Prolonged Mechanical Ventilator Weaning: Experience from Ontario

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1 Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto Director of Research, Provincial Centre of Weaning Excellence, Toronto East General Hospital

2 Prolonged Mechanical Ventilator Weaning: Experience from Ontario Louise Rose Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto Director of Research, Provincial Centre of Weaning Excellence, Toronto East General Hospital

3 Simple weaning Wean to extubation on first attempt Difficult weaning Fail initial weaning and require up to 3 SBTs or 7 days from first SBT Prolonged weaning Fail > 3 weaning SBTs and > 7 days weaning from first SBT Boles et al. (2007) Eur Respir J. 29:

4 Weaning in the PMV patient should be slow-paced and individualized include gradually lengthening TM trials non-fatiguing comfortable ventilatory support between TM trials 3

5 3 weaning units Inclusion: COPD 15d vent Failed T-piece trial Intervention PSV or SBTs 4

6 3 weaning units Inclusion: COPD 15d vent Failed T-piece trial Intervention PSV or SBTs N = ± 161 (PSV) vs 130 ± 106 h (SB) = NS 4

7 Weaning Method Esteban et al N Engl J Med; 332, Brochard et al Am J Respir Crit Care Med; 150,

8 6

9 Weaning Duration 2011 by British Medical Journal Publishing Group Blackwood B et al. BMJ 2011;342:bmj.c7237

10 Weaning Duration 2011 by British Medical Journal Publishing Group Blackwood B et al. BMJ 2011;342:bmj.c7237

11 Weaning Duration 2011 by British Medical Journal Publishing Group Blackwood B et al. BMJ 2011;342:bmj.c7237

12 TIPS protocol - Barlow Respiratory Hospital. Scheinhorn D J et al. Chest 2001;119:

13 Scheinhorn D J et al. Chest 2001;119: N = 252 TIPS, 238 HC 29 to 17 days (p < 0.001) 2001 by American College of Chest Physicians

14

15 PMV: Reported Weaning success 25.6% to 80.7% Ventilator dependence 3.1% to 67.5% Mortality 4.5% to 50.4% One-year survival 23.0% to 69.0% Discharged home 0.8% to 80.0% Review of 40 international studies Rose et al. (2009) ICM 35: (Suppl 1): S186

16 Chronic Ventilation Strategy Taskforce, Final Report - June 2006

17 Provincial Centre of Excellence n Prolonged-Ventilation Weaning 8-bed specialized centre for adult GTA ICU patients: 21 days MV in ICU clinical team considers patient weanable within 90 days patient able to participate in care decisions patient medically stable defined as: sepsis treated and controlled (if applicable) hemodynamically stable no new onset complex arrhythmias, or acute coronary syndrome renal function stable adequate oxygenation tracheostomy in situ; and adequate nutrition support protocol

18 Who we are not.. Patients with ongoing need for a ventilator but have: clearly irreversible disease such as high spinal cord injury progressive neuromuscular disease or advanced dementia

19 What we do... Patients stay for maximum of 12 weeks Individualized weaning program progressive trach mask trials Individualized PT program aim to mobilize early Optimize nutritional status SLP assessments for communication and swallowing Manage anxiety and other psychological/social issues

20

21 Who are our patients.. All Patients Jan 2004 to Mar 2011 n = 144 Invasive ventilation 115 (80%) Non-invasive ventilation 11 (8%) Trach mask 18 (12%)

22 Who are our patients.. All Patients Jan 2004 to Mar 2011 n = (58%) patients admitted from other ICUs 60 (42%) patients from TEGH ICU Invasive ventilation 115 (80%) Non-invasive ventilation 11 (8%) Trach mask 18 (12%)

23 Who are our patients..

24 Who are our patients.. ICU LOS prior to admission 56 (39-90) days

25 Outcomes..

26 Outcomes.. Median (IQR) LOS 64 (35-109) days

27 Outcomes

28 Outcomes ICU HDU/Floor Rehab Home LTMV Nursing home

29 Long-term Outcomes 43/91 (47%) survived to 1 year 27/78 (35%) to 2 years 19/53 (36%) to 3 years 7/22 (32%) to 5 years

30 Long-term Outcomes 43/91 (47%) survived to 1 year 27/78 (35%) to 2 years 19/53 (36%) to 3 years 7/22 (32%) to 5 years

31 Long-term Outcomes 25 participants Mean time from dx 2.1 ± 1.4 yrs 9% IES-R >33 35% HADS anxiety >11 13% HADS depression >11 Mean SF-36 50±22 SRI summary scale 62±15

32 126 patients with tracheostomy 103 survivors had 457 transitions in postdischarge care 67% readmitted 44% dead 1 year 9% alive/functional $3.5 million per one-year independent survivor Unroe et al. (2010). Ann Intern Med. 153;

33

34 Thank you for your attention Questions?

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