Discontinuing MV in ICU Up

to Date

Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases , Assiut University

• Simple weaning” (group 1) includes

patients who succeed the first weaning trial

and are extubated without difficulty

, “Difficult weaning” (group 2) includes patients who fail the first weaning

trial and require up to 3 spontaneous

breathing trials or 7 days to achieve

successful weaning, and

“prolonged weaning” (group 3) includes patients who require more than 7

days of weaning after the first weaning trial.

• Several indexes have been employed to assess the

patient's ability to recover spontaneous breathing.

• Variables such as minute ventilation (Ve), maximum

inspiratory pressure (PImax), breathing frequency,

rapid shallow breathing index (RSBI, i.e., respiratory

frequency/tidal volume), tracheal airway occlusion

pressure 0.1 s (P 0.1), P0.1/ PImax >0.3,

P0.1Xf/VT<300 , a combined index named CROP

(compliance, rate, O2, pressure index) >13, IWI>25

and CORE >8 have been used in common clinical

practice

• P0.1/PImax > 0.3

— P0.1 is pressure at the airway opening

0.1 s after start of inspiratory flow

— Correlates with central respiratory drive

• P0.1 x f/VT <300

• CROP index (dynamic compliance,

respiratory rate, oxygenation, maximum

inspiratory pressure index) >13

— Cdyn x PImax x (PaO2/PAO2)/f

— >13 good

— Cdyn = dynamic compliance

• IWI (integrative weaning index) >25

— (CRS x SaO2)/(f/VT)

— CRS = static compliance of the

respiratory system

• CORE index (dynamic compliance,

oxygenation, rate, effort) >8

— Cdyn x (PImax/P0.1) x (PaO2/PAO2)/f

• Among the numerous parameters used

in clinical practice, the rapid shallow

breathing index is one of the most

accurate.

First Recommendation

For acutely hospitalized patients

ventilated more than 24 h, we suggest

that the initial SBT be conducted with

inspiratory pressure augmentation (5-

8 cm H2O) rather than without (T-piece

or CPAP)

Second Recommendation

For acutely hospitalized patients

ventilated for more than 24 h, we

suggest protocols attempting to

minimize sedation

Third Recommendation

For patients at high risk for extubation

failure who have been receiving

mechanical ventilation for more than

24 h and who have passed an SBT, we

recommend extubation to preventive

NIV

Third Recommendation

Patients at high risk for failure of

extubation may include those

patients with hypercapnia, COPD,

congestive heart failure, or other

serious comorbidities

Noninvasive ventilation as a weaning strategy for

mechanical ventilation in adults with respiratory

failure: a Cochrane systematic review Karen E.A. Burns et al CMAJ 2014. DOI:10.1503

Noninvasive weaning reduces rates of

death and pneumonia without increasing

the risk of weaning failure or reintubation.

In subgroup analyses, mortality benefits

were significantly greater in patients with

COPD

Fourth Recommendation

For acutely hospitalized adults who have

been mechanically ventilated for > 24 h,

we suggest protocolized rehabilitation

directed toward early mobilization

Fifth Recommendation

We suggest managing acutely

hospitalized adults who have been

mechanically ventilated for > 24 h with a

ventilator liberation protocol

Sixth Recommendation

We suggest performing a CLT in

mechanically ventilated adults who meet

extubation criteria and are deemed high

risk for PES

Seventh Recommendation

For adults who have failed a CLT but are

otherwise ready for extubation, we

suggest administering systemic steroids

at least 4 h before extubation; a repeated

CLT is not required

Diaphragm Ultrasound as a

Novel Guide of Weaning from

Invasive Ventilation

Gamal Agmy , MD , FCCP Professor of Chest Diseases and respiratory ICU,

Assiut University, Assiut , Egypt

Diaphragm Ultrasound as a

Novel Guide of Weaning from

Invasive Ventilation

Gamal Agmy , MD , FCCP Professor of Chest Diseases and respiratory ICU,

Assiut University, Assiut , Egypt

http://www.youtube.com/watch?v=bFcYP8xDRmM

• DT was calculated as percentage

from the following formula:

T end-inspiration − T end-expiration

T end-expiration

• It was recorded at total lung

capacity (TLC) and residual volume

(RV).

• DT was significantly different between

patients who failed and patients who

succeeded SBT.

• A cutoff value of a DT >40% was

associated with a successful SBT with a

sensitivity of 88%, a specificity of 92%, a

positive predictive value (PPV) of 95%,

and a negative predictive value (NPV) of

82%.