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Weaning from Mechanical Ventilation
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Another active area of investigation is the relationship between sedation, delirium, and weaning. Following up on the work of Kress et al., Girard and colleagues randomly assigned 336 mechanically ventilated patients to a daily spontaneous awakening trial followed by a spontaneous breathing trial or to a spontaneous breathing trial and usual care. The primary endpoint was time breathing without assistance [9]. They showed that the paired awakening and breathing trials led to more days without MV, shorter ICU and hospital length of stay, and improved mortality. Since then, light sedation and “pain first” management has been formalized in the Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption Guidelines developed by the Society of Critical Care Medicine [10].
Acute Lung Injury/Acute Respiratory Distress Syndrome
Published in Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba, Acute Care Surgery and Trauma, 2016
Kristin P. Colling, Juan J. Blondet, Greg J. Beilman
In 1999, the Agency for Healthcare Policy and Research (AHCPR) and the McMaster University Evidence Based Practice Center published the first evidence-based report on the criteria for discontinuation of mechanical ventilation [49]. At the same time, the American College of Chest Physicians, the Society for Critical Care Medicine, and the American Association for Respiratory Care formed a task force to incorporate the recommendations from the AHCPR–McMaster University and produce evidence-based clinical practice guidelines for managing the weaning process of mechanically ventilated patients [50]. These guidelines were developed from data derived from multiple meta-analyses and individual RCTs. The most important of their recommendations include the use of spontaneous breathing to assess the potential for formal discontinuation of ventilatory support. The technique as described includes the use of a 30–120 min spontaneous breathing trial (SBT) to identify candidates for permanent ventilator discontinuation, evaluation, and treatment of causes of failed SBT, and daily reevaluation with SBT. Candidates for SBT include those patients with evidence for improvement in their underlying process, adequate oxygenation (PEEP <5–8 cm H2O, and FiO2 <0.4–0.5), hemodynamic stability, and the capability to initiate an inspiratory effort. SBT can be accomplished by utilizing low levels of continuous positive airway pressure (CPAP) (5 cm H2O), low levels of pressure support (5–7 cm H2O), or “T-piece” breathing.
Diaphragmatic Ultrasound after Thoracic and Abdominal Surgery
Published in Massimo Zambon, Ultrasound of the Diaphragm and the Respiratory Muscles, 2022
Luigi Vetrugno, Daniele Orso, Elena Bignami, Gianmaria Cammarota
Diaphragmatic dysfunction is more frequently unilateral than bilateral. It must also be borne in mind that the left hemidiaphragm is more challenging to assess than the right hemidiaphragm [12]. Using new software and an anatomical motional (M)-mode for the ultrasound evaluation of diaphragmatic excursion, Pasero et al. were able to identify a greater proportion of patients exhibiting left diaphragm dysfunction following cardiac surgery [13]. The software used permits the free rotation to the M-mode line even if the acoustic window is not favourable for the good alignment of the ultrasound beam for left hemidiaphragmatic movements. An alternative solution, in the case of drainages and dressings inhibiting an anterior approach, would be the lateral approach as described by Lerolle et al. [14]. These authors found a linear correlation between excursion evaluated by ultrasound and the trans-diaphragmatic pressure gradient – an expression of the contribution of the diaphragm to the maximal inspiratory effort. Furthermore, Pierre-Henri Moury et al. recently assessed weaning from mechanical ventilation in cardiac surgical patients by evaluating diaphragm thickening during the spontaneous breathing trial (SBT) at the zone of apposition [15]. The authors found that diaphragm thickening could be markedly reduced in postoperative cardiac surgery, with 75% of patients found to have a thickening fraction (TF) less than 20%. This incidence was higher compared with those published by previous studies (reporting incidences around 60%). Diaphragmatic dysfunction in the study by Pierre-Henri Moury and colleagues mainly implied difficulty in weaning from invasive mechanical ventilation in the immediate postoperative period, and the authors did not correlate their data with respect to mechanical ventilation weaning failure.
Effects of high-flow nasal oxygen cannula versus other noninvasive ventilation in extubated patients: a systematic review and meta-analysis of randomized controlled trials
Published in Expert Review of Respiratory Medicine, 2022
Kaiyuan Guo, Gang Liu, Wei Wang, Guancheng Guo, Qi Liu
Invasive mechanical ventilation (IMV) is a vital life-saving tool for patients with acute respiratory failure (ARF). However, IMV is only a supportive treatment and does not cure the disease. It is very important to extubate patients in a timely manner and to minimize the time on IMV after ARF has been corrected. Otherwise, delayed extubation may cause prolonged IMV, which does not benefit the patient and is associated with more complications, longer intensive care unit (ICU) and hospital stays, higher medical expenses, and poorer prognosis [1,2]. One obstacle to successful extubation and IMV weaning is post-extubation respiratory insufficiency, which is caused by multiple detrimental factors such as upper airway obstruction, decreased respiratory muscle force, atelectasis and high respiratory workload, and hemodynamic instability, especially in high-risk patients. Severe respiratory insufficiency results in ARF, which occurs in 10%–20% of patients who pass a spontaneous breathing trial and meet the weaning criteria [3,4]. Post-extubation ARF leads to extubation failure and reintubation [5]. Therefore, it is essential to switch to an appropriate strategy of breathing support for patients who have post-extubation ARF or who are at high risk of ARF.
Can’t Hit Pause? On the Constitutive Elements of Responsible Ventilator Management & the Apnea Test
Published in The American Journal of Bioethics, 2020
Ultimately, the characterization of the apnea test performed without explicit informed consent as “so flagrantly breaching fundamental norms of health law and medical ethics” is decidedly lacking. We have demonstrated this by highlighting a constitutive feature of mechanical ventilation, its responsible use by the patient’s physician, and how pausing the ventilator for a spontaneous breathing trial or apnea test where indicated is not only clinically and ethically justified but intrinsic and necessary. We have argued that attempts to decouple constitutive elements of a medical treatment undermines the professional practice of medicine and places an undue moral burden upon surrogates and family members. While our clinical experience and the authors’ reflections may suggest that improvement is needed in how mechanical ventilation is described to a patient or their surrogate decision maker, it does not follow to excise the pause button from the critical care physician’s responsible ventilator management: a sine qua non of mechanical ventilation itself.
Diaphragmatic ultrasound in weaning ventilated patients: a reliable predictor?
Published in Expert Review of Respiratory Medicine, 2022
Khalil El Gharib, Marc Assaad, Michel Chalhoub
Successful liberation from MV is dependent on several factors, mainly adequate oxygenation, stable hemodynamics needing no or low-dose vasopressors, and intact neurologic status allowing complete clearance of airway secretions. Patients traditionally undergo spontaneous breathing trial (SBT); once judged to have passed the aforementioned criteria and exhibit a rapid shallow breathing index (RSBI) of less than 105 breaths/min/L, they are extubated [2]. However, more than 20% of these patients are re-intubated either due to unexpected cardiopulmonary destabilization, stagnating secretions, or even diaphragmatic dysfunction, as accessory muscles become more fatigued, unmasking the latter, despite an initially comforting RSBI [3].