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Cheng YW, Kuo CH, Kuo YH, Tu TH, Chen YY, Hsu YH, Liao WC. Predictive value of hematologic indices on weaning from mechanical ventilation and 30-day mortality in patients with traumatic brain injury in an intensive care unit: A retrospective analysis of MIMIC-IV data. Neurotherapeutics 2025; 22:e00559. [PMID: 40011133 PMCID: PMC12047397 DOI: 10.1016/j.neurot.2025.e00559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Revised: 02/10/2025] [Accepted: 02/14/2025] [Indexed: 02/28/2025] Open
Abstract
The management of traumatic brain injury (TBI) in intensive care units is dependent on the wise use of life-support systems. This study investigated the utility of various hematologic indices to predict successful weaning and risk of short-term mortality in TBI patients. Data of patients with TBI requiring mechanical ventilation were extracted from the MIMIC-IV database and retrospectively reviewed. Successful weaning was defined as no re-intubation or death within 48 h, non-invasive ventilation under 48 h post-extubation, and passing a spontaneous breathing test with specific respiratory and cardiovascular stability criteria. The systemic inflammatory response index (SIRI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), and glucose-to-lymphocyte ratio (GLR) were evaluated for their predictive value using logistic regression and receiver operating characteristic (ROC) analyses. A total of 414 patients were included. After adjustment, higher PLR and GLR (adjusted odds ratio [aOR] = 0.766, 95 % confidence interval [CI]: 0.66-0.89) and GLR (aOR = 0.761, 95 % CI: 0.65-0.89) were significantly associated with a lower likelihood of weaning success, while higher NLR (aOR = 1.70, 95 % CI: 1.18-2.45) was associated with increased 30-day mortality. The area under the ROC curve (AUC) values for predicting weaning success were 0.636 for PLR and 0.634 for GLR. NLR showed good predictive accuracy for 30-day mortality with an AUC = 0.752. In conclusions, in patients with TBI, PLR, GLR, and NLR may serve as predictors of mechanical ventilation weaning success and 30-day mortality.
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Affiliation(s)
- Yu-Wen Cheng
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chao-Hung Kuo
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsuan Kuo
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsung-Hsi Tu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yang-Yi Chen
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Hone Hsu
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Wei-Chuan Liao
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Gupta A, Singh O, Juneja D. Clinical prediction scores predicting weaning failure from invasive mechanical ventilation: Role and limitations. World J Crit Care Med 2024; 13:96482. [PMID: 39655298 PMCID: PMC11577531 DOI: 10.5492/wjccm.v13.i4.96482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 08/27/2024] [Accepted: 08/30/2024] [Indexed: 10/31/2024] Open
Abstract
Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.
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Affiliation(s)
- Anish Gupta
- Institute of Critical Care Medicine, Max Hospital, Gurugram 122022, Haryana, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
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Karthika M, Al Enezi FA, Pillai LV, Arabi YM. Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients. Crit Care Res Pract 2023; 2023:9141441. [PMID: 37795474 PMCID: PMC10547562 DOI: 10.1155/2023/9141441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5-120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5-120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results The RSBI 5-120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5-120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5-120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5-120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome.
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Affiliation(s)
- Manjush Karthika
- Faculty of Medical and Health Sciences, Liwa College, Abu Dhabi, UAE
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
| | - Farhan A. Al Enezi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Lalitha V. Pillai
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
- Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Chen WT, Huang HL, Ko PS, Su W, Kao CC, Su SL. A Simple Algorithm Using Ventilator Parameters to Predict Successfully Rapid Weaning Program in Cardiac Intensive Care Unit Patients. J Pers Med 2022; 12:501. [PMID: 35330500 PMCID: PMC8950402 DOI: 10.3390/jpm12030501] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/25/2022] [Accepted: 03/19/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ventilator weaning is one of the most significant challenges in the intensive care unit (ICU). Approximately 30% of patients fail to wean, resulting in prolonged use of ventilators and increased mortality. There are numerous high-performance prediction models available today, but they require a large number of parameters to predict and are thus impractical in clinical practice. OBJECTIVES This study aims to create an artificial intelligence (AI) model for predicting weaning time and to identify the most simplified key predictors that will allow the model to achieve adequate accuracy with as few parameters as possible. METHODS This is a retrospective study of to-be-weaned patients (n = 1439) hospitalized in the cardiac ICU of Cheng Hsin General Hospital's Department of Cardiac Surgery from November 2018 to August 2020. The patients were divided into two groups based on whether they could be weaned within 24 h (i.e., "patients weaned within 24 h" (n = 1042) and "patients not weaned within 24 h" (n = 397)). Twenty-eight variables were collected including demographic characteristics, arterial blood gas readings, and ventilation set parameters. We created a prediction model using logistic regression and compared it to other machine learning techniques such as decision tree, random forest, support vector machine (SVM), extreme gradient boosting, and artificial neural network. Forward, backward, and stepwise selection methods were used to identify significant variables, and the receiver operating characteristic curve was used to assess the accuracy of each AI model. RESULTS The SVM [receiver operating characteristic curve (ROC-AUC) = 88%], logistic regression (ROC-AUC = 86%), and XGBoost (ROC-AUC = 85%) models outperformed the other five machine learning models in predicting weaning time. The accuracies in predicting patient weaning within 24 h using seven variables (i.e., expiratory minute ventilation, expiratory tidal volume, ventilation rate set, heart rate, peak pressure, pH, and age) were close to those using 28 variables. CONCLUSIONS The model developed in this research successfully predicted the weaning success of ICU patients using a few and easily accessible parameters such as age. Therefore, it can be used in clinical practice to identify difficult-to-wean patients to improve their treatment.
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Affiliation(s)
- Wei-Teing Chen
- Division of Thoracic Medicine, Department of Medicine, Cheng Hsin General Hospital, Tri-Service General Hospital, National Defense Medical Center, Taipei 112401, Taiwan;
| | - Hai-Lun Huang
- School of Public Health, National Defense Medical Center, Taipei 114201, Taiwan; (H.-L.H.); (P.-S.K.); (W.S.)
| | - Pi-Shao Ko
- School of Public Health, National Defense Medical Center, Taipei 114201, Taiwan; (H.-L.H.); (P.-S.K.); (W.S.)
| | - Wen Su
- School of Public Health, National Defense Medical Center, Taipei 114201, Taiwan; (H.-L.H.); (P.-S.K.); (W.S.)
- Institute of Aerospace and Undersea Medic, National Defense Medical Center, Taipei 114201, Taiwan
| | - Chung-Cheng Kao
- Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei 105309, Taiwan;
| | - Sui-Lung Su
- School of Public Health, National Defense Medical Center, Taipei 114201, Taiwan; (H.-L.H.); (P.-S.K.); (W.S.)
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Lin DH, Meyers B, Nisar S, Heinz ER. Role of Submandibular Ultrasound in Airway Management of a Patient With Angioedema. Cureus 2022; 14:e22823. [PMID: 35399468 PMCID: PMC8980192 DOI: 10.7759/cureus.22823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/29/2022] Open
Abstract
Angioedema is one of several life-threatening clinical scenarios that lacks clarity on when a patient requires intubation. We present a case of angiotensin-converting enzyme-inhibitor-induced angioedema with peri-oral swelling and normal airway measurements on ultrasound, who was intubated with an abundance of caution and extubated successfully. Current tests for intubation and extubation, such as traditional bedside assessments and the cuff leak test, vary in reliability for angioedema and similar urgent situations. Submandibular ultrasound is a quick, low-cost, non-invasive method for determining quantitative criteria for and assessing when intubation and extubation is indicated, which may lead to improved quality of care and patient safety.
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Kyriakoudi A, Rovina N, Koltsida O, Kostakou E, Konstantelou E, Kardara M, Kompoti M, Palamidas A, Kaltsakas G, Koutsoukou A. Weaning Failure in Critically Ill Patients Is Related to the Persistence of Sepsis Inflammation. Diagnostics (Basel) 2021; 12:diagnostics12010092. [PMID: 35054259 PMCID: PMC8774440 DOI: 10.3390/diagnostics12010092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/16/2021] [Accepted: 12/25/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: Septic patients undergoing mechanical ventilation (MV) often experience difficulty in weaning. Th aim of this study was to determine whether inflammatory biomarkers of sepsis could be indicative of the failure or success of spontaneous breathing trial (SBT) in these patients. Methods: Sixty-five patients on MV (42 septic and 23 intubated for other reasons) fulfilling the criteria for SBT were included in the study. Blood samples were collected right before, at the end of (30 min) and 24 h after the SBT. Serum inflammatory mediators associated with sepsis (IL-18, IL-18BP, TNF) were determined and correlated with the outcome of SBT. Results: A successful SBT was achieved in 45 patients (69.2%). Septic patients had a higher percentage of SBT failure as compared to non-septic patients (85% vs. 15%, p = 0.026), with an odds ratio for failing 4.5 times (OR = 4.5 95%CI: 1.16–17.68, p 0.022). IL-18 levels and the relative mRNA expression in serum were significantly higher in septic as compared to non-septic patients (p < 0.05). Sepsis was independently associated with higher serum IL-18 and TNF levels in two time-point GEE models (53–723, p = 0.023 and 0.3–64, p = 0.048, respectively). IL-18BP displayed independent negative association with rapid shallow breathing index (RSBI) (95% CI: −17.6 to −4, p = 0.002). Conclusion: Sustained increased levels of IL-18 and IL-18BP, acknowledged markers of sepsis, were found to be indicative of SBT failure in patients recovering from sepsis. Our results show that, although subclinical, remaining septic inflammation that sustaines for a long time complicates the weaning procedure. Biomarkers for the estimation of the septic burden and the right time for weaning are needed.
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Affiliation(s)
- Anna Kyriakoudi
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Nikoletta Rovina
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
- Correspondence: ; Tel.: +30-210-7763650
| | - Ourania Koltsida
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Eirini Kostakou
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Elissavet Konstantelou
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Matina Kardara
- 1st Department of Critical Care Medicine & Pulmonary Services, National and Kapodistrian University of Athens, Medical School, Evangelismos Hospital, 10676 Athens, Greece;
| | - Maria Kompoti
- Intensive Care Unit, General Hospital of Eleusis Thriasio, 13674 Athens, Greece;
| | - Anastasios Palamidas
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Georgios Kaltsakas
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
| | - Antonia Koutsoukou
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (A.K.); (O.K.); (E.K.); (E.K.); (A.P.); (G.K.); (A.K.)
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Figueroa-Casas JB, Montoya R, Garcia-Blanco J, Lehker A, Hussein AM, Abdulmunim H, Kabbach G, Mahfoud A. Effect of Using the Rapid Shallow Breathing Index as Readiness Criterion for Spontaneous Breathing Trials in a Weaning Protocol. Am J Med Sci 2019; 359:117-122. [PMID: 32039763 DOI: 10.1016/j.amjms.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/10/2019] [Accepted: 11/06/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study aimed to compare the effect of using versus not using the Rapid-Shallow Breathing Index (RSBI) as a readiness criterion for Spontaneous Breathing Trials (SBT) on SBT success. MATERIALS AND METHODS Daily readiness screens were performed within a respiratory therapist-driven weaning protocol. Patients who passed these screens underwent a one-time measurement of the RSBI and then a SBT regardless of RSBI result. The proportion of passed readiness screens reaching SBT success was compared to the proportion that would have been obtained if RSBI ≤ 105 br/min/L had been used as an additional screen criterion. RESULTS Two hundred and fifty SBTs performed on 157 patients were analyzed. The sensitivity of RSBI ≤ 105 br/min/L to predict SBT success was 94.8% (95% CI 90.6-97.5). Relative to potentially using RSBI, 14.4% additional SBTs were performed. A third of these were successful, and no complications were detected in the rest that failed. The proportion of passed readiness screens reaching SBT success would have been 4% (95% CI 1.2-6.8) (P = 0.002) lower if RSBI had been used. CONCLUSIONS The inclusion of the RSBI in a readiness screen may not be useful in a weaning protocol.
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Affiliation(s)
- Juan B Figueroa-Casas
- Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Science Center, Paul L. Foster School of Medicine, El Paso, Texas.
| | - Ricardo Montoya
- Respiratory Care Department, University Medical Center of El Paso, El Paso, Texas
| | - Jose Garcia-Blanco
- Division of Pulmonary and Critical Care Medicine, University of Miami/Jackson Memorial Health, Miami, Florida
| | - Angelica Lehker
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, Texas
| | - Ahmed M Hussein
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, Texas
| | - Haider Abdulmunim
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, Texas
| | - Giselle Kabbach
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, Texas
| | - Antonyos Mahfoud
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, Texas
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Khalil Y, Mustafa EED, Youssef A, Imam MH, Behiry AFE. Neuromuscular dysfunction associated with delayed weaning from mechanical ventilation in patients with respiratory failure. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yehia Khalil
- Department of Chest, Faculty of Medicine , Alexandria University, Egypt
| | | | - Ahmed Youssef
- Department of Chest, Faculty of Medicine , Alexandria University, Egypt
| | - Mohamed Hassan Imam
- Department of Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University, Egypt
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Mowafy SM, Abdelgalel EF. Diaphragmatic rapid shallow breathing index for predicting weaning outcome from mechanical ventilation: Comparison with traditional rapid shallow breathing index. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sherif M.S. Mowafy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essam F. Abdelgalel
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Baptistella AR, Sarmento FJ, da Silva KR, Baptistella SF, Taglietti M, Zuquello RÁ, Nunes Filho JR. Predictive factors of weaning from mechanical ventilation and extubation outcome: A systematic review. J Crit Care 2018; 48:56-62. [PMID: 30172034 DOI: 10.1016/j.jcrc.2018.08.023] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/06/2018] [Accepted: 08/18/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation and extubation outcomes. METHODS Systematic review of scientific articles using four electronic databases: PubMed, Embase, PEDro and Cochrane Library. Search terms included "weaning", "extubation", "withdrawal" and "discontinuation", combined with "mechanical ventilation" and "predictive factors", "predictive parameters" and "predictors for success". In this study, we included original articles that presented predictive factors for weaning or extubation outcomes in adult patients and not restricted to a single disease. Articles not written in English were excluded. RESULTS A total of 43 articles were included, with a total of 7929 patients and 56 different parameters related to weaning and extubation outcomes. Rapid Shallow Breathing Index (RSBI) was the most common predictor, discussed in 15 studies (2159 patients), followed by Age and Maximum Inspiratory Pressure in seven studies. The other 53 parameters were found in less than six studies. CONCLUSION There are several parameters used to predict weaning and extubation outcomes. RSBI was the most frequently studied and seems to be an important measurement tool in deciding whether to wean/extubate a patient. Furthermore, the results demonstrated that weaning and extubation should be guided by several parameters, and not only to respiratory ones.
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Affiliation(s)
- Antuani Rafael Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil.
| | | | | | - Shaline Ferla Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
| | | | | | - João Rogério Nunes Filho
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
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Zhou P, Zhang Z, Hong Y, Cai H, Zhao H, Xu P, Zhao Y, Lin S, Qin X, Guo J, Pan Y, Dai J. The predictive value of serial changes in diaphragm function during the spontaneous breathing trial for weaning outcome: a study protocol. BMJ Open 2017; 7:e015043. [PMID: 28645964 PMCID: PMC5623446 DOI: 10.1136/bmjopen-2016-015043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/17/2017] [Accepted: 05/23/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION There is a variety of tools being used in clinical practice for the prediction of weaning success from mechanical ventilation. However, their diagnostic performances are less than satisfactory. The purpose of this study is to investigate the value of serial changes in diaphragm function measured by ultrasound during the spontaneous breathing trial (SBT) as a weaning predictor. METHODS AND ANALYSIS This is a prospective observational study conducted in a 10-bed medical emergency intensive care unit (EICU) in a university-affiliated hospital. The study will be performed from November 2016 to December 2017. All patients in the EICU who are expected to have mechanical ventilation for more than 48 hours through endotracheal tube are potentially eligible for this study. Patients will be included if they fulfil the criteria for SBT. All enrolled patients will be ventilated with an Evita-4 by using volume assist control mode prior to SBT. Positive end-expiratory pressure (PEEP) will be set to 5 cmH2O and fractional inspired oxygen (FiO2) will be set to a value below 0.5 that guarantees oxygen saturation by pulse oximetry (SpO2) greater than 90%. Enrolled patients will undergo SBT for 2 hours in semirecumbent position. During the SBT, the patients will breathe through the ventilator circuit by using flow triggering (2 L/min) with automatic tube compensation of 100% and 5 cmH2O PEEP. The FiO2 will be set to the same value as used before SBT. If the patients fail to tolerate the SBT, the trial will be discontinued immediately and the ventilation mode will be switched to that used before the trial. Patients who pass the 2-hour SBT will be extubated. Right diaphragm excursion and bilateral diaphragm thickening fraction will be measured by ultrasonography during spontaneous breathing. Images will be obtained immediately prior to the SBT, and at 5, 30, 60, 90 and 120 min after the initiation of SBT. Rapid shallow breathing index will be simultaneously calculated at the bedside by a respiratory nurse. ETHICS AND DISSEMINATION The study protocol is approved by the ethics committee of Sir Run Run Shaw Hospital, an affiliate of Zhejiang University, Medical College. The results will be published in a peer-reviewed journal and shared with the worldwide medical community. TRIAL REGISTRATION NUMBER ISRCTN42917473; Pre-results.
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Affiliation(s)
- Pengmin Zhou
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huabo Cai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Zhao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peifeng Xu
- Department of Respiratory Therapy Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiming Zhao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shengping Lin
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuchang Qin
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - JiaWei Guo
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Pan
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junru Dai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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12
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Goncalves EC, Lago AF, Silva EC, de Almeida MB, Basile-Filho A, Gastaldi AC. How Mechanical Ventilation Measurement, Cutoff and Duration Affect Rapid Shallow Breathing Index Accuracy: A Randomized Trial. J Clin Med Res 2017; 9:289-296. [PMID: 28270888 PMCID: PMC5330771 DOI: 10.14740/jocmr2856w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Decreased accuracy of the rapid shallow breathing index (RSBI) can stem from 1) the method used to obtain this index, 2) duration of mechanical ventilation (MV), and 3) the established cutoff point. The objective was to evaluate the values of RSBI determined by three different methods, using distinct MV times and cutoff points. METHODS This prospective study included 40 subjects. Before extubation, three different methods were employed to measure RSBI: pressure support ventilator (PSV) (PSV = 5 - 8 cm H2O; positive end-expiratory pressure (PEEP) = 5 cm H2O) (RSBI_MIN), automatic tube compensation (ATC) (PSV = 0, PEEP = 5 cm H2O, and 100% tube compensation) (RSBI_ATC), and disconnected MV (RSBI_SP). The results were analyzed according to the MV period (less than or over 72 h) and to the outcome of extubation (< 72 h, successful and failed; > 72 h successful and failed). The accuracy of each method was determined at different cutoff points (105, 78, and 50 cycles/min/L). RESULTS The RSBI_MIN, RSBI_ATC, and RSBI_SP values in the group < 72 h were 38 ± 18, 45 ± 26 and 55 ± 22; in the group > 72 h, RSBI_SP value was higher than those of RSBI_ATC and RSBI_MIN (78 ± 29, 51 ± 19 and 39 ± 14) (P < 0.001). For patients with MV > 72 h who failed in removing MV, the RSBI_SP was higher (93 ± 28, 58 ± 18 and 41 ± 10) (P < 0.000), with greater accuracy at cutoff of 78. CONCLUSION RSBI_SP associated with cutoff point < 78 cycles/min/L seems to be the best strategy to identify failed extubation in subjects with MV for over 72 h.
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Affiliation(s)
- Elaine Cristina Goncalves
- Department of Physiotherapy, Ribeirao Preto Medical School, University of Sao Paulo, SP, 14049-900, Ribeirao Preto, Brazil
| | - Alessandra Fabiane Lago
- Department of Physiotherapy, Ribeirao Preto Medical School, University of Sao Paulo, SP, 14049-900, Ribeirao Preto, Brazil
| | - Elaine Caetano Silva
- Department of Physiotherapy, Ribeirao Preto Medical School, University of Sao Paulo, SP, 14049-900, Ribeirao Preto, Brazil
| | | | - Anibal Basile-Filho
- Division of Intensive Care, Department of Surgery and Anatomy, Ribeirao Preto, Medical School, University of Sao Paulo, SP, 14049-900, Ribeirao Preto, Brazil
| | - Ada Clarice Gastaldi
- Department of Physiotherapy, Ribeirao Preto Medical School, University of Sao Paulo, SP, 14049-900, Ribeirao Preto, Brazil
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13
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Ghoneim AHA, El-Komy HMA, Gad DM, Abbas AMM. Assessment of weaning failure in chronic obstructive pulmonary disease patients under mechanical ventilation in Zagazig University Hospitals. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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14
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Abstract
Invasive mechanical ventilation can successfully support the patient with acute respiratory failure, but it is associated with considerable risks. Numerous complications of invasive mechanical ventilation have been identified, and these may contribute to increased mortality. Therefore after clinical improvement has occurred, considerable emphasis is placed on expeditiously freeing the patient from the ventilator. This process of getting a patient off mechanical ventilation has been variably termed weaning, liberation, or discontinuation (terms which may be used interchangeably), and can be further divided into “readiness testing” and “progressive withdrawal.” Over the last decade, new developments in our understanding of the process of weaning have provided investigators with the tools to address a number of key questions: How should readiness for weaning (and trials of spontaneous breathing) be determined? What is the role of weaning parameters in deciding when to initiate the weaning process? What is the best mode for conducting a spontaneous breathing trial and how should the patient be monitored? What are the mechanisms for weaning (and spontaneous breathing trial) failure? What is the best technique to facilitate progressive withdrawal? What other factors can facilitate liberation from mechanical ventilation? What are the risks of extubation failure and how can extubation outcome best be predicted? What is the role for protocols in facilitating weaning from mechanical ventilation?.
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Affiliation(s)
- Scott K. Epstein
- Medical Intensive Care Unit, Pulmonary and Critical Care Division, New England Medical Center, and Tufts University School of Medicine, Boston, MA.
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15
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Abstract
Predicting successful liberation of patients from mechanical ventilation has been a focus of interest to clinicians practicing in intensive care. Various weaning indices have been investigated to identify an optimal weaning window. Among them, the rapid shallow breathing index (RSBI) has gained wide use due to its simple technique and avoidance of calculation of complex pulmonary mechanics. Since its first description, several modifications have been suggested, such as the serial measurements and the rate of change of RSBI, to further improve its predictive value. The objective of this paper is to review the utility of RSBI in predicting weaning success. In addition, the use of RSBI in specific patient populations and the reported modifications of RSBI technique that attempt to improve the utility of RSBI are also reviewed.
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Affiliation(s)
- Manjush Karthika
- Faculty of Health and Biomedical Sciences, Symbiosis Institute of Research and Innovation, Symbiosis International University, Pune, India
| | - Farhan A Al Enezi
- Intensive Care Department, King Saud Bin Abdulaziz University of Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Lalitha V Pillai
- Faculty of Health and Biomedical Sciences, Symbiosis Institute of Research and Innovation, Symbiosis International University, Pune, India; Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University of Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
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16
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Brook AD, Kollef MH. An Outcomes-Based Approach to Ventilatory Management: Review of Two Examples. J Intensive Care Med 2016. [DOI: 10.1177/088506669901400603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Predictive value of rapid shallow breathing index in relation to the weaning outcome in ICU patients. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2016.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Cho SH, Lee JH, Jang SH. Efficacy of pulmonary rehabilitation using cervical range of motion exercise in stroke patients with tracheostomy tubes. J Phys Ther Sci 2015; 27:1329-31. [PMID: 26157212 PMCID: PMC4483390 DOI: 10.1589/jpts.27.1329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/11/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] In this study, stroke patients who were intubated with tracheostomy tubes
performed cervical range of motion exercises, and changes in their pulmonary and coughing
functions were examined. [Subjects and Methods] Twelve stroke patients who were intubated
with tracheostomy tubes participated in the study. The subjects were randomly assigned to
either the control group (n=6), which did not perform cervical range of motion exercises,
or the experimental group (n=6), which did perform exercises. [Results] With regards to
forced vital capacity, forced expiratory volume at one second, and peak cough flow rate
before and after the exercises, the control group did not show any significant differences
while the experimental group showed statistically significant increases in all three
parameters. [Conclusion] The results indicate that cervical range of motion exercises can
effectively improve the pulmonary function and coughing ability of stroke patients
intubated with tracheostomy tubes, and that cervical range of motion exercises can help in
the removal of tracheostomy tubes.
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Affiliation(s)
- Sung-Hyoun Cho
- Department of Physical Therapy, Nambu University, Republic of Korea
| | - Jung-Ho Lee
- Department of Physical Therapy, Kyungdong University, Republic of Korea
| | - Sang-Hun Jang
- Department of Physiotherapy, Gimcheon University, Republic of Korea
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19
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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 : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R21. [PMID: 24456585 PMCID: PMC4056081 DOI: 10.1186/cc13705] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/20/2014] [Indexed: 01/08/2023]
Abstract
Introduction The process of weaning may impose cardiopulmonary stress on ventilated patients. Heart-rate variability (HRV), a noninvasive tool to characterize autonomic function and cardiorespiratory interaction, may be a promising modality to assess patient capability during the weaning process. We aimed to evaluate the association between HRV change and weaning outcomes in critically ill patients. Methods This study included 101 consecutive patients recovering from acute respiratory failure. Frequency-domain analysis, including very low frequency, low frequency, high frequency, and total power of HRV was assessed during a 1-hour spontaneous breathing trial (SBT) through a T-piece and after extubation after successful SBT. Results Of 101 patients, 24 (24%) had SBT failure, and HRV analysis in these patients showed a significant decrease in total power (P = 0.003); 77 patients passed SBT and were extubated, but 13 (17%) of them required reintubation within 72 hours. In successfully extubated patients, very low frequency and total power from SBT to postextubation significantly increased (P = 0.003 and P = 0.004, respectively). Instead, patients with extubation failure were unable to increase HRV after extubation. Conclusions HRV responses differ between patients with different weaning outcomes. Measuring HRV change during the weaning process may help clinicians to predict weaning results and, in the end, to improve patient care and outcome.
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20
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Strategies for Predicting Successful Weaning from Mechanical Ventilation. ACTA ACUST UNITED AC 2013. [DOI: 10.1201/b14020-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Saugel B, Rakette P, Hapfelmeier A, Schultheiss C, Phillip V, Thies P, Treiber M, Einwächter H, von Werder A, Pfab R, Eyer F, Schmid RM, Huber W. Prediction of extubation failure in medical intensive care unit patients. J Crit Care 2012; 27:571-7. [DOI: 10.1016/j.jcrc.2012.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 01/14/2012] [Accepted: 01/22/2012] [Indexed: 11/16/2022]
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Huaringa AJ, Wang A, Haro MH, Leyva FJ. The weaning index as predictor of weaning success. J Intensive Care Med 2012; 28:369-74. [PMID: 23753219 DOI: 10.1177/0885066612463681] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The quest to obtain an accurate way to predict success when weaning a patient from mechanical ventilation continues. The established parameters such as tidal volume (Vt), respiratory rate (f), negative inspiratory force (NIF), vital capacity (VC), and minute ventilation (V) have not predicted weaning accurately. The frequency-to-tidal volume ratio (f/Vt), or rapid shallow breathing index (RSBI) is a good predictor of weaning success if the value is low, but not when the value approximates 105. Because of the aforementioned, we decided to add 2 corrective factors to the RSBI. The first one was elastance index (EI = peak pressure/NIF) and the second one, the ventilatory demand index (VDI = minute ventilation/10). The result of the product of the RSBI × EI × VDI was called the weaning index (WI). METHODS In order to assess the discriminatory power of WI, we obtained weaning parameters and calculated WI for 59 patients in our intensive care unit and extubated them if RSBI was ≤105. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operating characteristics (ROC) curves were obtained. The results were compared with the previous studies involving the RSBI. RESULTS The WI sensitivity was 98%, specificity was 89%, PPV was 95%, NPV was 94%, and area under the ROC curve was 95.9. CONCLUSIONS The WI is a simple and reproducible parameter that integrates breathing pattern, compliance, inspiratory muscle strength, and ventilatory demand and is the most accurate predictor of weaning success.
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Affiliation(s)
- Armando J Huaringa
- Department of Medicine, White Memorial Medical Center and Loma Linda University School of Medicine, Los Angeles, CA, USA
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23
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Castro AAM, Cortopassi F, Sabbag R, Torre-Bouscoulet L, Kümpel C, Ferreira Porto E. Respiratory muscle assessment in predicting extubation outcome in patients with stroke. Arch Bronconeumol 2012; 48:274-9. [PMID: 22607984 DOI: 10.1016/j.arbres.2012.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 04/25/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with cerebral infarction often present impaired consciousness and unsatisfactory extubation. We aimed to assess the respiratory mechanics components that might be associated with the success of extubation in stroke patients. METHODS Twenty consecutive patients with stroke who needed mechanical ventilation support were enrolled. The maximal inspiratory pressure, gastric and the esophageal pressure (Pdi/Pdimax), minute volume, respiratory rate, static compliance, airway resistance, rapid and superficial respiration index (RSRI), inspiratory time/total respiratory cycle (Ti/Ttot), and PaO(2)/FiO(2) were measured. RESULTS The group who presented success to the extubation process presented 12.5±2.2=days in mechanical ventilation and the group who failed presented 13.1±2=days. The mean Ti/Ttot and Pdi/Pdimax for the failure group was 0.4±0.08 (0.36-0.44) and 0.5±0.7 (0.43-0.56), respectively. The Ti/Ttot ratio was 0.37±0.05 (0.34-0.41; p=0.0008) and the Pdi/Pdimax was 0.25±0.05 for the success group (0.21-0.28; p<0.0001). A correlation was found between Pdi/Pdimax ratio and the RSRI (r=0.55; p=0.009) and PaO(2)/FiO(2) (r=-0.59; p=0.005). Patients who presented a high RSRI (OR, 3.66; p=0.004) and Pdi (OR, 7.3; p=0.002), and low PaO(2)/FIO(2) (OR, 4.09; p=0.007), Pdi/Pdimax (OR, 4.12; p=0.002) and RAW (OR, 3.0; p=0.02) developed mechanical ventilation extubation failure. CONCLUSION Muscular fatigue index is an important predicting variable to the extubation process in prolonged mechanical ventilation of stroke patients.
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Affiliation(s)
- Antonio A M Castro
- Respiratory Diseases Department, Federal University of São Paulo and Adventist University, São Paulo, Brazil.
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Castro AAM, Cortopassi F, Sabbag R, Torre-Bouscoulet L, Kümpel C, Porto EF. WITHDRAWN: Respiratory Muscle Assessment in Predicting Extubation Outcome in Patients With Stroke. Arch Bronconeumol 2012:S0300-2896(12)00096-8. [PMID: 22494544 DOI: 10.1016/j.arbres.2012.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/06/2012] [Accepted: 02/13/2012] [Indexed: 11/18/2022]
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.arbr.2012.06.007. The duplicate article has therefore been withdrawn.
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Affiliation(s)
- Antonio A M Castro
- Respiratory Diseases Department, Federal University of São Paulo and Adventist University, Rua Cônego Eugênio Leite, 632, Pinheiros, 05414000 São Paulo, SP, Brazil; Federal University of Pampa (Unipampa), Rio Grande do Sul, Brazil
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Adams RC, Gunter OL, Wisler JR, Whitmill ML, Cipolla J, Lindsey DE, Stehly C, Steinberg SM, Cook CH, Stawicki SP. Dynamic Changes in Respiratory Frequency/Tidal Volume May Predict Failures of Ventilatory Liberation in Patients on Prolonged Mechanical Ventilation and Normal Preliberation Respiratory Frequency/Tidal Volume Values. Am Surg 2012. [DOI: 10.1177/000313481207800138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rapid shallow breathing index (RSBI, respiratory frequency [f] divided by tidal volume [Vt]) has been used to prognosticate liberation from mechanical ventilation (LMV). We hypothesize that dynamic changes in RSBI predict failed LMV better than isolated RSBI measurements. We conducted a retrospective study of patients who were mechanically ventilated (MV) for longer than 72 hours. Failed LMV was defined as need for reinstitution of MV within 48 hours post-LMV. Ventilatory frequency (f) and Vt (liters) were serially recorded. The instantaneous RSBI (i-RSBI) was defined as f/Vt. Dynamic f/Vt ratio (d-RSBI) was defined as the ratio between two consecutive i-RSBI (f/Vt) measurements ([f2/Vt2]/[f1/Vt1]). RSBI Product (RSB-P) was defined as (i-RSBI 3 d-RSBI). Data from 32 patients were analyzed (Acute Physiology and Chronic Health Evaluation II 13.4, male 69%, mean age 57 years). Mean length of stay was 19.5 days (11.5 ventilator; 14.1 intensive care unit days). For LMV failures, mean time to reinstitution of invasive MV was 20.8 hours. All patients had pre-LMV i-RSBI less than 100. Failed LMVs had higher i-RSBI values (68.9, n = 18) than successful LMVs (44.2, n = 23, P < 0.01). Failures had higher d-RSBI (1.48) than successful LMVs (1.05, P < 0.04). The RSB-P was higher for failed LMVs (118) than for successful LMVs (48.8, P < 0.01) with failures having larger proportion of pre-LMV d-RSBI values greater than 1.5 (39.0 vs 10.7%, P < 0.03). Pre-LMV RSB-P may offer early prediction of failed LMV in patients on MV for longer than 72 hours despite normal pre-LMV i-RSBI. Divergence between RSB-P for successful and failed LMVs occurred earlier than i-RSBI divergence with a greater proportion of pre-LMV d-RSBI greater than 1.5 among failures.
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Affiliation(s)
- Raeanna C. Adams
- Department of Surgery, Division of Trauma & Surgical Critical Care, Vanderbilt, University Medical Center, Nashville, Tennessee
| | - Oliver L. Gunter
- Department of Surgery, Division of Trauma & Surgical Critical Care, Vanderbilt, University Medical Center, Nashville, Tennessee
| | - Jonathan R. Wisler
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
| | - Melissa L. Whitmill
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
| | - James Cipolla
- St. Luke's, Regional Level I Trauma Center, Bethlehem, Pennsylvania
| | - David E. Lindsey
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
| | - Christy Stehly
- St. Luke's, Regional Level I Trauma Center, Bethlehem, Pennsylvania
| | - Steven M. Steinberg
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
| | - Charles H. Cook
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
| | - Stanislaw P.A. Stawicki
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus, Ohio
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Comparisons of predictive performance of breathing pattern variability measured during T-piece, automatic tube compensation, and pressure support ventilation for weaning intensive care unit patients from mechanical ventilation. Crit Care Med 2011; 39:2253-62. [PMID: 21666447 DOI: 10.1097/ccm.0b013e31822279ed] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the influence of different ventilatory supports on the predictive performance of breathing pattern variability for extubation outcomes in intensive care unit patients. DESIGN AND SETTING A prospective measurement of retrospectively analyzed breathing pattern variability in a medical center. PATIENTS Sixty-eight consecutive and ready-for-weaning patients were divided into success (n=45) and failure (n=23) groups based on their extubation outcomes. MEASUREMENTS Breath-to-breath analyses of peak inspiratory flow, total breath duration, tidal volume, and rapid shallow breathing index were performed for three 30-min periods while patients randomly received T-piece, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure, and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials. Coefficient of variations and data dispersion (standard descriptor values SD1 and SD2 of the Poincaré plot) were analyzed to serve as breathing pattern variability indices. MAIN RESULTS Under all three trials, breathing pattern variability in extubation failure patients was smaller than in extubation success patients. Compared to the T-piece trial, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure decreased the ability of certain breathing pattern variability indices to discriminate extubation success from extubation failure. The areas under the receiver operating characteristic curve of these breathing pattern variability indices were: T-piece (0.73-0.87)>100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure (0.60-0.79)>5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure (0.53-0.76). Analysis of the classification and regression tree indicated that during the T-piece trial, a SD1 of peak inspiratory flow>3.36 L/min defined a group including all extubation success patients. Conversely, the combination of a SD1 of peak inspiratory flow ≤3.36 L/min and a coefficient of variations of rapid shallow breathing index ≤0.23 defined a group of all extubation failure patients. The decision strategies using SD1 of peak inspiratory flow and coefficient of variations of rapid shallow breathing index measured during 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials achieved a less clear separation of extubation failure from extubation success. CONCLUSIONS Since 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure reduce the predictive performance of breathing pattern variability, breathing pattern variability measurement during the T-piece trial is the best choice for predicting extubation outcome in intensive care unit patients patients.
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Savi A, Teixeira C, Silva JM, Borges LG, Pereira PA, Pinto KB, Gehm F, Moreira FC, Wickert R, Trevisan CBE, Maccari JG, Oliveira RP, Vieira SRR. Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care 2011; 27:221.e1-8. [PMID: 21958979 DOI: 10.1016/j.jcrc.2011.07.079] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 06/29/2011] [Accepted: 07/17/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Predictor indexes are often included in weaning protocols and may help the intensive care unit (ICU) staff to reach expected weaning outcome in patients on mechanical ventilation. OBJECTIVE The objective of this study is to evaluate the potential of weaning predictors during extubation. DESIGN This is a prospective clinical study. SETTINGS The study was conducted in 3 medical-surgical ICUs. PATIENTS Five hundred consecutive unselected patients ventilated for more than 48 hours were included. METHODS AND MEASUREMENTS All patients were extubated after 30 minutes of successful spontaneous breathing trial and followed up for 48 hours. The protocol evaluated hemodynamics, ventilation parameters, arterial blood gases, and the weaning indexes frequency to tidal volume ratio; compliance, respiratory rate, oxygenation, and pressure; maximal inspiratory pressure; maximal expiratory pressure; Pao(2)/fraction of inspired oxygen; respiratory frequency; and tidal volume during mechanical ventilation and in the 1st and 30th minute of spontaneous breathing trial. RESULTS Reintubation rate was 22.8%, and intensive care mortality was higher in the reintubation group (10% vs 31%; P < .0001). The areas under the receiver operating characteristic curve showed that tests did not discriminate which patients could tolerate extubation. CONCLUSION Usual weaning indexes are poor predictors for extubation outcome in the overall ICU population.
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Affiliation(s)
- Augusto Savi
- Intensive Care Unit of Moinhos de Vento Hospital, Porto Alegre, Rua Ramiro Barcelos 910, Brazil.
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Su KC, Tsai CC, Chou KT, Lu CC, Liu YY, Chen CS, Wu YC, Lee YC, Perng DW. Spontaneous breathing trial needs to be prolonged in critically ill and older patients requiring mechanical ventilation. J Crit Care 2011; 27:324.e1-7. [PMID: 21798702 DOI: 10.1016/j.jcrc.2011.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/31/2011] [Accepted: 06/09/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate a modified weaning procedure to predict extubation outcome in critically older and ventilated patients. METHODS We retrospectively analyzed extubation outcome in older (≥ 70 years) and ventilated patients. In period I (2007), patients passing a 2-hour spontaneous breathing trial (SBT) were extubated. In period II (2008), patients underwent an 8-hour SBT on day 1 and a 2-hour SBT, followed by extubation on day 2. Weaning parameters were recorded at baseline (T(0)) (periods I and II), 2 and 8 (T(8)) hours after SBT (period II). RESULTS The demographic data of patients in each period (n = 64 and 67, respectively) were similar. Patients in period II demonstrated a higher rate of SBT failure but a significantly lower rate of extubation failure and reintubation mortality. In period II, successfully extubated patients demonstrated a significantly lower value of rapid shallow breathing index (RSBI) at T(8). The ratio of RSBI at T(8) over T(0) (T(8)/T(0) ≤ 1.4) demonstrated good diagnostic value (sensitivity 89.5%, specificity 80.0%, accuracy 88.4%) in predicting successful extubation. CONCLUSIONS For critically older and ventilated patients, a prolonged SBT in conjunction with evolution of the RSBI ratio over baseline during SBT may serve as a useful procedure to predict extubation outcome.
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Affiliation(s)
- Kang-Cheng Su
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei City, 112 Taiwan
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Rose L, Presneill JJ. Clinical Prediction of Weaning and Extubation in Australian and New Zealand Intensive Care Units. Anaesth Intensive Care 2011; 39:623-9. [DOI: 10.1177/0310057x1103900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our objective was to describe, in Australian and New Zealand adult intensive care units, the relative frequency in which various clinical criteria were used to predict weaning and extubation, and the weaning methods employed. Participant intensivists at 55 intensive care units completed a self-administered questionnaire, using visual analogue scales (0=not at all predictive, 10=perfectly predictive, not used=null score) to record the perceived utility of 30 potential predictors. Survey response rate was 71% (164/230). Those variables thought most predictive of weaning readiness were respiratory rate (median score 8.0, interquartile range 7.0 to 8.6) effective cough (7.3, 5.9 to 8.2) and pressure support setting (7.2, 6.0 to 8.0). The most highly rated predictors of extubation success were effective cough (8.0, 7.0 to 9.0), respiratory rate (8.0, 7.0 to 8.5) and Glasgow Coma Score (7.9, 6.1 to 8.3). Variables perceived least predictive of weaning and extubation success were P0.1, Acute Physiological and Chronic Health Evaluation score II, mean arterial pressure, electrolytes and maximum inspiratory pressure (individual median scores <5). Most popular clinical criteria were those perceived to have high predictive accuracy, both for weaning (respiratory rate 96%, pressure support setting 94% and Glasgow coma score 91%) and extubation readiness (respiratory rate 98%, effective cough 94% and Glasgow Coma Score 92%). Weaning mostly employed pressure support ventilation (55%), with less use of synchronised intermittent mandatory ventilation (32%) and spontaneous breathing trials (13%). Classic ventilatory performance predictors including respiratory rate and effective cough were reported to be of greater clinical utility than other more recently proposed measures.
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Affiliation(s)
- L. Rose
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - J. J. Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Intensive Care Unit, Mater Hospital, Brisbane, Queensland
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Karcz M, Vitkus A, Papadakos PJ, Schwaiberger D, Lachmann B. State-of-the-art mechanical ventilation. J Cardiothorac Vasc Anesth 2011; 26:486-506. [PMID: 21601477 DOI: 10.1053/j.jvca.2011.03.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Indexed: 02/01/2023]
Affiliation(s)
- Marcin Karcz
- Department of Anesthesiology, University of Rochester, Rochester, NY 14642, USA.
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Hadjitodorov S, Todorova L. Consultation system for determining the patients' readiness for weaning from long-term mechanical ventilation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2010; 100:59-68. [PMID: 20233635 DOI: 10.1016/j.cmpb.2010.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 01/26/2010] [Accepted: 02/12/2010] [Indexed: 05/28/2023]
Abstract
Determining the readiness of the patient for weaning from long-term mechanical ventilation with high degree of accuracy is a prerequisite for successful weaning attempt. A computer system for the determination of the moment for beginning the weaning process is proposed and realized as a program package WeaningMV. It is designed on the basis of four classification methods: stepwise discriminant analysis, stepwise logistic regression; intuitionistic fuzzy Voronoi diagrams and non-pulmonary weaning index, applied to 17 features (variables). The system is designed and preliminary tested on 151 patients with features in two classes "not ready for weaning" and "ready for weaning" and it has a high degree for sensitivity (0.99) and specificity (0.89). After the application of the system in the everyday physician's practice a set of 72 patients has been examined. For that set the sensitivity is 0.92 and the specificity 0.88. The system consults the medical team on the basis of objective processing of the information contained in the data and is suitable for use in the clinical practice as well as in the training of the respective specialists.
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Affiliation(s)
- Stefan Hadjitodorov
- Department of Biomedical Informatics, Centre of Biomedical Engineering Prof. I. Daskalov, Bulgarian Academy of Sciences, Acad. G. Bonchev Street, Block 105, 1113 Sofia, Bulgaria.
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Monaco F, Drummond GB, Ramsay P, Servillo G, Walsh TS. Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients? Br J Anaesth 2010; 105:326-33. [PMID: 20656695 DOI: 10.1093/bja/aeq184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vt(exp)), respiratory rate (f), minute volume (MV(exp)), rapid shallow breathing index (f/Vt), inspired-expired oxygen concentration difference [(I-E)O(2)], and end-tidal carbon dioxide concentration (Pe'(co(2))) at the end of a weaning trial to predict early weaning outcomes. METHODS Seventy-three patients who required >24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H(2)O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. RESULTS Pre-test probability for achieving the outcome was 44% in the cohort (n=32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H(+) concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I-E]O(2) and Pe'(co(2)) had weak discriminatory power [area under the ROC curve: [I-E]O(2) 0.64 (P=0.03); Pe'(co(2)) 0.63 (P=0.05)]. Using best cut-off values for [I-E]O(2) of 5.6% and Pe'(co(2)) of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. CONCLUSIONS In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.
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Affiliation(s)
- F Monaco
- Department of Cardiothoracic Anaesthesia and Intensive Care, Istituto Scientifico S. Raffaele, Via Olgettina 60, Milan 20132, Italy
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Boutou AK, Abatzidou F, Tryfon S, Nakou C, Pitsiou G, Argyropoulou P, Stanopoulos I. Diagnostic accuracy of the rapid shallow breathing index to predict a successful spontaneous breathing trial outcome in mechanically ventilated patients with chronic obstructive pulmonary disease. Heart Lung 2010; 40:105-10. [PMID: 20561873 DOI: 10.1016/j.hrtlng.2010.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Revised: 01/09/2010] [Accepted: 02/09/2010] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of 2 threshold values (105 breaths per minute [bpm]/L and 130 bpm/L) of the rapid shallow breathing index (RSBI) to predict a successful weaning trial outcome in a homogenous group of patients with chronic obstructive pulmonary disease (COPD). METHODS A consecutive population of patients with COPD who were intubated for hypercapnic respiratory failure during a 2-year period were studied prospectively. RSBI was measured by 2 investigators at minute 5 of the T-piece trial, whereas 2 other physicians evaluated the 30 minute T-piece trial as successful or unsuccessful, according to clinical criteria. RESULTS Of 64 patients with COPD (53 male, 11 female) who constituted the study population, 42 patients (35 male, 7 female; aged 70 ± 9.2 years) completed the spontaneous breathing trial (SBT) and remained clinically stable (group 1). The remaining 22 patients (18 male, 4 female; aged 71.9 ± 4.7 years) had to return to ventilatory support by the end of the SBT because of clinical deterioration (group 2). The 2 threshold values that were evaluated had low specificity (38.1% for < 105 bpm/L and 66.7% for < 130 bpm/L), low sensitivity (63.6% for < 105 bpm/L and 54.5% for < 130 bpm/L), and low diagnostic accuracy (46.8% for < 105 bpm/L and 65.6% for < 130 bpm/L) in predicting a successful T-piece trial outcome. CONCLUSION RSBI measured early during an SBT cannot accurately predict the successful outcome of a T-piece trial in a homogenous population of patients with COPD.
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Affiliation(s)
- Afroditi K Boutou
- Respiratory Failure Unit, G Papanikolaou Hospital, Aristotle University of Thessaloniki, Greece.
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Segal LN, Oei E, Oppenheimer BW, Goldring RM, Bustami RT, Ruggiero S, Berger KI, Fiel SB. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med 2009; 36:487-95. [PMID: 19946770 DOI: 10.1007/s00134-009-1735-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 11/04/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Rapid shallow breathing may occur at any time during spontaneous breathing trials (SBT), questioning the utility of a single determination of the rapid shallow breathing index (RSBI). We hypothesize that change in RSBI during SBT may more accurately predict successful extubation than a single determination. METHODS Prospective observational study. Seventy-two subjects were extubated. At 24 h, 63/72 remained extubated (Extubation Success), and 9 were re-intubated (Extubation Failure). Respiratory rate (RR), tidal volume (VT) and RSBI were measured every 30 min during 2-h T-piece SBT. Change in respiratory parameters was assessed as percent change from baseline. RESULTS Initial RSBI was similar in Extubation Success and Extubation Failure groups (77.0 +/- 4.8, 77.0 +/- 4.8, p = ns). Nevertheless, RSBI tended to remain unchanged or decreased in the Extubation Success group; in contrast RSBI tended to increase in the Extubation Failure group because of either increased RR and/or decreased VT (p < 0.001 for mean percent change RSBI over time), indicating worsening of the respiratory pattern. Quantitatively, only 7/63 subjects of the Extubation Success group demonstrated increased RSBI >or=20% at any time during the SBT. In contrast, in the Extubation Failure group, RSBI increased in all subjects during the SBT, and eight of nine subjects demonstrated an increase greater than 20%. Thus, with a 2-h SBT the optimal threshold was a 20% increase (sensitivity = 89%, specificity = 89%). Similar results were obtained at 30 min (threshold = 5% increase). Percent change of RSBI predicted successful extubation even when initial values were >or=105. CONCLUSION Percent change of RSBI during an SBT is a better predictor of successful extubation than a single determination of RSBI.
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Affiliation(s)
- Leopoldo N Segal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, 462 First Ave 7W54, New York, NY 10016, USA.
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Effects of obesity on breathing pattern, ventilatory neural drive and mechanics. Respir Physiol Neurobiol 2009; 168:198-202. [PMID: 19559105 DOI: 10.1016/j.resp.2009.06.012] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 06/16/2009] [Accepted: 06/17/2009] [Indexed: 11/23/2022]
Abstract
The purpose of this study was to assess whether obesity induces changes in breathing pattern and ventilatory neural drive and mechanics. Measurements performed in 34 male obese subjects (BMI, 39+/-6 kg/m(2)) and 18 controls (BMI, 23+/-3 kg/m(2)) included anthropometric parameters, spirometry, breathing patterns, mouth occlusion pressure, maximal inspiratory pressure and work of breathing. The results show that spirometric flow (FEV(1)% pred, FVC% pred) and maximal inspiratory pressure (P(Imax)) were significantly lowers (p<0.001) in obese subjects compared to controls. The (fR/VT) ratio was higher in obese subjects than in controls (p<0.001). The increase in (fR/VT) was associated with an increase in the ratio of mean inspiratory pressure to maximal inspiratory pressure (P(I)/P(Imax)) and the duty cycle (T(I)/T(TOT)) (p<0.001). The energy cost of breathing (W(rest)/W(crit)), which reflects the oxygen consumed by the respiratory muscle was greater in obese subject than in controls (p<0.001) inducing an increase in the effective inspiratory impedance on the respiratory muscles. It is concluded that obese subjects show impairment in breathing pattern and respiratory mechanics as assessed by rapid shallow breathing leading to ventilatory failure.
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Cohen J, Shapiro M, Grozovski E, Fox B, Lev S, Singer P. Prediction of extubation outcome: a randomised, controlled trial with automatic tube compensation vs. pressure support ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R21. [PMID: 19236688 PMCID: PMC2688139 DOI: 10.1186/cc7724] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 01/06/2009] [Accepted: 02/23/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Tolerance of a spontaneous breathing trial is an evidence-based strategy to predict successful weaning from mechanical ventilation. Some patients may not tolerate the trial because of the respiratory load imposed by the endotracheal tube, so varying levels of respiratory support are widely used during the trial. Automatic tube compensation (ATC), specifically developed to overcome the imposed work of breathing because of artificial airways, appears ideally suited for the weaning process. We further evaluated the use of ATC in this setting. METHODS In a prospective study, patients who had received mechanical ventilation for more than 24 hours and met defined criteria for a weaning trial, underwent a one-hour spontaneous breathing trial with either ATC (n = 87) or pressure support ventilation (PSV; n = 93). Those tolerating the trial were immediately extubated. The primary outcome measure was the ability to maintain spontaneous, unassisted breathing for more than 48 hours after extubation. In addition, we measured the frequency/tidal volume ratio (f/VT) both with (ATC-assisted) and without ATC (unassisted-f/VT) at the start of the breathing trial as a pretrial predictor of extubation outcome. RESULTS There were no significant differences in any of the baseline characteristics between the two groups apart from a significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II score in the ATC group (p = 0.009). In the PSV group, 13 of 93 (14%) patients failed the breathing trial compared with only 6 of 87 (6%) in the ATC group; this observed 8% difference, however, did not reach statistical significance (p = 0.12). The rate of reintubation was not different between the groups (total group = 17.3%; ATC = 18.4% vs. PSV = 12.9%, p = 0.43). The percentage of patients who remained extubated for more than 48 hours was similar in both groups (ATC = 74.7% vs. PSV = 73.1%; p = 0.81). This represented a positive predictive value for PSV of 0.85 and ATC of 0.80 (p = 0.87). Finally, the ATC-assisted f/VT was found to have a significant contribution in predicting successful liberation and extubation compared with the non-significant contribution of the unassisted f/VT (unassisted f/VT, p = 0.19; ATC-assisted f/VT, p = 0.005). CONCLUSIONS This study confirms the usefulness of ATC during the weaning process, being at least as effective as PSV in predicting successful extubation outcome and significantly improving the predictive value of the f/VT. TRIAL REGISTRATION Current Controlled Trials ISRCTN16080446.
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Affiliation(s)
- Jonathan Cohen
- General Intensive Care Unit, Rabin Medical Center, Petah Tikva, Israel.
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Cohen J, Shapiro M, Singer P. Automatic Tube Compensation in the Weaning Process. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Teixeira C, Zimermann Teixeira PJ, Hohër JA, de Leon PP, Brodt SFM, da Siva Moreira J. Serial measurements of f/VT can predict extubation failure in patients with f/VT ≤ 105? J Crit Care 2008; 23:572-6. [DOI: 10.1016/j.jcrc.2007.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Revised: 11/19/2007] [Accepted: 12/02/2007] [Indexed: 11/25/2022]
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Vidotto MC, Sogame LCM, Calciolari CC, Nascimento OA, Jardim JR. The prediction of extubation success of postoperative neurosurgical patients using frequency-tidal volume ratios. Neurocrit Care 2008; 9:83-9. [PMID: 18250977 DOI: 10.1007/s12028-008-9059-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The process of discontinuing neurological patients from mechanical ventilation is still controversial. The aim of this study was to report the outcome from extubating patients undergoing elective craniotomy and correlate the result with the measured f/V (t) ratio. MATERIALS AND METHODS In a cohort prospective study, all consecutive patients who required mechanical ventilation for up to 6 h after elective craniotomy were eligible for inclusion in this study. Patients passing daily screening criteria automatically received a spontaneous breathing trial (SBT). Immediately previous to the extubation, the expired minute volume (VE), breathing frequency (f), and tidal volume (V (t)) were measured and the breathing frequency-to-tidal volume ratio (f/V (t)) was calculated; consciousness level based on Glasgow Coma Scale (GCS) was evaluated at the same time. The extubation was considered a failure when patients needed reintubation within 48 h. RESULTS Ninety-two patients were extubated and failure occurred in 16%. Despite 15 patients failed extubation just one of them presented the f/V (t) score over 105. The best cutoff value for f/V (t) observed was 62, but with low specificity (0.53) and negative predictive values (0.29). Area under the ROC curve for the f/V (t) was 0.69 +/- 0.07 (P = 0.02). Patients who failed the extubation process presented higher incidence of pneumonia (80%), higher need for tracheostomy (33%) and mortality rate of 40%. CONCLUSION The f/V (t) ratio does not predict extubation failure in patients who have undergone elective craniotomy. Patients who fail extubation present higher incidence of pneumonia, tracheostomy and higher mortality rate.
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Affiliation(s)
- Milena C Vidotto
- Respiratory Physiotherapy Especialization Course, Federal University of São Paulo (Unifesp), Sao Paulo, Brazil.
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El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:221. [PMID: 18710593 PMCID: PMC2575571 DOI: 10.1186/cc6959] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Mechanical ventilation is the defining event of intensive care unit (ICU) management. Although it is a life saving intervention in patients with acute respiratory failure and other disease entities, a major goal of critical care clinicians should be to liberate patients from mechanical ventilation as early as possible to avoid the multitude of complications and risks associated with prolonged unnecessary mechanical ventilation, including ventilator induced lung injury, ventilator associated pneumonia, increased length of ICU and hospital stay, and increased cost of care delivery. This review highlights the recent developments in assessing and testing for readiness of liberation from mechanical ventilation, the etiology of weaning failure, the value of weaning protocols, and a simple practical approach for liberation from mechanical ventilation.
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Affiliation(s)
- Mohamad F El-Khatib
- Department of Anesthesiology, School of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
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Abstract
OBJECTIVE Because the results of a meta-analysis are used to formulate the highest level recommendation in clinical practice guidelines, clinicians should be mindful of problems inherent in this technique. Rather than reviewing meta-analysis in abstract, general terms, we believe readers can gain a more concrete understanding of the problems through a detailed examination of one meta-analysis. The meta-analysis on which we focus is that conducted by an American College of Chest Physicians/American Association for Respiratory Care/American College of Critical Care Medicine Task Force on ventilator weaning. DATA SOURCE Two authors extracted data from all studies included in the Task Force's meta-analysis. DATA SYNTHESIS AND OVERVIEW: The major obstacle to reliable internal validity and, thus, reliable external validity (generalizability) in biological research is systematic error, not random error. If systematic errors are present, averaging (as with a meta-analysis) does not decrease them--instead, it reinforces them, producing artifact. The Task Force's meta-analysis commits several examples of the three main types of systematic error: selection bias (test-referral bias, spectrum bias), misclassification bias (categorizing reintubation as weaning failure, etc.), and confounding (pressure support treated as unassisted breathing). Several additional interpretative errors are present. CONCLUSIONS An increase in study size, as achieved through the pooling of data in a meta-analysis, is mistakenly thought to increase external validity. On the contrary, combining heterogeneous studies poses considerable risk of systematic error, which impairs internal validity and, thus, external validity. The strength of recommendations in clinical practice guidelines is based on a misperception of the relative importance of systematic vs. random error in science.
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Abstract
Over the past 2 decades, the art of "weaning" from mechanical ventilation has been informed by increasing published basic science and outcomes studies. Although monitoring technologies can provide vast amounts of information before, during, and after liberation from mechanical ventilation, little data exists on how to maximally harness even routinely monitored, basic physiologic parameters. Overdependence on technology and derived variables, without data to demonstrate benefit, may even inhibit the patient's progress if it is used inappropriately. We review the scientific evidence for best using routinely available physiologic data and a few more sophisticated and invasive monitoring technologies during weaning. We also suggest future study designs that would better inform the process of liberation from the ventilator and endotracheal extubation.
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Affiliation(s)
- Jonathan M Siner
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208057, New Haven, CT 06520-8057, USA.
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Jubran A, Tobin MJ. Noninvasive Respiratory Monitoring. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tobin MJ, Jubran A. Variable performance of weaning-predictor tests: role of Bayes' theorem and spectrum and test-referral bias. Intensive Care Med 2006; 32:2002-12. [PMID: 17091239 DOI: 10.1007/s00134-006-0439-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 10/06/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We examined whether variation in reported reliability of the frequency-to-tidal volume ratio (f/V(T)) in predicting weaning success is explained by spectrum and test-referral bias, as reflected by variation in pretest probability of success. DESIGN Two authors extracted data from all studies on reliability of f/V(T) as a weaning predictor. RESULTS Prevalence of successful weaning in studies of f/V(T) revealed significant heterogeneity; mean success rate was 0.75. The heterogeneity and high success rate reflects occurrence of spectrum bias, suggested by the lower value of f/V(T) in subsequent studies than in the original report (77.4 vs. 89.1) and test-referral bias, suggested by lower specificity of f/V(T) in subsequent studies than in the original report (0.52 vs. 0.64). When data from studies in the ACCP Task Force's meta-analysis of studies on f/V(T) were entered into a Bayesian model with pretest probability (prevalence of success) as the operating point, observed posttest probabilities were closely correlated with values predicted by the original report on f/V(T): positive-predictive value r = 0.86 and negative-predictive value r = 0.82. Average sensitivity, the most precise measure of screening-test reliability, was 0.87 +/- 0.14 and average specificity 0.52 +/- 0.26. CONCLUSIONS Much of the heterogeneity in performance of f/V(T) can be explained by variation in pretest probability of successful outcome, which may be secondary to spectrum and test-referral bias. The average sensitivity of 0.87 indicates that f/V(T) is a reliable screening test for successful weaning.
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Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr Veterans Affairs Hospital, and Stritch School of Medicine, Loyola University of Chicago, Hines, IL 60141, USA.
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Kuo PH, Wu HD, Lu BY, Chen MT, Kuo SH, Yang PC. Predictive value of rapid shallow breathing index measured at initiation and termination of a 2-hour spontaneous breathing trial for weaning outcome in ICU patients. J Formos Med Assoc 2006; 105:390-8. [PMID: 16638649 DOI: 10.1016/s0929-6646(09)60135-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/PURPOSE The rapid shallow breathing index (RSBI) is a weaning parameter usually measured at the start of a spontaneous breathing trial (SBT). This study investigated the value of RSBI measured at the beginning and termination of SBT as a predictor of weaning outcome. METHODS RSBI was measured during the initial 1 minute (RSBI1) and at termination (RSBI2) of an SBT in 172 patients recovering from acute respiratory failure. RESULTS Weaning was successful in 106 patients and failed in 66 patients. Among the 66 patients with weaning failure, 12 required reintubation within 48 hours (extubation failure), and the remaining 54 patients could not be extubated after SBT (trial failure). There were no differences between RSBI1 in the three groups (69.4 +/- 27.5, 81.7 +/- 24.4 and 75.5 +/- 26.5, respectively), but RSBI2 was significantly higher in patients with extubation failure (95.9 +/- 20.6) and trial failure (98.0 +/- 50.0) than in patients with weaning success (64.6 +/- 26.3) (both p < 0.001). Logistic regression revealed that RSBI2 was superior to RSBI1 and various physiologic indices in predicting weaning outcome. For the 118 extubated patients, the mean area under the receiver operating characteristic curve for RSBI2 and RSBI1 was 0.83 and 0.63, respectively. Using a threshold value of 105, the sensitivity, specificity, accuracy and likelihood ratio for weaning outcome were 0.91, 0.25, 0.85 and 1.38 for RSBI2 and 0.89, 0.16, 0.60 and 1.06 for RSBI1, respectively. CONCLUSION This study found that RSBI measured at the completion of SBT was superior to that measured at the start in predicting weaning outcome in critically ill patients.
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Affiliation(s)
- Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
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Vassilakopoulos T, Routsi C, Sotiropoulou C, Bitsakou C, Stanopoulos I, Roussos C, Zakynthinos S. The combination of the load/force balance and the frequency/tidal volume can predict weaning outcome. Intensive Care Med 2006; 32:684-91. [PMID: 16523330 DOI: 10.1007/s00134-006-0104-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Accepted: 02/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine whether an appropriately designed combination of an index of ventilatory endurance and the frequency divided by tidal volume ratio (f/VT) provides prognostic information for weaning outcome not offered by any index alone. DESIGN AND SETTING Prospective study in a multidisciplinary intensive care unit, university hospital. PATIENTS 124 consecutive mechanically ventilated patients. INTERVENTIONS We designed an index of ventilatory endurance (load/force balance) calculated as the mean inspiratory airway pressure (PI) during controlled mechanical ventilation/maximum inspiratory pressure (MIP) [PI equals the triplicate of mean airway pressure (Paw) displayed by the ventilator] and tested its capacity in predicting weaning outcome at 48 h along with f/VT and many other indices in 75 consecutive mechanically ventilated patients ready to wean. A stepwise discriminant function analysis was used to test the performance of appropriately designed index combination. Threshold values of indices and their combination were prospectively validated in another group of 45 consecutive patients. RESULTS Stepwise discriminant analysis showed that PI/MIP and f/VT were the only indices that remained in the model with the function D=7.628xmean Paw/MIP+0.0158xf/VT-2.374. The cutoff point of D=0.5 had 94% sensitivity, 67% specificity, and 87% correct classifications. Prospective validation demonstrated similar results. The simplified discriminant function D=15xmean Paw/MIP+0.003xf/VT-5 and the cut-off point of D=1.0 had 89% sensitivity, 67% specificity, and 85% correct classifications. CONCLUSIONS The combination of mean Paw/MIP and f/VT in a simplified discriminant function is useful in predicting weaning outcome.
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Affiliation(s)
- Theodoros Vassilakopoulos
- Department of Critical Care and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, 45-47 Ipsilandou Str., 10675, Athens, Greece
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Abstract
Important advances have been made over the past decade towards understanding the optimal approach to ventilating patients with acute respiratory failure. Evidence now supports the use of noninvasive positive pressure ventilation in selected patients with hypercapnic respiratory failure and chronic obstructive pulmonary disease, cardiogenic pulmonary edema, and for facilitating the discontinuation of ventilatory support in patients with chronic pulmonary disease. The concept of a lung protective ventilatory strategy has revolutionized the management of the acute respiratory distress syndrome. The process of liberation from mechanical ventilation is becoming more standardized, with evidence supporting daily trials of spontaneous breathing in all suitable mechanically ventilated patients. This article critically reviews the most important recent advances in mechanical ventilation and suggests future directions for further research in the field.
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Affiliation(s)
- Carolyn S Calfee
- Cardiovascular Research Institute, San Francisco, California, USA.
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Jubran A, Grant BJB, Laghi F, Parthasarathy S, Tobin MJ. Weaning prediction: esophageal pressure monitoring complements readiness testing. Am J Respir Crit Care Med 2005; 171:1252-9. [PMID: 15764727 DOI: 10.1164/rccm.200503-356oc] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Several variables are recommended for identifying if a patient is ready for a trial of weaning from mechanical ventilation, but there is no agreement as to whether monitoring any variable during the trial enhances patient management. To determine whether repeated measurements of esophageal pressure throughout a trial are more reliable than measurements of esophageal pressure or frequency-to-VT ratio during the first minute of the trial, we studied 60 patients. A trend index that quantified esophageal pressure swings over time was more reliable than the first-minute measurements: sensitivity, 0.91, and specificity, 0.89. Area under receiver operating characteristic curve for trend index (0.94) was greater than for first-minute measurement of esophageal pressure (0.44, p < 0.05) and tended to be greater than that for frequency-to-VT ratio (0.78, p = 0.13). The likelihood ratio was highest for the trend index (8.2, p < 0.05). The advantage of the trend index may be related to the progressive increase in esophageal pressure throughout a failed weaning trial, whereas breathing pattern changed little after 2 minutes of spontaneous breathing. In conclusion, continuous monitoring of esophageal pressure swings during a spontaneous breathing trial provides additional guidance in patient management over tests used for deciding when to initiate weaning.
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Affiliation(s)
- Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. VA Hospital, 111N 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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Todorova L, Temelkov A. Weaning from long-term mechanical ventilation: a nonpulmonary weaning index. J Clin Monit Comput 2004; 18:275-81. [PMID: 15779839 DOI: 10.1007/s10877-005-2221-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Despite the extensive investigations in the area of weaning, clinicians are still struggling with the question of when to begin the process of weaning. Clinical weaning indices designed to predict the weaning potential are most frequently based on pulmonary factors. However, many physiological, respiratory, and mechanical factors also have impact on weaning, but are often overlooked. We suggest a new "nonpulmonary weaning index" (NPWI), which assesses the influence of factors such as blood albumin and total blood protein on the weaning success. METHODS We assess the information value of 17 clinical and paraclinical indices in a retrospective study covering 151 patients on a long-term (at least 7 days) mechanical ventilation. The most informative of those 17 indices are used in the formulation of NPWI. Its threshold differentiates the successful from the unsuccessful weaning trials. RESULTS From all 17 indices the most significant are: total blood protein, blood albumin, PaO2, hematocrit, lactate, the ratio PaO2/FiO2, hemoglobine, and RUE. The proposed index uses only two of them: blood albumin and total blood protein. It is easily calculated and can easily be tracked in time. It has high sensitivity and specificity. CONCLUSIONS The results of this study suggest that in the decision whether to attempt weaning from long-term mechanical ventilation, more attention should be paid to the nonpulmonary factors.
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Affiliation(s)
- L Todorova
- Department of Biomedical Informatics, Central Laboratory of Biomedical Engineering, Bulgarian Academy of Sciences, Acad. G. Bonchev Street, Block 105, 1113 Sofia, Bulgaria.
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