Weaning strategy from failed extubation

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Weaning strategy from failed extubation :

Weaning strategy from failed extubation Dr Bikram Gupta MD Anaesthesia PDCC in Critical Care

Understandings the discontinuation problem:

Understandings the discontinuation problem Who are the patients and what are their outcomes? What is wrong with patients on prolonged ventilator support What factors impact upon respiratory muscle fatigue and weakness ?

Who are the patients and what are their outcomes? :

Who are the patients and what are their outcomes? Lung failure Pump failure Aetiology Gas exchange problem hypoxemia Ventilatory problem Hypoxemia&hypercapnia Examples ARDS Cardiogenic pulm. edema CNS depression Respiratory muscle fatigue/weakness Outcomes 80-90% of pt , MV discontinued within 72 hrs e.g.- postop pt,drug overdose, pure lung failure that reverses rapidly 10-20% of pt, MV is more difficult to discontinue

What is wrong with patients on prolonged ventilator support :

What is wrong with patients on prolonged ventilator support 1.Inadequate respiratory drive Nutritional deficiency, sedatives,CNS abnormality, sleep deprivation 2.Inability of the lungs to carry out gas exchange effectively If underlying cause is not improved 3.Inspiratory respiratory muscle fatigue/weakness Contributors to respiratory muscle fatigue- CNS depression Mechanical defects- flail chest and kyphoscoliosis Lung disease that increases the work of breathing Mediators of on going active disease(e.g., sepsis, ventilator induced diaphragmatic dysfunction) 4.Psychological dependency 5. Combination of these factors

What factors impact upon respiratory muscle fatigue and weakness ? :

What factors impact upon respiratory muscle fatigue and weakness ? Possible causes of ins. muscle fatigue Nutritional and metabolic deficiencies Hypokalemia Hypomagnesemia Hypocalcemia Hypophosphatemia hypothyroidism Corticosteroids Chronic renal failure Systemic diseases Decreased protein synthesis Decreased glycogen stores Hypoxemia and hypercapnia Failure of the cardiovascular system (e.g. disease, ventilator) Neuromuscular dysfunction/disease Drugs/ critical illness polyneuropathy & myopathy

Criteria for predicting successful discontinuation:

Criteria for predicting successful discontinuation When is it appropriate to begin the discontinuation process?? Predictive indices for total discontinuation of mechanical ventilation. When is it appropriate to extubate the patient?? perspective

Criteria for predicting successful discontinuation :

Criteria for predicting successful discontinuation When is it appropriate to begin the discontinuation process Predictive indices for total discontinuation of mechanical ventilation When is it appropiate to extubate the patient ? Perspective ?

When is it appropriate to begin the discontinuation process?? :

When is it appropriate to begin the discontinuation process?? Consider a carefully monitored spontaneous breathing trial (SBT) of discontinuation when the following criteria fulfills :- The underlying reason(s) for MV has been stabilized and the patient is improving, The pt is haemodynamically stable on minimal-to-no pressors, Oxygenation is adequate (e.g. P/F >200,PEEP no more than 7.5 cm H 2 O, FiO 2 <50%) The patient is able to initiate spontaneous breathing efforts

SBTs:

SBTs Variably performed with a T-Piece, with low level pressure support ventilation, or with just a predetermined amount of CPAP Patients should be closely monitored first five minutes If pt deteriorates or becomes distressed during this brief period of observation, MV should be reinstituted.

Art of weaning :

Art of weaning “Art of weaning” centers on the judgment whether weaning induced distress is a manifestation of agitated delirium, sedative and narcotic withdrawl,pain and tube discomfort, or respiratory failure. When in doubt, the provider should assume the letter. No validated test To help decide in these situations, we sometimes observe patients who are difficult to wean while keeping them heavily sedated.

Slide 11:

If under these circumstances, unassisted breathing can be sustained without hypercapnia, hypoxemia,tachypnea, and tachycardia, conclude that resp failure is no longer present, that agitation may be related to pain, anxiety, or sedative/hypnotic withdrawl , and proceed with a trial of extubation if and when it believe that the the patient is able to protect his or her airway against the possibility of aspiration.

Predictive indices for total discontinuation of mechanical ventilation :

Predictive indices for total discontinuation of mechanical ventilation A few predictors have been shown to be of some use. Those include – RR <38 bpm RSBI <100 bpm per L An inspiratory pressure/maximal inspiratory pressure <0.3 The combination of a RR of >38 bpm and a RSBI more than 100 bpm per litre appears to reduce the probability of successful extubation. It is recommended that RSBI measurements be made while patients are spontaneously breathing, not during the first minute of SB.

When is it appropriate to extubate the patient ? :

When is it appropriate to extubate the patient ? The most common cause of extubation failure are upper airway obstruction and inability to protect the airway and clear secretions. Patients at the highest risk of postextubation upper-airway obstruction are those who have been on prolonged MV, are female, and who have had repeated or traumatic intubations.

Cuff-leak test:

Cuff-leak test It is performed by comparing the exhaled volume before and after the balloon of the endotracheal tube has been deflated. One study showed that a cuff leak of less than 110 ml measured during assist control ventilation within 24 hours of extubation identified patients at high risk of postextubation stridor .

Slide 15:

Patients may also fail extubation because they are unable to protect their airways or clear their secretions. A prospective observational study showed that the strongest predictors of extubation failure in patients who passed a SB trial were- Poor cough defined as a cough peak flow measurements < 60 L per minute secretion volume of 2.5 ml per hour or greater and Poor mentation as determined by the inability to complete any of the four following tasks on command : open eyes, follow observer with eyes, grasp hand, and stick out tongue.

Slide 16:

Once extubation has been taken place, the authors proceed cautiously before instituting feedings by mouth. Because there is no clinically reliable way of assessing the adequacy of swallowing at the bedside, a formal swallowing evaluation (e.g., speech pathology consult and video fluoroscopic evaluation of swallow) should be considered in patients at increased risk of aspiration before resuming oral feedings.

Risk factors of extubation:

Risk factors of extubation Older age Debilitation Sedation Oral or nasal enteral feeding tubes h/o dysphagia Acute stroke Cervical spine surgery Muscle weakness Tracheostomy

Perspective ? :

Perspective ? When the patient’s clinical condition has been stabilised , it is reasonable to consider starting the dis

Principles and modes of discontinuing :

Principles and modes of discontinuing

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