The Difficult-to-wean Patient

Nicolino Ambrosino; Luciano Gabbrielli

Expert Rev Resp Med. 2010;4(5):685-692.

Where to Treat the Difficult-to-wean Patient

It has been claimed that ICUs are expensive resources^[2] and probably lack the necessary focus, personnel and organization to care for difficult-to-wean patients.^[13,14] Therefore, alternative solutions have been investigated. Two types of units have been proposed as solutions to the problem of the inappropriate use of ICUs:^[27]

Respiratory intermediate care units (RICUs) within acute care hospitals manage patients with ARF or ACRF with noninvasive ventilation, resulting in a significant reduction in ICU admissions and need for invasive MV,^[3,4] with an adequate level of assistance, which is less costly than in a ICU. These units may also provide multidisciplinary rehabilitation^[28] and serve as a bridge to home care programs or long-term care facilities.^[29] Some of these RICUs may work also as 'step-down' units for difficult-to-wean patients;^[30,31]
Specialized regional weaning centers (WCs), often located within rehabilitation hospitals, treat difficult-to-wean patients transferred from several acute care hospitals. Dedicated WCs offer specialized teams (e.g., nurses, respiratory therapists, nutritionists, psychologists and speech therapists) and also relieve pressure on scarce ICU beds at a lower costs. Variable mortality and weaning success rate have been reported.^{[9–11,31–33]}

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Cite this: The Difficult-to-wean Patient - Medscape - Oct 01, 2010.

Abstract and Introduction
Definition of difficult-to-wean Patient
Causes of Prolonged MV
Clinical Consequences of Prolonged MV
Where to Treat the Difficult-to-wean Patient
How to Manage these Patients
Outcome
Costs
Expert Commentary
Five-year View
References
Sidebar

Box 1. Factors associated with prolonged weaning.
Systemic Chronic diseases, comorbidities, nutrition and metabolic disturbances Severity of illness Impaired cardiovascular performance Left ventricular dysfunction, myocardial ischemia and cardiomyopathy Neurologic Critical illness neuromuscular abnormalities Respiratory Unresolved causes of respiratory failure Imbalance between work of breathing and respiratory muscle capacity Upper airway obstruction Treatment complications Ventilator-associated pneumonitis and infections Barotrauma Tracheostomy Sedation Cognitive Delirium, depression and anxiety Sleep deprivation Treatment setting Weaning protocols Staffing Staff training

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The Difficult-to-wean Patient

Where to Treat the Difficult-to-wean Patient

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