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[Factors determining the successful weaning of patients with "difficult weaning"]
F Rubini1, E Zanotti, P Brigada
1Divisione di Pneumologia, Fondazione S. Maugeri, Istituto di Riabilitazione di Montescano, Pavia.
Objective:
Weaning from mechanical ventilation is often possible in the most of patients, even if sometimes it is very difficult. For example, 25-53% of COPD patients cannot be weaned. The different modalities used do not justify this. The aim of the study was the evaluation of a further weaning trial in tracheotomized patients who underwent mechanical ventilation for at least 15 days in several ICU and in whom several attempts of weaning failed.
Design:
A retrospective study (January 1993-February 1995).
Setting:
Intermediate Intensive Respiratory Care Unit of Centro Medico Di Montescano.
Patients:
Thirty-nine patients (29 male; 26 COPD, 3 post-surgery respiratory failure, 5 restrictive diseases, 4 with cardiovascular failure and 1 neurological disease) who had been tracheotomized and undergoing mechanical ventilation from at least 15 days. An initial evaluation in which respiratory mechanics and echocardiography were performed was made and then they underwent further weaning trials based on progressive decrease of the level of pressure support and periodic disconnection from MV and on medical therapy and strong physiokinesitherapy.
Results:
Twenty-six out of 39 patients (66%) could reach definitive weaning (COPD 65%, post-surgery respiratory failure 66%, restrictive 60%, cardiovascular failure 100%, neurological disease 0%) after 17 days of average time of ventilation (range from 4 to 90). Among the important factors in determining a difficult or impossible weaning there are: a) previous wrong ventilation settings 8/26; b) cardiovascular problems 7/26; c) alterations in respiratory mechanics 2/26; d) previous excessive sedation 2/26; e) uncorrect timing of disconnection 2/26; f) poor physiokinesitherapy 2/26; g) unknown causes 3/26. Also the ICU from which the patients has been transferred plays an important role.
Conclusions:
The conclusion is drawn weaning from mechanical ventilation can be reached also in a part of those patients who are thought not weanable with a further, prolonged and expensive weaning trial.