Aula 3 - Desmame

Desmame da VM
Conceitos
Fisioterapia Cardiorrespiratória
Rafael Orcy
Resumo
• The term "weaning" is used to describe the gradual process of
decreasing ventilator support.
• It is estimated that 40% of the duration of mechanical ventilation is

dedicated to the process of weaning.
• Spontaneous breathing trial (SBT) assesses the patient’s ability to

breathe while receiving minimal or no ventilator support.
Resumo
Resumo
• cause of respiratory failure has been resolved or not.
• Delayed weaning can lead to complications such as ventilator induced

lung injury (VILI), ventilator associated pneumonia (VAP), and
ventilator induced diaphragmatic dysfunction.
• premature weaning can lead to complications like loss of the airway,

defective gas exchange, aspiration and respiratory muscle fatigue
SBT
• Spontaneous breathing trial (SBT) assesses the patient’s ability to
breathe while receiving minimal or no ventilator support.
• A combination of subjective and objective criteria is usually used to

determine disease reversal.
• Usually the criteria used are improvement of gas exchange,

improvement of mental status, neuromuscular functional assessment
and radiographic signs
Objective
• In the present article, we review some of the recent studies about
weaning predictors, criteria, procedure, as well as assessment for
extubation a mechanically ventilated patient.

2. Weaning predictors
• 2.1. Heart rate variability
• The process of weaning leads to changes in the hemodynamic and
autonomic nervous systems. Two prospective observational studies
showed that reduced heart rate variability during spontaneous
breathing trials (SBT) was significantly associated with extubation
failure.
• need validation in larger groups of patients.

• 2.2. Sleep quality
• Poor quality of sleep may affect the function of the respiratory

muscles and weaning outcome.
• In a cross sectional study, Chen et al. assessed the quality of sleep using the
Verran and Snyder-Halpern Sleep Scale and found that poor quality of sleep
was significantly associated with weaning failure
• 2.3. Hand grip strength
• Muscle weakness can negatively affect the weaning outcome (15). Cottereau
et al. assessed handgrip strength by a handheld dynamometer and found that
handgrip strength was significantly associated with difficult or prolonged
weaning but not with extubation failure
• 2.4. Diaphragmatic dysfunction

• The acquired diaphragmatic dysfunction following prolonged mechanical ventilation
can affect the weaning outcome (17).
• DiNino et al. assessed diaphragmatic dysfunction by measuring the difference

between diaphragm thickness at the end of inspiration and expiration using
ultrasonography to view the diaphragm in the zone of apposition. They found that a
difference of 30% or more could predict extubation failure with a sensitivity of 88%
and a specificity of 71%
• 2.5. Oxidative stress markers Oxidative stress is a key mechanism

involved in ventilator induced respiratory muscle dysfunction. Verona
et al. estimated the plasma levels of oxidative stress markers before
and after SBT. They found higher plasma concentration of
malondialdehyde and vitamin C, and lower level of nitric oxide in
plasma were significantly associated with SBT failure
3. Weaning criteria
3. Weaning criteria
3. Weaning criteria
4. Weaning procedure
• 4.1. Planning
• Step1: A weaning plan starts with assessing the ability of the patient for
spontaneous breathing. Three main strategies are used by clinicians to
perform SBT.
• SBT Strategies * T-piece trial, * Continuous positive airway pressure

(CPAP) * Invasive ventilation with low level of pressure support (5-8
cmH2O) or automatic tube compensation.
SBT Duration
• at least 30 minutes and not longer than 120 minutes
• The initial few minutes of the SBT should be monitored closely before
judgment is made to continue the SBT.
Criteria of successful SBT
4. Weaning procedure
• Step 2 :
• If SBT was successful, step 2 would be assessment for airway removal.
• But, if SBT was unsuccessful, the collective task force in 2001 (2)
recommended the following processes as step 2: * Searching for an
underlying cause of respiratory failure andcorrecting it if possible. * Using a
comfortable non-fatiguing form of respiratory support. * Screen every 24
hours for readiness for another SBT.
5. Assessment for extubation
• Extubation failure is defined as reintubation within 48 hours of extubation.
Re-intubation is associated with prolonged hospital and ICU stay and more
tracheostomies.
• It equals number of re-intubated patients divided by total number of

extubated patients. A value too high suggests that weaning is done too
early, and a value too low suggests unnecessary conservative practices.
• a value of 5-20% is generally accepted

Stridor at extubation
• Stridor at extubation occurs due to narrowing of the upper airways.
Cuff leak test has been introduced as a predictor of stridor after
extubation.
• A value of < 110 ml is considered to identify patients at high risk for

stridor after extubation.
• Steroids and/or epinephrine can treat post extubation stridor. It is

also possible to give steroids and/or epinephrine 24 hours before
extubation for patients with low cuff leak value.
• Airway protection capacity
• The ability of the patient to protect his airway from excessive
secretions by effective cough is evaluated.
• . Patients judged to be not capable of protecting their airway
effectively should not be extubated.
• Mental status
• A literature review showed that a Glasgow coma score > 8 was associated
with successful extubation, if airway protection capacity is adequate
The role of non-invasive ventilation (NIV)
• It showed that NIV when used prophylactically in patients

with high risk for extubation failure was associated with
lower risk for re-intubation and ICU mortality. However,
when patients already developed respiratory distress, NIV
didn’t show the same benefits.
The role of high flow nasal cannula (HFNC)
• Modern HFNC devices provide gas flow with a high rate up to

70 Litter/minutr and thus can provide oxygen with a high
FiO2 up to 100%.
• associated with better oxygenation and lower re-intubation

rate.

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Desmame da VM

• It is estimated that 40% of the duration of mechanical ventilation is

• Spontaneous breathing trial (SBT) assesses the patient’s ability to

• Delayed weaning can lead to complications such as ventilator induced

• premature weaning can lead to complications like loss of the airway,

• A combination of subjective and objective criteria is usually used to

• Usually the criteria used are improvement of gas exchange,

• In the present article, we review some of the recent studies about

weaning predictors, criteria, procedure, as well as assessment for

extubation a mechanically ventilated patient.

• need validation in larger groups of patients.

• 2.2. Sleep quality

• Poor quality of sleep may affect the function of the respiratory

• 2.3. Hand grip strength

• 2.4. Diaphragmatic dysfunction

• DiNino et al. assessed diaphragmatic dysfunction by measuring the difference

• 2.5. Oxidative stress markers Oxidative stress is a key mechanism

• SBT Strategies * T-piece trial, * Continuous positive airway pressure

• It equals number of re-intubated patients divided by total number of

• a value of 5-20% is generally accepted

• A value of < 110 ml is considered to identify patients at high risk for

• Steroids and/or epinephrine can treat post extubation stridor. It is

• It showed that NIV when used prophylactically in patients

• Modern HFNC devices provide gas flow with a high rate up to

• associated with better oxygenation and lower re-intubation

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