Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial

A Daniel Martin, Barbara K Smith, Paul D Davenport, Eloise Harman, Ricardo J Gonzalez-Rothi, Maher Baz, A Joseph Layon, Michael J Banner, Lawrence J Caruso, Harsha Deoghare, Tseng-Tien Huang, Andrea Gabrielli, A Daniel Martin, Barbara K Smith, Paul D Davenport, Eloise Harman, Ricardo J Gonzalez-Rothi, Maher Baz, A Joseph Layon, Michael J Banner, Lawrence J Caruso, Harsha Deoghare, Tseng-Tien Huang, Andrea Gabrielli

Abstract

Introduction: Most patients are readily liberated from mechanical ventilation (MV) support, however, 10% - 15% of patients experience failure to wean (FTW). FTW patients account for approximately 40% of all MV days and have significantly worse clinical outcomes. MV induced inspiratory muscle weakness has been implicated as a contributor to FTW and recent work has documented inspiratory muscle weakness in humans supported with MV.

Methods: We conducted a single center, single-blind, randomized controlled trial to test whether inspiratory muscle strength training (IMST) would improve weaning outcome in FTW patients. Of 129 patients evaluated for participation, 69 were enrolled and studied. 35 subjects were randomly assigned to the IMST condition and 34 to the SHAM treatment. IMST was performed with a threshold inspiratory device, set at the highest pressure tolerated and progressed daily. SHAM training provided a constant, low inspiratory pressure load. Subjects completed 4 sets of 6-10 training breaths, 5 days per week. Subjects also performed progressively longer breathing trials daily per protocol. The weaning criterion was 72 consecutive hours without MV support. Subjects were blinded to group assignment, and were treated until weaned or 28 days.

Results: Groups were comparable on demographic and clinical variables at baseline. The IMST and SHAM groups respectively received 41.9 ± 25.5 vs. 47.3 ± 33.0 days of MV support prior to starting intervention, P = 0.36. The IMST and SHAM groups participated in 9.7 ± 4.0 and 11.0 ± 4.8 training sessions, respectively, P = 0.09. The SHAM group's pre to post-training maximal inspiratory pressure (MIP) change was not significant (-43.5 ± 17.8 vs. -45.1 ± 19.5 cm H2O, P = 0.39), while the IMST group's MIP increased (-44.4 ± 18.4 vs. -54.1 ± 17.8 cm H2O, P < 0.0001). There were no adverse events observed during IMST or SHAM treatments. Twenty-five of 35 IMST subjects weaned (71%, 95% confidence interval (CI) = 55% to 84%), while 16 of 34 (47%, 95% CI = 31% to 63%) SHAM subjects weaned, P = .039. The number of patients needed to be treated for effect was 4 (95% CI = 2 to 80).

Conclusions: An IMST program can lead to increased MIP and improved weaning outcome in FTW patients compared to SHAM treatment.

Trial registration: ClinicalTrials.gov: NCT00419458.

Figures

Figure 1
Figure 1
CONSORT diagram.

References

    1. Zilberberg MD, Luippold RS, Sulsky S, Shorr AF. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Crit Care Med. 2008;36:724–730. doi: 10.1097/CCM.0B013E31816536F7.
    1. Zilberberg MD, de Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical ventilation: Implications for healthcare delivery*. Crit Care Med. 2008. pp. 1451–1455.
    1. Purro A, Appendini L, De Gaetano A, Gudjonsdottir M, Donner CF, Rossi A. Physiologic determinants of ventilator dependence in long-term mechanically ventilated patients. Am J Respir Crit Care Med. 2000;161:1115–1123.
    1. Vassilakopoulos T, Zakynthinos S, Roussos C. The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. Am J Respir Crit Care Med. 1998;158:378–385.
    1. Carlucci A, Ceriana P, Prinianakis G, Fanfulla F, Colombo R, Nava S. Determinants of weaning success in patients with prolonged mechanical ventilation. Crit Care. 2009;13:R97. doi: 10.1186/cc7927.
    1. DeRuisseau KC, Shanely RA, Akunuri N, Hamilton MT, Van Gammeren D, Zergeroglu AM, McKenzie M, Powers SK. Diaphragm unloading via controlled mechanical ventilation alters the gene expression profile. Am J Respir Crit Care Med. 2005;172:1267–1275. doi: 10.1164/rccm.200503-403OC.
    1. Gayan-Ramirez G, de Paepe K, Cadot P, Decramer M. Detrimental effects of short-term mechanical ventilation on diaphragm function and IGF-I mRNA in rats. Intensive Care Med. 2003;29:825–833.
    1. Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med. 2008;34:7–16. doi: 10.1007/s00134-007-0866-x.
    1. Knisely AS, Leal SM, Singer DB. Abnormalities of diaphragmatic muscle in neonates with ventilated lungs. J Pediatr. 1988;113:1074–1077. doi: 10.1016/S0022-3476(88)80585-7.
    1. Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358:1327–1335. doi: 10.1056/NEJMoa070447.
    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. Crit Care. 2010;14:R127. doi: 10.1186/cc9094.
    1. Hussain SN, Mofarrahi M, Sigala I, Kim HC, Vassilakopoulos T, Maltais F, Bellenis I, Chaturvedi R, Gottfried SB, Metrakos P, Danialou G, Matecki S, Jaber S, Petrof BJ, Goldberg P. Mechanical Ventilation-induced Diaphragm Disuse in Humans Triggers Autophagy. Am J Respir Crit Care Med. 2010;182:1377–1386. doi: 10.1164/rccm.201002-0234OC.
    1. Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, Bouyabrine H, Courouble P, Koechlin-Ramonatxo C, Sebbane M, Similowski T, Scheuermann V, Mebazaa A, Capdevila X, Mornet D, Mercier J, Lacampagne A, Philips A, Matecki S. Rapidly Progressive Diaphragmatic Weakness and Injury during Mechanical Ventilation in Humans. Am J Respir Crit Care Med. 2011;183:364–371. doi: 10.1164/rccm.201004-0670OC.
    1. Hulzebos EH, Helders PJ, Favie NJ, De Bie RA, Brutel de la Riviere A, Van Meeteren NL. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296:1851–1857. doi: 10.1001/jama.296.15.1851.
    1. Kulkarni S, Fletcher E, McConnell A, Poskitt K, Whyman M. Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdominal surgery - a randomised pilot study. Ann R Coll Surg Engl. 2010.
    1. Martin AD, Davenport PD, Franceschi AC, Harman E. Use of inspiratory muscle strength training to facilitate ventilator weaning: a series of 10 consecutive patients. Chest. 2002;122:192–196. doi: 10.1378/chest.122.1.192.
    1. Aldrich TK, Karpel JP. Inspiratory muscle resistive training in respiratory failure. Am Rev Respir Dis. 1985;131:461–462.
    1. Sprague SS, Hopkins PD. Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther. 2003;83:171–181.
    1. Caruso P, Denari SD, Ruiz SA, Bernal KG, Manfrin GM, Friedrich C, Deheinzelin D. Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics. 2005;60:479–484. doi: 10.1590/S1807-59322005000600009.
    1. American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998;30:992–1008. doi: 10.1097/00005768-199806000-00033.
    1. Caruso P, Friedrich C, Denari SD, Ruiz SA, Deheinzelin D. The unidirectional valve is the best method to determine maximal inspiratory pressure during weaning. Chest. 1999;115:1096–1101. doi: 10.1378/chest.115.4.1096.
    1. Nozawa E, Azeka E, Ignez ZM, Feltrim Z, Auler JO Junior. Factors associated with failure of weaning from long-term mechanical ventilation after cardiac surgery. Int Heart J. 2005;46:819–831. doi: 10.1536/ihj.46.819.
    1. Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M. Impact of renal dysfunction on weaning from prolonged mechanical ventilation. Crit Care. 1997;1:101–104. doi: 10.1186/cc112.
    1. Scheinhorn DJ, Hassenpflug M, Artinian BM, LaBree L, Catlin JL. Predictors of weaning after 6 weeks of mechanical ventilation. Chest. 1995;107:500–505. doi: 10.1378/chest.107.2.500.
    1. Scheinhorn DJ, Hassenpflug MS, Votto JJ, Chao DC, Epstein SK, Doig GS, Knight EB, Petrak RA. Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest. 2007;131:85–93. doi: 10.1378/chest.06-1081.
    1. Pilcher DV, Bailey MJ, Treacher DF, Hamid S, Williams AJ, Davidson AC. Outcomes, cost and long term survival of patients referred to a regional weaning centre. Thorax. 2005;60:187–192. doi: 10.1136/thx.2004.026500.
    1. Capdevila XJ, Perrigault PF, Perey PJ, Roustan JP, d'Athis F. Occlusion pressure and its ratio to maximum inspiratory pressure are useful predictors for successful extubation following T-piece weaning trial. Chest. 1995;108:482–489. doi: 10.1378/chest.108.2.482.
    1. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324:1445–1450. doi: 10.1056/NEJM199105233242101.
    1. Nemer SN, Barbas CS, Caldeira JB, Guimaraes B, Azeredo LM, Gago R, Souza PC. Evaluation of maximal inspiratory pressure, tracheal airway occlusion pressure, and its ratio in the weaning outcome. J Crit Care. 2009;24:441–446. doi: 10.1016/j.jcrc.2009.01.007.
    1. Bruton A. A pilot study to investigate any relationship between sustained maximal inspiratory pressure and extubation outcome. Heart Lung. 2002;31:141–149. doi: 10.1067/mhl.2002.122840.
    1. Yang KL. Inspiratory pressure/maximal inspiratory pressure ratio: a predictive index of weaning outcome. Intensive Care Med. 1993;19:204–208. doi: 10.1007/BF01694771.
    1. Teixeira C, Teixeira PJ, de Leon PP, Oliveira ES. Work of breathing during successful spontaneous breathing trial. J Crit Care. 2009;24:508–514. doi: 10.1016/j.jcrc.2008.10.013.
    1. Jubran A, Grant BJ, Laghi F, Parthasarathy S, Tobin MJ. Weaning prediction: esophageal pressure monitoring complements readiness testing. Am J Respir Crit Care Med. 2005;171:1252–1259. doi: 10.1164/rccm.200503-356OC.
    1. O'Donnell DE, Banzett RB, Carrieri-Kohlman V, Casaburi R, Davenport PW, Gandevia SC, Gelb AF, Mahler DA, Webb KA. Pathophysiology of dyspnea in chronic obstructive pulmonary disease: a roundtable. Proc Am Thorac Soc. 2007;4:145–168.
    1. Scano G, Innocenti-Bruni G, Stendardi L. Do obstructive and restrictive lung diseases share common underlying mechanisms of breathlessness? Respir Med. 2010;104:925–933. doi: 10.1016/j.rmed.2010.02.019.
    1. Mioxham J, Jolley C. Breathlessness, fatigue and the respiratory muscles. Clin Med. 2009;9:448–452.
    1. St Croix CM, Morgan BJ, Wetter TJ, Dempsey JA. Fatiguing inspiratory muscle work causes reflex sympathetic activation in humans. J Physiol. 2000;529(Pt 2):493–504. doi: 10.1111/j.1469-7793.2000.00493.x.
    1. Sheel AW, Derchak PA, Morgan BJ, Pegelow DF, Jacques AJ, Dempsey JA. Fatiguing inspiratory muscle work causes reflex reduction in resting leg blood flow in humans. J Physiol. 2001;537:277–289. doi: 10.1111/j.1469-7793.2001.0277k.x.
    1. Witt JD, Guenette JA, Rupert JL, McKenzie DC, Sheel AW. Inspiratory muscle training attenuates the human respiratory muscle metaboreflex. J Physiol. 2007;584:1019–1028. doi: 10.1113/jphysiol.2007.140855.
    1. Campbell EJ, Gandevia SC, Killian KJ, Mahutte CK, Rigg JR. Changes in the perception of inspiratory resistive loads during partial curarization. J Physiol. 1980;309:93–100.
    1. Kellerman BA, Martin AD, Davenport PW. Inspiratory strengthening effect on resistive load detection and magnitude estimation. Med Sci Sports Exerc. 2000;32:1859–1867. doi: 10.1097/00005768-200011000-00007.
    1. Fuster A, Sauleda J, Sala E, Barcelo B, Pons J, Carrera M, Noguera A, Togores B, Agusti AG. Systemic inflammation after inspiratory loading in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2008;3:149–153.
    1. Orozco-Levi M, Lloreta J, Minguella J, Serrano S, Broquetas JM, Gea J. Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164:1734–1739.
    1. Wang X, Jiang TX, Road JD, Redenbach DM, Reid WD. Granulocytosis and increased adhesion molecules after resistive loading of the diaphragm. Eur Respir J. 2005;26:786–794. doi: 10.1183/09031936.05.00105204.
    1. Jiang TX, Reid WD, Road JD. Free radical scavengers and diaphragm injury following inspiratory resistive loading. Am J Respir Crit Care Med. 2001;164:1288–1294.
    1. Reid WD, Belcastro AN. Time course of diaphragm injury and calpain activity during resistive loading. Am J Respir Crit Care Med. 2000;162:1801–1806.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir