L|beranon from mechan|ca|

venn|anon
John F. McConville, M.D.
Associate Professor
University of Chicago

D|sc|osure
no conlcLs of lnLeresL Lo dlsclose
Objectives:

Pinpoint patient readiness for spontaneous
breathing trials (SBT)
List criteria for passing an SBT
Identify non-ventilator strategies for reducing
duration of mechanical ventilation
A. RR: 40 and Vt: 250 ml after 1 min CPAP of 5 cmH
2
O
B. MV settings of AC 20/450/12/60%
C. BP of 90/45 mmHg on norepinephrine, vasopressin,
dobutamine
D. 65 yr old male with lung cancer, pneumonia, acute
renal failure, and CHF on CXR with a RR of 30 and
Vt of 300 ml after 1 min CPAP (5 cmH2O)
Audience Response Question
Whlch of Lhe followlng condluons
suggesLs readlness for a S81?
Mechanical ventilation: Primary
prevention
! EGDT in the initial treatment of sepsis
! Use of NIV in selected patients with:
AECOPD
Acute cardiogenic pulmonary edema
Rivers. N Engl J Med. 2001; 345:13681377.
Brochard. N Engl J Med 1995;333:817-822.
Masip. JAMA. 2005;294:3124-3130.
Gray. N Engl J Med. 359;(24): 142-151.
McConville JF, Kress JP. N Engl J Med 2012;367:2233-2239
Intubation
Tx RF etiology
Extubation
liberation duration
MV International Study Group
!AMA 2002,287:343-333.
69% Acute respiratory failure
post-surgical, pneumonia, CHF, sepsis, trauma, ARDS
Intubation
Tx RF etiology
Extubation
liberation duration
Duration of time on MV
60% 40%
Esteban Chest 1994;106:1186
Esteban JAMA 2002;287:345
Esteban AJRCCM 2008;177:170
136 brain injury-MV pts. Readiness criteria daily
Extubation delay = days b/t readiness and extubation
Complications of MV
Coplin AJRCCM 2000;162:1530
0
5
10
15
20
25
30
35
40
Pneum (%) Mortality
(%)
Hosp LOS
Delay (37/136) No delay (99/136)
Intubation
Tx of RF
Extubation
Liberation duration
GOAL: minimize time on MV
1970 through early 1980s
Weaning = disconnect patients from MV
for gradually increasing periods
Predictors sought to identify earliest time
a patient could resume spontaneous
breathing
Yang and Tobin NEJM 1991;324:1445-50.
Frequency/tidal volume ratio (f/Vt)
Calculated during a 1 minute spontaneous
breathing trial (SBT)
Ratio of < 105 best determines success
If clinical equipoise about SBT success
" f/Vt of 80 # LR of 7.5 and 95% success rate
Weaning predictors
Meade Chest 2001;120:400S
Systematic review and meta-
analysis
51 weaning predictors
Take home:
No ideal predictors for liberation readiness
5 predictors minimally helpful
NIF, VE, Vt, RR and f/Vt
Intermittent mandatory ventilation (IMV)
had replaced disconnecting MV for short
periods time as the primary means of
weaning
By the mid 1980s
1990s: Mode of weaning studies
Brochard and Esteban studies
1002 medical surgical MV patients
SIMV vs. PSV vs. T-piece
Brochard AJRCCM 1994;150:896-903
Esteban NEJM 1995;332:345-350
76% passed the initial SBT
Mode of weaning studies
Duration of weaning (days)
Brochard AJRCCM 1994;150:896-903
Esteban NEJM 1995;332:345-350
300 adult patients
Intervention group received
- daily screen respiratory function
- SBT: if passed # M.D. notified
Control pts were screened daily
Ely NEJM 1996;335:1864-1869
When can they breathe?
To pass screen test:
PaO
2
:FiO
2
ratio >200
PEEP ! 5
adequate cough
no vasopressor or sedatives in use
f/Vt ratio ! 105 during 1 min CPAP 5 cmH
2
0
Ely NEJM 1996;335:1864-1869
2 hour SBT on CPAP of 5 cm H
2
0
SBT terminated if:
RR > 35 for more than 5 minutes
O
2
% < 90%
HR > 140/min
sustained " in HR by 20%
SBP > 180 mmHg or < 90 mmHg
increased anxiety or diaphoresis
Ely NEJM 1996;335:1864-1869
P
t
s

o
n

M
V

(
%
)

Days after passed screen
Intervention group was sicker ( higher APACHE and LIS)
Median duration of MV until successful screen
test# 3 vs. 2 days (intervention and control)
Ely NEJM 1996;335:1864-1869
Decreased in intervention group:
Duration of MV
Reintubation rate
Cost of ICU stay
Ely NEJM 1996;335:1864-1869
roLocols: noL Always 8euer
Lecuve
MlCu/SlCu: kollef CCM '97, Marellch ChesL '00
L1AC: vlLacca A!8CCM '01, Schelnhorn ChesL '01

noL Superlor
nuSu: namen A!8CCM '01
eds: 8andolph !AMA '03
Academlc, well-sLaed MlCu: krlshnan A!8CCM '04
Take home points
Most patients can be liberated
quickly
Systematic approaches are needed
Physicians are bad at recognizing
when the weaning period begins
Assess readiness early
Whlch of Lhe followlng sLaLemenLs
abouL a S81 ls false?
A. Successful 30 mln S81 suggesLs adequaLe sLrengLh for
llberauon
8. valldaLed for 1-plece, Sv, or CA
C. A pauenL wlLh 88 of 30 and vL of 300ml aer a 60
mlnuLe S81 should noL be llberaLed
u. 8esL lf performed wlLh an alerL pauenL o sedauon

L. PosplLal morLallLy ls lncreased ln pLs falllng 3 S81s
Audience Response Question
What mode for SBT
T-piece = PSV 7 cm H
2
O
T-piece: 78% liberated and 38 reintubated
PSV: 86% liberated and 36 reintubated
Esteban AJRCCM 1997;156:459
Esteban AJRCCM 1999;159:512
30 min SBT = 120 min SBT
88% and 85% passed
13.5% and 13.4% reintubated
Duration of SBT
Patients are ready to breathe earlier
than we think

Systematic approach is much more
important than SBT mode and
duration
SBT summary
Why do patients fail SBTs?
Worsening respiratory mechanics
increased respiratory resistance
decreased lung compliance
gas trapping

Cardiac etiology
Tobin AJRCCM 1997;155:906-15
McConville JF, Kress JP. N Engl J Med 2012;367:2233-2239
Load > Strength
Why do patients fail SBTs?
8reaLhlng Challenges Lhe Clrculauon
- 19 hemodynamlcally sLable,
venulaLed sub[ecLs
- S81 (1-plece) for 60 mlnuLes
- lallures lncreased C
2

exLracuon whlle successes
lncrease C
1
Jubran AJRCCM 1998; 158:1763
Why do patients fail SBTs?
S
v
O
2

(
%
)

Weaning classification
Boles ERJ 2007;29:1033-1056
Simple: 1
st
SBT & liberation successful

Difficult: requires up to 3 SBTs
< 7 days 1
st
SBT to liberation

Prolonged: fail at least 3 SBTs or
> 7 days weaning after 1
st
SBT
Weaning classification
Funk ERJ 2010;35:88-94
257 patients prospective study
Simple: 59% # 13% hospital mortality
Difficult: 26% # 9% hospital mortality
Prolonged: 14% # 32% hospital
mortality
Other factors effecting liberation
Sedation strategies
- medications
- interruption
Timing of awakening and SBT
Physical therapy
k|chmond Ag|tanon Sedanon Score (kASS)
+4 Combanve Combanve, v|o|ent, danger to sta
+3 Very Ag|tated u||s or removes tubes, aggress|ve
+2 Ag|tated Ireq non-purposefu| movement,
hghts venn|ator
+1 kest|ess Anx|ous, but movements not aggress|ve or v|gorous
0 A|ert and Ca|m
-1 Drowsy Not fu||y a|ert, susta|ned awaken|ng vo|ce (eye
open|ng]contact >10 sec)
-2 L|ght Sedanon 8r|ey awakens to vo|ce
(eye open|ng and contact<10sec)
-3 Mod Sedanon Movement or eye open to vo|ce
-4 Deep Sedanon No response to vo|ce, but movement or eye
open|ng to phys|ca| snmu|anon
-S Unarousab|e No response to vo|ce of phys|ca| snm.
Wake Up! Daily Sedation Interruption
Kress NEJM 2000;342:1471
Intervention
(wake-up)

Control P
value
N 68 60
MV duration, d 4.9 (2.5-8.6) 7.3 (3.4-16.1) 0.004
ICU LOS, d 6.4 (3.9-12.0) 9.9 (4.7-17.9) 0.02
Hosp LOS, d 13.3 (7.3-20.0) 16.9 (8.5-26.6) 0.19
Clrard LanceL 2008, 371:126-134
Wake up! And breathe.
SBT only SAT +SBT p value
n = 168 167
Vent free
days
11.7 14.8 0.01
Duration of
MV (days)
6.0 4.8 0.02
ICU LOS 12.8 9.1 0.02
Hosp LOS 19 14.8 0.04
Self
Extubation
6 16 0.03
SchwelckerL LanceL 2009, 373:1874-1882
Wake up! And move?
Intervention Patients
Daily passive ROM and PT/OT
Control Patients
PT and OT per primary team
Both groups received protocol-directed
SBT
Daily sedation interruption
Nutrition
Glycemic control
Outcome
Intervention
(n = 49)
Control
(n = 55) P value
Ventilator-free days 23.5 [7.4,25.6] 21.1 [0.0,23.8] 0.05
MV duration, days 3.4 [2.3,7.3] 6.1 [4.0,9.6] 0.02
ICU LOS, days 5.9 [4.5,13.2] 7.9 [6.1,12.9] 0.08
Hospital LOS, days 13.5 [8.0,23.1] 12.9 [8.9,19.8] 0.93
Hospital mortality, % 18 26 0.53
Wake up! And move?
SchwelckerL LanceL 2009, 373:1874-1882
Take home points
Stop sedation every day
SBT early! (awake if possible)
Awakening and Breathing Coordination,
Delirium monitoring, Early mobilization
and Exercise # ABCDE approach
How to reduce duration of MV
Daily interruption of sedative infusions
Paired interruption of sedatives and SBT
Early physical and occupational therapy
No sedative use in MV patients
ARDS
$ Vt of 6ml/kg (ideal body weight)
$ Conservative fluid strategy
$ Prone positioning
$ Early paralysis
Strategies to reduce VAP
N Engl J Med 2000, 342:1301-1308.
Strm. Lancet. 2010; 375: 475-480.
N Engl J Med. 2006; 354: 1-12.
N Engl J Med 2010, 363:1107-1116.
N Engl J Med. 2013; 368: 2159-2168.
Dezfulian. A. J. Med. 2005;118,11-18
Whlch sLaLemenL ls false?
Audience Response Question
A. 8e-lnLubauon ls assoclaLed wlLh lncreased morLallLy
8. neumonla pauenLs requlrlng Mv are aL an lncreased
rlsk of llberauon fallure desplLe passlng an S81
C. Medlcal lCu pauenLs are more llkely Lo fall llberauon
auempLs Lhan surglcal lCu pauenLs

u. A Lrlal of nlv ls recommended for pauenLs
developlng resplraLory dlsLress 18 hours posL-llberauon
Mode of weaning studies: part II
Computer driven weaning
automated reduction in PSV based on
continuous evaluation of:
RR, Vt and end-tidal CO
2

Computer driven weaning
Closed-loop, automated system (Drger Smartcare)
- 144 Subjects: SBT when minimal PSV achieved
- Reduced weaning time (median 5.0 v 3.0d),
days ventilated, ICU LOS
Lellouche et.al: Am J Respir Crit Care Med 174: 894, 2006
1he same auLomaLed, closed-loop sysLem
- 102 pauenLs
- no dlerence ln wean durauon, hrs venulaLed
Rose L: Intensive Care Med 34:1788; 2008
Extubation failure
0
2
4
6
8
10
12
14
16
18
MICU
Mixed
Peds
SICU
CTS
Trauma
Neuro
%

p
a
t
i
e
n
t
s

e
x
t
u
b
a
t
e
d

N~ 35,000 (60 studies)
LpsLeln Sk. !"#$%& ()&"* 2009,34(2):198 -208.
Extubation failure = increased mortality
0
10
20
30
40
50
60
70
Death ICU LOS Home
Failure Success
LpsLeln ChesL 1997,112,186
Liberation readiness vs. SBT success
auenLs passed a 30-60 mln S81
eak cough ow < 60L/mln: 88 4.8
Secreuons > 2.3 mL/h: 88 3.0
Can'L compleLe 4 slmple commands: 88 4.3
All 3: 88 23 (100 fallure)
none: 3 fallure
Salam: Intensive Care Med 30:1334; 2004
37 ICUs in 8 countries
Liberation failure in 121 of 900 pts (13.4%)
Logistic regression identified:
f/Vt (OR 1.009 per unit)
+ fluid balance in 24 hr prior (OR 1.70)
MV for pneumonia (OR 1.77)
Frutos-Vivar Chest 2006;130:1664
Liberation readiness vs. SBT success
Frutos-Vivar Chest 2006;130:1664
R
e
i
n
t
u
b
a
t
i
o
n

r
a
t
e

(
%
)

f/Vt ratio
Liberation readiness vs. SBT success
Frutos-Vivar Chest 2006;130:1664
R
e
i
n
t
u
b
a
t
i
o
n

r
a
t
e

(
%
)

Fluid balance
Liberation readiness vs. SBT success
NIPPV in liberation failure
Post liberation respiratory distress
- Keenan, JAMA 2002 # NO
- Esteban, NEJM 2004 # NO
Preventive for high risk patients
- Nava, CCM 2005 # YES
- Ferrer, AJRCCM 2006 # YES
Failure of more than one consecutive SBT
Chronic heart failure
P
a
CO
2
> 45 mmHg after extubation
More than one co-morbidity other than heart
failure
Weak cough
Upper airway stridor at extubation
Age > 65
APACHE II score > 12 on the day of extubation
Medical, pediatric or multispecialty ICU patient
Pneumonia as etiology of respiratory failure
Risk factors for liberation failure

Time to reintubation likely matters
Time to reintubation (hrs) Deaths (%)
0-12 24
13-24 39
25-48 50
49-72 69
Epstein. AJRCCM. 1998; 158:489493.
Assess kead|ness
SLable 8
/l >200 on LL < 3 cmP20
Lxtubate
Iu|| Venn|atory Support
Airway
Cough
Secretions
Mentation
Define
mechanism
of failure
and treat
Not SIMV
Progressive withdrawal vs. SBT
RT-RN
Driven
Protocol
30-120 m|n S81
S < 7, CA = 3, or 1-plece
Sllde adapLed from Creg SchmldL, M.u.
Summary of key o|nts
Assess readlness" every day
MosL pauenLs can be llberaLed qulckly
hyslclans are bad aL recognlzlng when
Lhe weanlng perlod" beglns
S81 success = llberauon readlness /
kecommended kead|ng and Add|nona|
kesources
Yang and Tobin. NEJM 1991;324:1445
Meade. Chest 2001;120:400S
Ely. NEJM 1996;335:1864-1869
MacIntyre. Chest. 2001 120: 375S-396S.
Girard. Lancet 2008, 371:126-134
Salam. Intensive Care Med 2004, 30:1334-1339
Esteban. NEJM 2004,350:2452-2460
Nava. CCM 2006,33:2465-2479
Cuesuons?