Ventilator Weaning and Spontaneous Breathing Trials; an Educational Review

Hossam Zein, Alireza Baratloo, Ahmed Negida, Saeed Safari, Hossam Zein, Alireza Baratloo, Ahmed Negida, Saeed Safari

Abstract

The term "weaning" is used to describe the gradual process of decreasing ventilator support. It is estimated that 40% of the duration of mechanical ventilation is dedicated to the process of weaning. Spontaneous breathing trial (SBT) assesses the patient's ability to breathe while receiving minimal or no ventilator support. The collective task force in 2001 stated that the process of SBT and weaning should start by assessing whether the underlying cause of respiratory failure has been resolved or not. Weaning predictors are parameters that are intended to help clinicians predict whether weaning attempts will be successful or not. Although the international consensus conference in 2005 did not recommend their routine use for clinical decision making, researchers did not stop working in this area. In the present article, we review some of the recent studies about weaning predictors, criteria, procedure, as well as assessment for extubation a mechanically ventilated patient.

Keywords: Ventilator weaning; airway extubation; emergency service; hospital; mechanical ventilation; ventilator induced lung injury.

References

    1. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, et al. Evolution of mechanical ventilation in response to clinical research. American journal of respiratory and critical care medicine. 2008;177(2):170–7.
    1. MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375s–95s.
    1. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. The New England journal of medicine. 1996;335(25):1864–9.
    1. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. The American journal of medicine. 1993;94(3):281–8.
    1. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. American journal of respiratory and critical care medicine. 1997;155(3):906–15.
    1. Tobin MJ, Guenther SM, Perez W, Lodato RF, Mador MJ, Allen SJ, et al. Konno-Mead analysis of ribcage-abdominal motion during successful and unsuccessful trials of weaning from mechanical ventilation. The American review of respiratory disease. 1987;135(6):1320–8.
    1. MacIntyre NR. The ventilator discontinuation process: an expanding evidence base. Respiratory care. 2013;58(6):1074–86.
    1. Ely EW, Baker AM, Evans GW, Haponik EF. The prognostic significance of passing a daily screen of weaning parameters. Intensive care medicine. 1999;25(6):581–7.
    1. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. The European respiratory journal. 2007;29(5):1033–56.
    1. Huang CT, Tsai YJ, Lin JW, Ruan SY, Wu HD, Yu CJ. Application of heart-rate variability in patients undergoing weaning from mechanical ventilation. Critical care (London, England) 2014;18(1):R21.
    1. Seely AJ, Bravi A, Herry C, Green G, Longtin A, Ramsay T, et al. Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Critical care (London, England) 2014;18(2):R65.
    1. Hammash MH, Moser DK, Frazier SK, Lennie TA, Hardin-Pierce M. Heart rate variability as a predictor of cardiac dysrhythmias during weaning from mechanical ventilation. American journal of critical care : an official publication, American Association of Critical-Care Nurses. 2015;24(2):118–27.
    1. Arcentales A, Caminal P, Diaz I, Benito S, Giraldo BF. Classification of patients undergoing weaning from mechanical ventilation using the coherence between heart rate variability and respiratory flow signal. Physiological measurement. 2015;36(7):1439–52.
    1. Chen CJ, Hsu LN, McHugh G, Campbell M, Tzeng YL. Predictors of sleep quality and successful weaning from mechanical ventilation among patients in respiratory care centers. The journal of nursing research : JNR. 2015;23(1):65–74.
    1. Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Clinical review: Critical illness polyneuropathy and myopathy. Critical care (London, England) 2008;12(6):238.
    1. Cottereau G, Dres M, Avenel A, Fichet J, Jacobs FM, Prat D, et al. Handgrip Strength Predicts Difficult Weaning But Not Extubation Failure in Mechanically Ventilated Subjects. Respiratory care. 2015
    1. Hermans G, Agten A, Testelmans D, Decramer M, Gayan-Ramirez G. Increased duration of mechanical ventilation is associated with decreased diaphragmatic force: a prospective observational study. Critical care (London, England) 2010;14(4):R127.
    1. DiNino E, Gartman EJ, Sethi JM, McCool FD. Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax. 2014;69(5):423–7.
    1. Verona C, Hackenhaar FS, Teixeira C, Medeiros TM, Alabarse PV, Salomon TB, et al. Blood markers of oxidative stress predict weaning failure from mechanical ventilation. Journal of cellular and molecular medicine. 2015;19(6):1253–61.
    1. Penuelas O, Thille AW, Esteban A. Discontinuation of ventilatory support: new solutions to old dilemmas. Current opinion in critical care. 2015;21(1):74–81.
    1. Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. European Respiratory Journal. 2007;29(5):1033–56.
    1. Bailey CR, Jones RM, Kelleher AA. The role of continuous positive airway pressure during weaning from mechanical ventilation in cardiac surgical patients. Anaesthesia. 1995;50(8):677–81.
    1. Jones DP, Byrne P, Morgan C, Fraser I, Hyland R. Positive end-expiratory pressure vs T-piece. Extubation after mechanical ventilation. Chest. 1991;100(6):1655–9.
    1. Ladeira Magdaline T, Vital Flávia MR, Andriolo Régis B, Andriolo Brenda NG, Atallah Álvaro N, Peccin Maria S. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database of Systematic Reviews [Internet] 2014. Available from: .
    1. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. The New England journal of medicine. 1991;324(21):1445–50.
    1. Dojat M, Harf A, Touchard D, Laforest M, Lemaire F, Brochard L. Evaluation of a knowledge-based system providing ventilatory management and decision for extubation. American journal of respiratory and critical care medicine. 1996;153(3):997–1004.
    1. Liu L, Liu H, Yang Y, Huang Y, Liu S, Beck J, et al. Neuroventilatory efficiency and extubation readiness in critically ill patients. Critical care (London, England) 2012;16(4):R143.
    1. Sellares J, Ferrer M, Cano E, Loureiro H, Valencia M, Torres A. Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU. Intensive care medicine. 2011;37(5):775–84.
    1. Tonnelier A, Tonnelier JM, Nowak E, Gut-Gobert C, Prat G, Renault A, et al. Clinical relevance of classification according to weaning difficulty. Respiratory care. 2011;56(5):583–90.
    1. Penuelas O, Frutos-Vivar F, Fernandez C, Anzueto A, Epstein SK, Apezteguia C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. American journal of respiratory and critical care medicine. 2011;184(4):430–7.
    1. Funk GC, Anders S, Breyer MK, Burghuber OC, Edelmann G, Heindl W, et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. The European respiratory journal. 2010;35(1):88–94.
    1. Jeong BH, Ko MG, Nam J, Yoo H, Chung CR, Suh GY, et al. Differences in clinical outcomes according to weaning classifications in medical intensive care units. PloS one. 2015;10(4):e0122810.
    1. MacIntyre NR. Patient-ventilator interactions: optimizing conventional ventilation modes. Respiratory care. 2011;56(1):73–84.
    1. McConville JF, Kress JP. Weaning Patients from the Ventilator. New England Journal of Medicine. 2012;367(23):2233–9.
    1. Blackwood B, Burns KE, Cardwell CR, O'Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. The Cochrane database of systematic reviews. 2014;11:Cd006904.
    1. Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis. Critical care (London, England) 2015;19(1):48.
    1. Aitken Leanne M, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh Samantha J. Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Cochrane Database of Systematic Reviews [Internet] 2015. Available from: .
    1. Burry L, Rose L, McCullagh Iain J, Fergusson Dean A, Ferguson Niall D, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database of Systematic Reviews [Internet] 2014. Available from: .
    1. Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Critical care medicine. 2011;39(12):2612–8.
    1. Fisher MM, Raper RF. The 'cuff-leak' test for extubation. Anaesthesia. 1992;47(1):10–2.
    1. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest. 1996;110(4):1035–40.
    1. Jaber S, Jung B, Chanques G, Bonnet F, Marret E. Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials. Critical care (London, England) 2009;13(2):R49.
    1. Hilberman M, Dietrich HP, Martz K, Osborn JJ. An analysis of potential physiological predictors of respiratory adequacy following cardiac surgery. The Journal of thoracic and cardiovascular surgery. 1976;71(5):711–20.
    1. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure A different approach to weaning. Chest. 1996;110(6):1566–71.
    1. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive care medicine. 2004;30(7):1334–9.
    1. King CS, Moores LK, Epstein SK. Should patients be able to follow commands prior to extubation? Respiratory care. 2010;55(1):56–65.
    1. Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Role of noninvasive positive-pressure ventilation in postextubation respiratory failure: a meta-analysis. Respiratory care. 2007;52(11):1472–9.
    1. Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation Effects on oxygenation, comfort, and clinical outcome. American journal of respiratory and critical care medicine. 2014;190(3):282–8.
    1. Brotfain E, Zlotnik A, Schwartz A, Frenkel A, Koyfman L, Gruenbaum SE, et al. Comparison of the effectiveness of high flow nasal oxygen cannula vs. standard non-rebreather oxygen face mask in post-extubation intensive care unit patients. The Israel Medical Association journal : IMAJ. 2014;16(11):718–22.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe