Breathing measurement reduces false-negative classification of tachypneic preextubation trial failures

DeHaven, C. Bryan; Kirton, Orlando C.; Hart, Andrew; Shatz, David V.; Civetta, Joseph M.

doi:10.1097/00003246-199606000-00017

Cited by 45 publications

(21 citation statements)

References 22 publications

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“…Indeed, it is conceivable that iatrogenic factors such as endotracheal tube discomfort or demandvalve insensitivity/unresponsiveness, rather than true ventilator dependence, caused the failure of the SBT in at least some of these patients. 3,15,[32][33][34][35] Thus, it is unclear how many patients who are unable to tolerate an SBT would still be able to tolerate long-term ventilator discontinuation. Although the number is likely to be small, it is probably not zero, and this needs to be considered when dealing with patients who repeatedly fail an SBT.…”

Section: The Evidence Base Supporting Ventilator Withdrawal Strategiementioning

confidence: 99%

The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

MacIntyre

2013

Respir Care

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The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. Continued ventilator dependence can be a result of persistent illness or can be a result of poor management. It is obviously important for the clinician to be able to assess both of these issues. An evidence-based task force has recommended regular assessments focusing on the causes of ventilator dependence, regular assessments for evidence of disease stability/reversal, use of regular spontaneous breathing trials (SBTs) as the primary assessment tool for ventilator discontinuation potential, use of separate assessments to evaluate the need for an artificial airway in patients tolerating the SBT, and the use of comfortable, interactive ventilator modes (that do not need to be "weaned") in between regular SBTs. More recent developments have focused on the importance of linking sedation reduction protocols to ventilator discontinuation protocols. Patients with repeated SBT failures are often considered to require prolonged mechanical ventilation (PMV). These patients often receive tracheostomies and are probably better managed with more gradual reductions in support and gradually lengthened spontaneous breathing periods. PMV patients have a high 1-year mortality, and many may ultimately require lifelong support. This evidence base is growing, but the earlier guidelines are standing the test of time. Indeed, practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement, and further clinical studies, especially in the patient requiring PMV, are needed.

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Section: The Evidence Base Supporting Ventilator Withdrawal Strategiementioning

confidence: 99%

The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

MacIntyre

2013

Respir Care

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“…We therefore conclude that compliance with the spontaneous breathing trial is one critical feature characterizing our patient collective. Based on previous findings reporting that 105 out of 589 extubated patients had a preextubation respiratory rate >30 breaths/ min [41] , one might suppose that spontaneous breathing would have principally been possible in some of our patients. However, due to obvious vegetative stress and the patients' impaired insight into the actual clinical condition, such a procedure seems questionable in stroke patients.…”

Section: Discussionmentioning

confidence: 85%

Discontinuous versus Continuous Weaning in Stroke Patients

Teismann¹,

Oelschläger

Werstler³

et al. 2015

Cerebrovasc Dis

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Background: An increasing number of stroke patients have to be supported by mechanical ventilation in intensive care units (ICU), with a relevant proportion of them requiring gradual withdrawal from a respirator. To date, weaning studies have focused merely on mixed patient groups, COPD patients or patients after cardiac surgery. Therefore, the best weaning strategy for stroke patients remains to be determined. Methods: Here, we designed a prospective randomized controlled study comparing adaptive support ventilation (ASV), a continuous weaning strategy, with biphasic positive airway pressure (BIPAP) in combination with spontaneous breathing trials, a discontinuous technique, in the treatment of stroke patients. The primary endpoint was the duration of the weaning process. Results: Only the 40 (out of 54) patients failing in an initial spontaneous breathing trial (T-piece test) were included into the study; the failure proportion is considerably larger compared to previous studies. Eligible patients were pseudo-randomly assigned to one of the two weaning groups. Both groups did not differ regarding age, gender, and severity of stroke. The results showed that the median weaning duration was 10.7 days (±SD 7.0) in the discontinuous weaning group, and 8 days (±SD 4.5) in the continuous weaning group (p < 0.05). Conclusions: To the best of our knowledge, this is the first clinical study to show that continuous weaning is significantly more effective compared to discontinuous weaning in mechanically ventilated stroke patients. We suppose that the reason for the superiority of continuous weaning using ASV as well as the bad performance of our patients in the 2 h T-piece test is caused by the patients' compliance. Compared to patients on surgical and medical ICUs, neurological patients more often suffer from reduced vigilance, lack of adverse-effects reflexes, dysphagia, and cerebral dysfunction. Therefore, stroke patients may profit from a more gradual withdrawal of weaning.

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“…Many investigators have demonstrated reliable predictors of successful extubation or discontinuation of MVS [2], and among them, the ratio of respiratory frequency to tidal volume (f/V T ) [3, 4, 5, 6, 7, 8], the work of breathing [9, 10, 11]and the oxygen cost of breathing (OCOB) [12, 13, 14, 15]have frequently been found to be the most reliable. However, these results have aroused controversy at present.…”

Section: Introductionmentioning

confidence: 99%

Continuous Monitoring of Oxygen Consumption in Patients Undergoing Weaning from Mechanical Ventilation

Miwa

Takamori

et al. 2003

Respiration

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Background: The extubation or discontinuation of mechanical ventilatory support (MVS) is only the final step in the weaning process, and an improvement in the efficiency of the weaning process is required for more successful extubation or discontinuation of MVS. Objective: To evaluate whether continuous monitoring of oxygen consumption (v̇_O2) using the metabolic gas monitor is a useful predictor of failure to tolerate a weaning trial of reduced MVS. Method: Twenty adult patients meeting the criteria for weaning, who required MVS ≧7 days and who were previously deemed to have failed weaning by their attending physicians. A weaning trial was defined as a 30-min period during the strengthening training of our standardized weaning protocol. The average v̇_O2, respiratory rate (RR), tidal volume (TV), minute ventilation (v̇_E) and energy expenditure (EE) were recorded in respiratory muscles for a stable period of 20 min at rest and for the last 5 min of the trial. Subsequently, the oxygen cost of breathing (OCOB), the ratio of respiratory frequency to tidal volume (f/V_T), ΔRR, ΔTV, Δv̇_E, and ΔEE were calculated. Results: Two hundred and eight weaning trials, including 145 successful trials and 63 failed trials from 20 patients were evaluated. In nonparametric analysis, a statistical difference in OCOB, ΔRR, and ΔEE was found between successful and failed weaning trials, while no statistical differences were found for the other parameters. An OCOB <30% was the most accurate predictor of outcome of a weaning trial, and an f/V_T <105 was the least accurate. In a multiple logistic analysis, the OCOB revealed the highest odds ratio among all parameters. Conclusions: Measuring the OCOB was clinically beneficial in avoiding the induction of an excessive movement load on the respiratory muscles. In patients treated with MVS, continuous monitoring of v̇_O2 is a useful to predict success or failure of trials attempting to reduce MVS.

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Breathing measurement reduces false-negative classification of tachypneic preextubation trial failures

Cited by 45 publications

References 22 publications

The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

Discontinuous versus Continuous Weaning in Stroke Patients

Continuous Monitoring of Oxygen Consumption in Patients Undergoing Weaning from Mechanical Ventilation

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