2. Weaning from mechanical ventilation.
Three groups
• 1) Simple Weaning (first trial)
– Early detection
• 2) Difficult Weaning (more than 1 attempt, up to one
week)
– Reasons for failure
• 3) Prolonged Weaning (more than 1 week or than
three attemps)
– Global management
Boles JM. ERJ 2007
6. 476 Participating centers (50 countries)
0
10
20
30
40
50
60
I
t
a
l
y
U
K
C
h
i
n
a
U
S
A
T
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r
k
e
y
A
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s
t
r
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I
n
d
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M
e
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i
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o
T
h
a
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n
d
S
w
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d
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n
C
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a
G
r
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c
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P
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d
B
e
l
g
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m
H
u
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g
a
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y
S
u
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R
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m
a
n
y
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n
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i
a
B
a
n
g
l
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h
B
o
s
n
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-
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S
l
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n
i
a
54%
8%
13%
19%
4%
2%
Centers
(N)
Preliminary Data
8. Days from 1st SA to end of MV
Group 1
Group 2
Group 3
Preliminary Data
9. Application of WIND classification
Discharge alive
from Study Hospital
Discharge alive
from Study ICU
Group
6180
patients
Group 0
N=1531
25%
Group 1
N=3229
52%
N=2978
92%
N=2718
85%
Group 2
N=650
11%
N=453
70%
N=402
62%
Group 3
N=766
12%
N=570
75%
N=491
65%
Preliminary Data
10. Mode of MV at First Separation Attempt
0
200
400
600
800
1000
1200
1400
1600
1800
2000
P
S
V
V
A
C
P
C
/
B
I
P
A
P
/
A
P
R
V
C
P
A
P
S
I
M
V
P
R
V
C
O
t
h
e
r
P
A
V
/
N
A
V
A
45%
13% 11%
5% 2% 0.5%
Preliminary Data
13% 11%
11. Ely E.W. et coll. N Engl J Med 1996; 335: 1864-9
• Intervention Group
1) A daily screening of
respiratory function
(by the respiratory
therapists of the unit)
Ø PaO2/FIO2 > 200
Ø PEEP< 5 cm H2O
Ø Adequate cough
Ø f/VT < 105 c/min
Ø No vasopressor
agents or sedatives
2) A 2-hour trial of
spontaneous
breathing
3) Notification of the
physician of the
successful results
Identifying patients capable of breathing spontaneously
and duration of mechanical ventilation
Patients
Receiving
Mechanical
Ventilation
(%)
Days after Succesful Screening
SIMV
14. 0
2
4
6
8
10
12
14
16
18
0:00 0:28 0:57 1:26 1:55 2:24 2:52
PS
level
cmH2O)
Time (h:min)
Observation
Maintain
Adaptation
PS min
E
X
T
U
B
A
T
I
O
N
Reduction of
!PSV
Message:
« separation from ventilator »
PEEP £ 5 cmH2O
Weaning with «SmartCare »
19. Question 1
• The rapid shallow breathing index:
A. Is best measured after 1-2 minutes of unassisted breathing
B. Can be measured after 1-2 minutes on low pressure support
ventilation SBT
C. Can be re-measured after 15-20 minutes of low pressure
support ventilation
D. A value at 65 breaths/min/L indicates that the patient can be
extubated
E. A value at 250 breaths/min/L indicates that the SBT should be
of short duration (30 min)
F. None of the above
21. Straus C, et al. AJRCCM 1998;157:23-30
Total
E
R
22. Mahul et al Crit Care in revision
Spontaneous breathing trial and post-extubation work of breathing in
morbidly obese critically ill patients
23. Physiological Measures of Patient Respiratory Effort Among
Different Spontaneous Breathing Trial Techniques: A Systematic
Review and Physiological Meta-Analysis
Sklar M et al submitted
0.4
0.6
0.8
1.0
1.2
1.4
P
S
V
v
s
.
E
x
t
u
b
a
t
i
o
n
P
S
V
v
s
.
T
-
P
i
e
c
e
P
S
V
v
s
.
P
S
V
/
C
P
A
P
0
P
S
V
v
s
.
C
P
A
P
C
P
A
P
v
s
.
E
x
t
u
b
a
t
i
o
n
C
P
A
P
v
s
.
T
-
P
i
e
c
e
C
P
A
P
v
s
.
P
S
V
/
C
P
A
P
0
P
S
V
0
/
C
P
A
P
0
v
s
.
E
x
t
u
b
a
t
i
o
n
P
S
V
0
/
C
P
A
P
0
v
s
.
T
-
P
i
e
c
e
T
-
P
i
e
c
e
v
s
.
E
x
t
u
b
a
t
i
o
n
Ratio
of
means
(95%
CI)
Measurement
WOB
PTP
RSBI
n=239
24. n Failure,
2hr
Ext Reint Succ Ext,
48hr
2 hr
T-piece
246 22%
(54/246)
192 36 63%
(156/246)
2 hr
PSV 7
238 14%
(33/238)
205 38 70%
(167/238)
P 0.03 ns ns ns
Esteban A, et al. AJRCCM 1997;156:459-65
TEST: T-piece or PSV?
25.
26. Question 2
• The work of breathing during a SBT can be influenced
by:
A. The level of sedation
B. The fluid status of the patient
C. The amount of secretions
D. The type of SBT technique
E. None of the above
F. All of the above
30. Question 3
• A majority of the patients in the ICU:
A. Will take 3 to 7 days to be separated from the vent after the first
attempt
B. Can be extubated safely without SBT
C. Have a high probability of successful liberation
D. Will be at risk of reintubation
E. None of the above
