The Difficult-to-Wean Patient

How to Manage these Patients

Weaning Protocols

Difficult-to-wean patients usually undergo two weaning protocols,^[9] namely either a strategy of progressive reduction of level of assistance, such as pressure support ventilation,^[34] or progressively longer periods of SBT.^[35] Intermittent mandatory ventilation has been proved to be less effective than pressure support ventilation or SBT.^[35,36] Indeed, no significant difference in weaning success and mortality rate, duration of ventilatory assistance, WC or total hospital LOS was reported between these two weaning techniques in difficult-to-wean patients,^[9] although there is some evidence of a reduction in the duration of MV, weaning duration and LOS with the use of standardized protocols, both in the ICU and in the RICU.^[9,37,38] The usefulness of noninvasive ventilation in shortening the weaning time in 'acute weaning' is well defined, whereas similar evidence is lacking in difficult-to-wean patients.^[39] In our practice, we usually adopt progressive reduction of ventilatory support and, less frequently, progressively longer periods of SBT according to previously described protocols.^[9] On occasion we use a combination of both methods on an empirical basis.

Early Physiotherapy

An important component of the weaning protocols is the availability of physiotherapy. The early mobilization of critically ill patients is a relatively new management approach advocated to address ARF and reduce the disability associated with ICU-acquired weakness.^[40] This therapeutic approach has been reported in clinical studies and is recommended by the ERS and the European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.^[41] It has been demonstrated that early physiotherapy results in benefits in critical patients in the ICU.^[42–48] On the basis of these reports, the ERS Task Force suggests that efforts to prevent or treat respiratory muscle weakness might have a role in reducing weaning failure through appropriate implementation of physiotherapy in the ICU or transferring patients to dedicated units.^{[13,41,49,50]} In our practice, we use physiotherapy protocols as previously described.^[46]

Enteral Nutrition

Weaning from artificial nutritional intake with the subsequent possibility to eat is an essential rehabilitative outcome in severe tracheostomized difficult-to-wean chronic obstructive pulmonary disease (COPD) patients who may undergo different weaning protocols.^[18] In tracheostomized difficult-to-wean spontaneously breathing COPD patients, meals may induce an increase in respiratory rate, end-tidal carbon dioxide and dyspnea. Inspiratory pressure support ventilation may prevent dyspnea from worsening during meals.^[51]

Percutaneous endoscopic gastrostomy (PEG) as a measure of enteral tube feeding has gained wide acceptance, and it is currently the preferred method for providing enteral nutrition in long-term settings with the aim to prevent the most serious complications. Short-term studies have demonstrated the advantages of PEG as compared with the nasogastric tube feeding in patients with dysphagia due to chronic neurological diseases. PEG insertion is a quick procedure that is generally well tolerated by patients and a relatively low complication rate in the outcome has been described.^[18]

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

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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