New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi...

24
New insights on tracheal extubation after difficult weaning J. Mancebo, MD

Transcript of New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi...

Page 1: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

New insights on tracheal extubation after difficult weaning

J. Mancebo, MD

Page 2: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

COI (3yr)

-Covidien, and Maquet: Research grants

-Air Liquide: DMSB, Adv Board

-Faron and A-Lung: S Comm

-Covidien: Speaker at a mtg

-Braun: Consultancy

Page 3: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Beginning End

Screening SBT (<2h) Extubation

Extubation Reintubation NIV

Clinical approach

Predictors Techniques

Unplanned extubation

Page 4: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

ERJ 2007

Page 5: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

26/160 = 16%

Page 6: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

13 10

15

0

7 10

19

9 5

16

33

24

0

10

20

30

40

FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.

Rate of re-intubation (%)

Rate of ICU Mortality (%)

Simple weaning Difficult weaning Prolonged weaning

37

13

017

11

2

22

13

42

18

0

10

20

30

40

50

FUNK et al. PEÑUELAS et al. SELLARES et al. TONNELIER et al.

Page 7: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

1519

13 14 1510

16

50

27

33

43

35

26 28

0

10

20

30

40

50

60

Rate in % Reintubation rate

In-ICU mortality rate

Esteban 1997 [3] N=397

Esteban 1999 [4] N=453

Epstein 1997 [5] N=287

Vallverdú1998 [6] N=148

Thille 2011 [2] N=168

Frutos-Vivar 2011 [8] N=1142

Peñuelas2011 [7] N=2714

Thille AW, et al. COCC. 2013;19:57-64

Implications

Page 8: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...
Page 9: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...
Page 10: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

De Jonghe B, et al. JAMA 2002;288:2859-67

Patients under MV for at least of 7 days were screened daily for awakening (D1). Cohort study March 1999-June 2000 (5 ICUs). ICU acquired paresis: severe muscle weakness on D7 after awakening. Results: 95 patients achieved awakening, and 25% had ICUAP. Duration of MV after D1 longer in ICUAP patients compared to those w/o (18.2 vs 7.6 days, p=.03). Independent predictors of ICUAP: female, # days with dysfuction of 2 or more organs, duration of MV, and administration of corticosteroids.

Page 11: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...
Page 12: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

CCM 2007;35:2007-15

Page 13: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...
Page 14: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

AJRCCM 2013;187:1294-302

Clinical tolerance: ACV: 100% PSV+PEEP: 11/14 (79%) PSV no PEEP: 8/14 (57%) T-piece: 0%

Page 15: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

533 patients under mechanical ventilation (MV) over 18 months

Planned extubation without DNR order after at least 24h of MV: N = 225

Reintubation ≤ 7 days: N = 31 (14%)

All planned extubation: N = 310

66 patients ventilated less than 24h (1 reintubation)

19 patients died with a do-not-reintubate (DNR) order

175 patients died or transferred before meeting criteria for extubation

7 patients tracheotomized without prior extubation

25 terminal extubations

16 unplanned extubations (3% of intubated patients)

Thille AW, et al. CCM 2015;43:613-620

Page 16: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

CCM 2015;43:613-620

Page 17: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

1170 screened

855 Ventilated>48hrs

122 at risk*

25 excluded

97 randomised

48 NIV

49 Standard medical therapy

• Exclusion criteria (n.16). Not randomised (n.7). Refusal (n.2)

Nava S, et al. CCM 2005; 33:2465-70

*: hypercapnia, CHF, > 1 failed SBT, >1 comorbidity, upper aw obstr, weak cough

Page 18: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Nava S, et al. CCM 2005; 33:2465-70

- Reintubation: 4/48 (NIV) vs 12/49 (standard), P=0.027 - Reintubation was associated with higher mortality risk (P<0.01) - NIV use resulted in a reduced risk of ICU mortality (-10%, P<0.01) because of a reduction for the need of reintubation

Page 19: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Survival

n=27

n=22

n=83 n=79

n=61 n=52

AJRCCM 2006;173:164-70

Tolerance SBT and risk: age >65 yr, or CHF, or APACHE-II >12. Re IOT : 11% NIV vs 22% control p:NS

Page 20: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Ferrer M, et al. Lancet 2009

Page 21: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

AJRCCM 2012;186:1256-63

Page 22: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

ca 150h 210h 230h

Page 23: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Strategy-Proposal

-Simple: Screen often and as soon as possible. The pretest probability is not high. -Difficult: Understand the causes (respiratory/cardiovascular). Monitor respiratory muscle output, echocardiography, biomarkers, laringeal injuries. Ventilator settings: avoid the extremes. -Prolonged: Overall clinical practice and organization are probably relevant (sleep, sedatives, communication, nutrition, mobilization, …).

Page 24: New insights on tracheal extubation after difficult weaningab.wfsiccm2015.com/WFSICCM_AB/0450PMJordi MANCEBO.pdf · New insights on tracheal extubation after difficult weaning J ...

Conclusion

Extubation failure after weaning is a relevant clinical issue, but:

• We need to precisely understand the

pathophysiological mechanism/s explaining extubation failure.

• Unless much research is conducted in this field, the outcomes won’t improve much.