S2k-Guideline “Prolonged Weaning”

B. Schönhofer; J. Geiseler; D. Dellweg; O. Moerer; T. Barchfeld; H. Fuchs; O. Karg; S. Rosseau; H. Sitter; S. Weber-Carstens; M. Westhoff; W. Windisch

doi:10.1055/s-0034-1392809

Pneumologie 2015; 69(10): 595-607
DOI: 10.1055/s-0034-1392809

Guideline

S2k-Guideline “Prolonged Weaning”^[*]

Published by German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP)S2k-Leitlinie „Prolongiertes Weaning“Herausgegeben von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP)

Autoren

B. Schönhofer

¹Prof. Dr. Bernd Schönhofer, Pneumologie, Internistische Intensivmedizin und Schlafmedizin KRH Klinikum Siloah-Oststadt-Heidehaus, Stadionbrücke 4, 30459 Hannover; E-Mail: Bernd.Schoenhofer@t-online.de
J. Geiseler

²Dr. Jens Geiseler, Asklepios Fachkliniken München-Gauting, Klinik für Intensiv-, Schlaf- und Beatmungsmedizin, Robert-Koch-Allee 2, 82131 Gauting; E-Mail: j.geiseler@asklepios.com
D. Dellweg

³PD Dr. Dominic Dellweg, Fachkrankenhaus Kloster Grafschaft, Annostraße 1, 57392 Schmallenberg; E-Mail: d.dellweg@fkkg.de
O. Moerer

⁴Prof. Dr. Onnen Moerer, Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Robert-Koch Straße 40, 37075 Göttingen; E-Mail: omoerer@gwdg.de
T. Barchfeld

⁵Dr. Thomas Barchfeld, Klinikum Westfalen GmbH, Knappschaftskrankenhaus Dortmund, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Am Knappschaftskrankenhaus 1, 44309 Dortmund; E-Mail: thomas.barchfeld@klinikum-westfalen.de
H. Fuchs

⁶Dr. Hans Fuchs, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Freiburg, Mathildenstraße 1, 79106 Freiburg; E-Mail: hans.fuchs@uniklinik-freiburg.de
O. Karg

⁷Dr. Ortrud Karg, Asklepios Fachkliniken München-Gauting, Leitung Medizinische Krankenhausorganisation, Robert-Koch-Allee 2, 82131 Gauting; E-Mail: o.karg@t-online.de
S. Rosseau

⁸Dr. Simone Rosseau, Charité Universitätsmedizin Berlin, Charité – Campus Mitte, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Charitéplatz 1, 10117 Berlin; E-Mail: simone.rosseau@charite.de
H. Sitter

⁹PD Dr. Helmut Sitter, Philips-Universität Marburg, Institut für Chirurgische Forschung, Baldingerstraße, 35033 Marburg; E-Mail: sitter@med.uni-marburg.de
S. Weber-Carstens

¹⁰PD Dr. Steffen Weber-Carstens, Charité Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin; E-Mail: Steffen.Weber-Carstens@charite.de
M. Westhoff

¹¹Dr. Michael Westhoff, Lungenklinik Hemer, Klinik Pneumologie I, Theo-Funccius-Straße 1, 58675 Hemer; E-Mail: michaelwesthoff.mail@t-online.de
W. Windisch

¹²Prof. Dr. Wolfram Windisch, Kliniken der Stadt Köln gGmbH, Abteilung Pneumologie, Ostmerheimer Straße 200, 51109 Köln; E-Mail: WindischW@kliniken-koeln.de

Abstract

All mechanically ventilated patients must be weaned from the ventilator at some stage. According to an International Consensus Conference the criteria for “prolonged weaning” are fulfilled if patients fail at least 3 weaning attempts (i. e. spontaneous breathing trial, SBT) or require more than 7 days of weaning after the first SBT. This occurs in about 15 – 20 % of patients.

Because of the growing number of patients requiring prolonged weaning a German guideline on prolonged weaning has been developed. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies (see acknowledgement) engaged in the field chaired by the Association of Scientific and Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).

This guideline deals with the definition, epidemiology, weaning categories, underlying pathophysiology, therapeutic strategies, the weaning unit, transition to out-of-hospital ventilation and therapeutic recommendations for end of life care.

This short version summarises recommendations on prolonged weaning from the German guideline.

Zusammenfassung

Die Entwöhnung von der maschinellen Beatmung (Weaning) umfasst einen wesentlichen Teil der gesamten Beatmungszeit. Dabei kommt es bei ca. 15 – 20 % der Patienten zu einem prolongierten Weaning, das nach internationaler Vereinbarung dann angenommen wird, wenn das Weaning erst nach drei erfolglosen Spontanatmungsversuchen (Spontaneous Breathing Trial = SBT) oder nach über 7 Tagen Beatmung nach dem ersten erfolglosen SBT gelingt. Auf Initiative der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. (DGP) gemeinsam mit anderen wissenschaftlichen Gesellschaften und unter der Moderation der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) e.V. wurde der aktuelle Wissensstand zum Thema „Prolongiertes Weaning“ in einer S2k-Leitlinie zusammengefasst. In dieser Leitlinie werden Definitionen, Epidemiologie und Weaningkategorien, die zugrunde liegende Pathophysiologie, die verfügbaren Therapiestrategien, die Weaningeinheit, die Überleitung in eine außerklinische Beatmung und schließlich Empfehlungen zu Therapieentscheidungen am Ende des Lebens bei prolon- giertem bzw. erfolglosem Weaning abgehandelt. Die Besonderheiten bei pädiatrischen Patienten werden innerhalb der einzelnen Kapitel jeweils gesondert behandelt. In der vorliegenden Kurzfassung werden die wesentlichen Aspekte und Empfehlungen dieser Leitlinie zum prolongierten Weaning vorgestellt.

Volltext

Referenzen

References
1 Schönhofer B, Geiseler J, Dellweg D et al. Prolonged weaning: S2k-guideline published by the German Respiratory Society. Pneumologie 2014; 68: 19-75
2 Boles JM, Bion J, Connors A et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29: 1033-1056
3 Funk GC, Anders S, Breyer MK et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 2010; 35: 88-94
4 Esteban A, Alia I, Gordo F et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1997; (2 Pt 1) 156: 459-465
5 Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324: 1445-1450
6 Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 1997; 155: 906-915
7 Laghi F, Cattapan SE, Jubran A et al. Is weaning failure caused by low-frequency fatigue of the diaphragm?. Am J Respir Crit Care Med 2003; 167: 120-127
8 Beuret P, Roux C, Auclair A et al. Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med 2009; 35: 1090-1093
9 Jaber S, Chanques G, Matecki S et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29: 69-74
10 De Bast Y, De Backer D, Moraine JJ et al. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002; 28: 1267-1272
11 Krishnan JA, Moore D, Robeson C et al. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med 2004; 169: 673-678
12 Tobin MJ. Principles and practice of mechanical ventilation. New York: McGraw-Hill Inc; 1994
13 Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med 2008; 34: 7-16
14 Brochard L, Harf A, Lorino H et al. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis 1989; 139: 513-521
15 Nava S, Bruschi C, Rubini F et al. Respiratory response and inspiratory effort during pressure support ventilation in COPD patients. Intensive Care Med 1995; 21: 871-879
16 Imsand C, Feihl F, Perret C et al. Regulation of inspiratory neuromuscular output during synchronized intermittent mechanical ventilation. Anesthesiology 1994; 80: 13-22
17 Kumar PD, Rainey J, Kotton B. Tracheoesophageal fistula and massive pneumoperitoneum after prolonged mechanical ventilation. South Med J 2001; 94: 1027-1029
18 Hewitt MS, Garland DE, Ayyoub Z. Heterotopic ossification complicating prolonged intubation: case report and review of the literature. J Spinal Cord Med 2002; 25: 46-49
19 Holzapfel L, Chevret S, Madinier G et al. Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial. Crit Care Med 1993; 21: 1132-1138
20 Nordin U. The trachea and cuff-induced tracheal injury. An experimental study on causative factors and prevention. Acta Otolaryngol Suppl 1977; 345: 1-71
21 Rumbak MJ, Newton M, Truncale T et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004; 32: 1689-1694
22 Blot F, Similowski T, Trouillet JL et al. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 2008; 34: 1779-1787
23 Young D, Harrison DA, Cuthbertson BH et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013; 309: 2121-2129
24 Dulguerov P, Gysin C, Perneger TV et al. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999; 27: 1617-1625
25 Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006; 10: R55
26 Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope 2007; 117: 447-454
27 Ceriana P, Carlucci A, Navalesi P et al. Physiological responses during a T-piece weaning trial with a deflated tube. Intensive Care Med 2006; 32: 1399-1403
28 Dellweg D, Barchfeld T, Haidl P et al. Tracheostomy decannulation: implication on respiratory mechanics. Head Neck 2007; 29: 1121-1127
29 Plant PK, Owen JL, Elliott MW. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001; 56: 708-712
30 Elliott MW. Non-invasive ventilation for acute respiratory disease. Br Med Bull 2004; 72: 83-97
31 Schonhofer B, Euteneuer S, Nava S et al. Survival of mechanically ventilated patients admitted to a specialised weaning centre. Intensive Care Med 2002; 28: 908-916
32 Pilcher DV, Bailey MJ, Treacher DF et al. Outcomes, cost and long term survival of patients referred to a regional weaning centre. Thorax 2005; 60: 187-192
33 Schonhofer B, Bohrer H, Kohler D. Blood transfusion facilitating difficult weaning from the ventilator. Anaesthesia 1998; 53: 181-184
34 Hebert PC, Wells G, Blajchman MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340: 409-417
35 Hendrickson JE, Hillyer CD. Noninfectious serious hazards of transfusion. Anesth Analg 2009; 108: 759-769
36 Taylor RW, O'Brien J, Trottier SJ et al. Red blood cell transfusions and nosocomial infections in critically ill patients. Crit Care Med 2006; 34: 2302-2308 quiz 2309
37 Cahill NE, Dhaliwal R, Day AG et al. Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med 2010; 38: 395-401
38 McClave SA, Martindale RG, Vanek VW et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009; 33: 277-316
39 Ceriana P, Fanfulla F, Mazzacane F et al. Delirium in patients admitted to a step-down unit: analysis of incidence and risk factors. J Crit Care 2010; 25: 136-143
40 Maffiuletti NA. Physiological and methodological considerations for the use of neuromuscular electrical stimulation. Eur J Appl Physiol 2010; 110: 223-234
41 Gerovasili V, Stefanidis K, Vitzilaios K et al. Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized study. Crit Care 2009; 13: R161
42 Chiang LL, Wang LY, Wu CP et al. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther 2006; 86: 1271-1281
43 Gosselink R, Bott J, Johnson M et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34: 1188-1199
44 Clini EM, Antoni FD, Vitacca M et al. Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2006; 32: 1994-2001
45 Hiss SG, Postma GN. Fiberoptic endoscopic evaluation of swallowing. Laryngoscope 2003; 113: 1386-1393
46 Schonhofer B, Barchfeld T, Haidl P et al. Scintigraphy for evaluating early aspiration after oral feeding in patients receiving prolonged ventilation via tracheostomy. Intensive Care Med 1999; 25: 311-314
47 Windisch W, Brambring J, Budweiser S et al. Non-invasive and invasive mechanical ventilation for treatment of chronic respiratory failure. S2-Guidelines published by the German Medical Association of Pneumology and Ventilatory Support. Pneumologie 2010; 64: 207-240
48 Randerath WJ, Kamps N, Brambring J et al. Recommendations for invasive home mechanical ventilation. Pneumologie 2011; 65: 72-88
49 Lindsay ME, Bijwadia JS, Schauer WW et al. Shifting care of chronic ventilator-dependent patients from the intensive care unit to the nursing home. Jt Comm J Qual Saf 2004; 30: 257-265
50 McKim DA, Road J, Avendano M et al. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18: 197-215
51 Bigatello LM, Stelfox HT, Berra L et al. Outcome of patients undergoing prolonged mechanical ventilation after critical illness. Crit Care Med 2007; 35: 2491-2497
52 Cook D, Rocker G, Marshall J et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 2003; 349: 1123-1132
53 Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med 2000; 28: 3920-3924
54 Nava S, Sturani C, Hartl S et al. End-of-life decision-making in respiratory intermediate care units: a European survey. Eur Respir J 2007; 30: 156-164
55 Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. Crit Care Med 1999; 27: 73-77
56 Kirchhoff KT, Anumandla PR, Foth KT et al. Documentation on withdrawal of life support in adult patients in the intensive care unit. Am J Crit Care 2004; 13: 328-334
57 Schonhofer B, Berndt C, Achtzehn U et al. Weaning from mechanical ventilation. A survey of the situation in pneumologic respiratory facilities in Germany. Dtsch Med Wochenschr 2008; 133: 700-704

S2k-Guideline “Prolonged Weaning”[*]

Autoren

S2k-Guideline “Prolonged Weaning”^[*]