemodynamic stability, capability to initiate respiratory effort. The decision must be individualized.

Predictions of the outcome of weaning Variables used to predict weaning success: Gas exchange PaO 2 of > 60 mmHg with FiO 2 of < 0.35 A-a PaO 2 gradient of < 350 mmHg PaO 2 /FiO 2 ratio of > 200

Weaning success prediction Ventilation Pump Vital capacity > ml/kg BW Maximal negative insp pressure < -30 cmH 2 O Minute ventilation < 10 l/min Maximal voluntary ventilation more than twice resting MV

Weaning success prediction Tidal volume > 325 ml Tidal volume/BW > 4 ml/kg Dynamic Compliance > 22 ml/cmH 2 O Static compliance > 33 ml/cmH 2 O Rapid shallow breathing index < 105 breaths/min/L

Clinical observation of the Respiratory Muscles Initially thought to be reliable in predicting subsequent weaning failure from inductive plethysmographic studies not necessary a substantial increase in load will effect on the rate, depth, and pattern of breathing a manifestation of fatigue

Both respiratory rate and minute ventilation initially increase, may be followed by a paradoxical inward motion of the anterior abdominal wall during inspiration which indicates the insufficient diaphragmatic contraction to descend and move the abdominal content downward

Cyclic change in breathing patterns with either a chest wall motion or a predominantly abdominal wall motion are another indicator, called respiratory alternans

Duration of weaning prior to initial episode of fatigue (days) Fatigue criteria Hypoxia (PaO 2 <60, SpO2 <90%) Hypercarbia (PaCO 2 > 50 mmHg) Pulse rate > 120/min SBP > 180 or < 90 mmHg Respiratory rate > 30/min Clinical respiratory distress Fatigue Criteria

1. Maximal expiratory pressure 2. Peak expiratory flow rate 3. Cough strength 4. Secretion volume 5. Suctioning frequency 6. Cuff leak test 7. Neurological function (GCS) keep higher than 11 Parameters that assess airway patency and protection

Evidence-based medicine Recommendation 3. The removal of the artificial airway from a patient who has successfully been discontinued from ventilatory support should be based on assessment of airway patency and the ability of the patient to protect the airway.

Methods of Weaning Abrupt Discontinuation Extubation to NPPV, IPPB/IS… T- tube trials (ATC is preferred) SIMV to CPAP Pressure support/Volume Support

Spontaneous breathing protocol Communicate with patient, weaning is about to begin, allow pt to express fear whenever possible Obtain baseline value and monitoring clinical parameters; vital signs, subj distress, gas exchange, arrhythmia Ensure a calm atmosphere, avoid sedation Sit the patient upright in bed or chair Fit T-tube with adequate flow, observe for 2 hr

For How long I will have to monitor the weaning process with SBT in my patient?

Evidence-based medicine Recommendation 4. Formal assessments should be done during SBT rather than receiving substantial support. The criteria to assess patient tolerance during SBTs are respiratory pattern, gas exchange, hamodynamics stability and patient comfort. The tolerance of SBTs lasting 30 to 120 minutes should prompt for permanent ventilator discontinuation.

SIMV Protocol Switch to SIMV from assist mode or decrease RR Begin with RR 8/min decrease SIMV rate by two breaths per hour unless clinical deterioration if assume to fail, increase SIMV rate to previous level, until stable if stable at least 1 hour of rate 0/ min extubate in patient without respiratory disorders, decrease rate with half an hour interval, 2 hr extubate

Pressure Support Protocol Switch to PSV or decrease PS Begin PSV at 25 cmH 2 O, decrease PS by 2-4 cmH 2 O every hour unless clinical deterioration appears, adjust pressure until stable, if stable of PSV = 0 for at least one hour fit with T-tube or CPAP and then observe In patient without resp problems, decrease pressure at half an hour interval, if able to tolerate PSV = 0 for 2 hours, can be extubated

Failed to Wean Associated with intrinsic lung disease Associated with prolonged critical illness Incidence approximately 20% Increased risk in patient with longer duration of mechanical ventilation Increased risk of complications, mortality

Evidence-based medicine Recommendation 5. Patients receiving MV who fail an SBT should have the cause determined. Once causes are corrected, and if the patient still meets the criteria of weaning, subsequent SBTs should be performed every 24 hours.

Evidence-based medicine Recommendation 6. Patients receiving MV for respiratory failure who fail an SBT should receive a stable, nonfatiguing, comfortable form of ventilatory support.

Why a Weaning Protocol Reduced ventilator time Reduced weaning time; early beginning by non-physician healthcare workers Reduced cost Reduced complications: VAP

Evidence-based medicine Recommendation 7. Weaning protocols designed for non- physician health care professionals should be developed and implemented by ICUs. Protocols aimed at optimizing sedation should also be developed and implemented.

Evidence-based medicine Recommendation 8. Tracheostomy should be considered after period of stabilization on the ventilator when it becomes apparent that the patient will require prolonged MV. Tracheostomy should be performed when the patient appears likely to gain one or more benefits from the procedure.

Evidence-based medicine, cont. Required high levels of sedation to tolerate tube With marginal respiratory mechanics, lower resistance Derive psychological benefit from the ability to eat orally, communicate by articulated speech, enhanced mobility Assist physical therapy efforts

Evidence-based medicine Recommendation 9. Unless there is evidence for clearly irreversible disease, a patient requiring prolonged MV should not be considered permanently ventilator-dependent until 3 months of weaning attempts have failed.

Patient subgroups

Evidence-based medicine Recommendation 10. Anaesthesia/sedation strategies and ventilator management aimed at early extubation should be used in postsurgical patients.

SEMIQUANTITATIVE ASSESSMENT OF NEED FOR AIRWAY CARE Spont. cough Gag Sputum Quantity 0Vigorous0 0None 1Moderat e 1 11 pass 2Weak2 22 passes 3None3 3> 3 passes Sputum Viscosity Suctioning Frequency ( per last 8 h) Sputum Character 0Watery 0 > 3 h 0 Clear 1Frothy1q 2-3 h1Tan 2Thick2q 1-2 h2Yellow 3Tenaciou s 3< q 1 h3Green

RT role in Weaning from mechanical ventilation Psychological preparation

Nurse-led weaning ICCN 2001: Limited evidence suggesting that nurse-led weaning may reduce ventilation time; however, not clear whether it was nurse-led aspect or the clinical protocol that produced the effect Superior to doctor-led weaning, has huge implications for intensive care practice

Nurse-led weaning ICCN 2002; Retrospective study in patients with MV longer than 7 days, reduced average duration of MV support Some delays occurred: sedation; protocol needed, epidural analgesia, tracheostomy; surgical vs percutaneous, some staff lacked confidence and knowledge: continuous education programme

Daily Screening Resolution/improvement of patient’s underlying problem Adequate gas exchange (SaO 2 > 90%, PaO 2 /FiO 2 >200) Respiratory rate < 35/ min Absence of fever, temperature < 38C Adequate haemoglobin concentration, > g/dl Stable cardiovascular function: heart rate SBP>90

Daily Screening (cont.) Indices suggesting an adequate capacity of the ventilatory pump: respiratory rate of less than 30/ min, Maximum inspiratory pressure < -20 to -30 cmH 2 O Correction of metabolic and electrolyte disorders Normal state of consciousness Oriented, Mental ease, Positive attitude

Psychological preparation Knowing the patient; personal resources, motivation levels, and styles of coping, comes from continued and close contact with the patient Oriented; understanding what will happen and being informed of progress, able to control negative responses Mental ease; absence of anxiety and fear arising from being informed, reassured and supported Positive attitude; being motivated and co- operating