Respiratorentwöhnung – Definition und klinischer Kontext aus Sicht der Pädiatrie

Zusammenfassung

Trotz der Wichtigkeit ist standardisiertes Weaning in der Pädiatrie ein bisher zu wenig beachteter Aspekt pädiatrischer klinischer Intensivtherapie und Forschung. Erste mäßige Evidenz aus einzelnen Studien für Verbesserung des Weaningerfolgs besteht für die tägliche Evaluation der Weaningfähigkeit, für die Verwendung von Sedierungsprotokollen, für das tägliche Unterbrechen von Sedierung nach Abschluss der Akutphase, für den Einsatz von nicht invasiver Beatmung bei zu erwartendem schwierigenWeaning sowie für die Gabe von Steroiden zur Prophylaxe von Postextubationsstridor bei Risikopatienten. Aufgrund der in der pädiatrischen Intensivmedizin sehr unterschiedlichen Patientengruppen ist jedoch auch in diesen Punkten eine Generalisierung der Daten erschwert.

Timely weaning from invasive ventilation is of major importance to limit time of invasive ventilation and improve outcomes. However, in pediatrics only limited knowledge on the optimal weaning approach is available. In this review evidence from recent trials on weaning in pediatrics is summarized. Standardized daily evaluation of weaning readiness, daily interruption of sedation, use of pediatric sedation protocols, application of noninvasive ventilation and prophylactic treatment with steroids of patients with high risk for postextubation upper airway obstruction have been shown to decrease duration of invasive ventilation or to decrease the risk of extubation failure. However, due to the heterogeneous patient population in pediatric intensive care units, an individual approach might be necessary for certain subgroups of pediatric patients.

Kernaussagen

• Die standardisierte tägliche Evaluation von Beatmungs- und Vitalparametern mit dem Ziel Weaningfähigkeit festzulegen, verkürzt Beatmungszeiten.

• Der Entwöhnmodus hatte bei Kindern keinen Einfluss auf die Dauer der Beatmung.

• Sedierungsprotokolle sollten auch bei Kindern angewendet werden, um die Tiefe der Sedierung zu steuern.

• Tägliches Unterbrechen der Sedierung jenseits der Akutphase einer Beatmungstherapie reduzierte die Beatmungsdauer von Kindern.

• Bei der Anwendung von Propofol müssen aufgrund eines bei Kindern häufigeren Auftretens des Propofolinfusionssyndroms die Anwendungsbeschränkungen und die max. Dosisempfehlungen dringend beachtet werden.

• Die frühzeitige Tracheotomie ist bei Kindern aus verschiedenen Gründen nicht üblich.

• Die Anwendung eines Spontanatemversuchs vor Extubation ist im Kindesalter umstritten.

• Bei hohem Risiko für Postextubationsstridor ist eine prophylaktische Steroidgabe 6–24 h vor Extubation sinnvoll.

• Nicht invasive Beatmung nach Extubation ist auch bei Kindern machbar und sinnvoll, um das Risiko des Extubationsversagens zu vermindern.

Schlüsselwörter:

Exubation - Kinder - Weaning - Entwöhnung - Stridor - Sedierung - Beatmung - Pädiatrie

Key words:

Extubation - Child - Weaning - Stridor - Sedation - Ventilation - Pediatrics

• Literatur

• 1 Khemani RG, Markovitz BP, Curley MA. Characteristics of children intubated and mechanically ventilated in 16 PICUs. Chest 2009; 136: 765-771
• 2 Farias JA, Frutos F, Esteban A et al. What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study. Intensive Care Med 2004; 30: 918-925
• 3 Wolfler A, Calderoni E, Ottonello G et al. Daily practice of mechanical ventilation in Italian pediatric intensive care units: a prospective survey. Pediatr Crit Care Med 2011; 12: 141-146
• 4 Monteverde E, Fernandez A, Poterala R et al. Characterization of pediatric patients receiving prolonged mechanical ventilation. Pediatr Crit Care Med 2011; 12
• 5 Boles JM, Bion J, Connors A et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29: 1033-1056
• 6 Little LA, Koenig Jr. JC, Newth CJ. Factors affecting accidental extubations in neonatal and pediatric intensive care patients. Crit Care Med 1990; 18: 163-165
• 7 Kurachek SC, Newth CJ, Quasney MW et al. Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 2003; 31: 2657-2664
• 8 Foronda FK, Troster EJ, Farias JA et al. The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. Crit Care Med 2011; 39: 2526-2533
• 9 Randolph AG, Wypij D, Venkataraman ST et al. Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 2002; 288: 2561-2568
• 10 Twite MD. Is there a „right“ way to wean my patient from the ventilator? A critical appraisal of Randolph et al: Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: A randomized controlled trial (JAMA 2002; 288: 2561–2568). Pediatr Crit Care Med 2006; 7: 571-575
• 11 Bach JR, Niranjan V, Weaver B. Spinal muscular atrophy type 1: A noninvasive respiratory management approach. Chest 2000; 117: 1100-1105
• 12 Newth CJ, Venkataraman S, Willson DF et al. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009; 10: 1-11
• 13 deMoraes MA, Bonatto RC, Carpi MF et al. Comparison between intermittent mandatory ventilation and synchronized intermittent mandatory ventilation with pressure support in children. J Pediatr (Rio J) 2009; 85: 15-20
• 14 Curley MA, Harris SK, Fraser KA et al. State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med 2006; 7: 107-114
• 15 Franck LS, Harris SK, Soetenga DJ et al. The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med 2008; 9: 573-580
• 16 Amigoni A, Mozzo E, Brugnaro L et al. Assessing sedation in a pediatric intensive care unit using Comfort Behavioural Scale and Bispectral Index: these tools are different. Minerva Anestesiol 2012; 78: 322-329
• 17 Deeter KH, King MA, Ridling D et al. Successful implementation of a pediatric sedation protocol for mechanically ventilated patients. Crit Care Med 2011; 39: 683-688
• 18 Alexander E, Carnevale FA, Razack S. Evaluation of a sedation protocol for intubated critically ill children. Intensive Crit Care Nurs 2002; 18: 292-301
• 19 Gupta K, Gupta VK, Muralindharan J, Singhi S. Randomized controlled trial of interrupted versus continuous sedative infusions in ventilated children. Pediatr Crit Care Med 2012; 13: 131-135
• 20 Teng SN, Kaufman J, Czaja AS et al. Propofol as a bridge to extubation for high-risk children with congenital cardiac disease. Cardiol Young 2011; 21: 46-51
• 21 Arzneimittelkommission der deutschen Ärzteschaft. Mitteilungen: Schwere unerwünschte Arzneimittelnebenwirkungen nach Propofol-Infusionen zur Sedierung. Deutsches Ärzteblatt 2004; 101: 2759-2759
• 22 Farias JA, Retta A, Alia I et al. A comparison of two methods to perform a breathing trial before extubation in pediatric intensive care patients. Intensive Care Med 2001; 27: 1649-1654
• 23 Farias JA, Alia I, Retta A et al. An evaluation of extubation failure predictors in mechanically ventilated infants and children. Intensive Care Med 2002; 28: 752-757
• 24 Chavez A, de la Cruz R, Zaritsky A. Spontaneous breathing trial predicts successful extubation in infants and children. Pediatr Crit Care Med 2006; 7: 324-328
• 25 Baumeister BL, el-Khatib M, Smith PG, Blumer JL. Evaluation of predictors of weaning from mechanical ventilation in pediatric patients. Pediatr Pulmonol 1997; 24: 344-352
• 26 Thiagarajan RR, Bratton SL, Martin LD et al. Predictors of successful extubation in children. Am J Respir Crit Care Med 1999; 160: 1562-1566
• 27 Venkataraman ST, Khan N, Brown A. Validation of predictors of extubation success and failure in mechanically ventilated infants and children. Crit Care Med 2000; 28: 2991-2996
• 28 Khan N, Brown A, Venkataraman ST. Predictors of extubation success and failure in mechanically ventilated infants and children. Crit Care Med 1996; 24: 1568-1579
• 29 Manczur TI, Greenough A, Pryor D, Rafferty GF. Comparison of predictors of extubation from mechanical ventilation in children. Pediatr Crit Care Med 2000; 1: 28-32
• 30 Noizet O, Leclerc F, Sadik A et al. Does taking endurance into account improve the prediction of weaning outcome in mechanically ventilated children?. Crit Care 2005; 9
• 31 Harikumar G, Egberongbe Y, Nadel S et al. Tension-timeindex as a predictor of extubation outcome in ventilated children. Am J Respir Crit Care Med 2009; 180: 982-988
• 32 Riou Y, Chaari W, Leteurtre S, Leclerc F. Predictive value of the physiological deadspace / tidal volume ratio in the weaning process of mechanical ventilation in children. J Pediatr (Rio J ) 2012; 88: 217-221
• 33 Ferguson LP, Walsh BK, Munhall D, Arnold JH. A spontaneous breathing trial with pressure support overestimates readiness for extubation in children. Pediatr Crit Care Med 2011; 12
• 34 Carron JD, Derkay CS, Strope GL et al. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000; 110: 1099-1104
• 35 Lewis CW, Carron JD, Perkins JA et al. Tracheotomy in pediatric patients: a national perspective. Arch Otolaryngol Head Neck Surg 2003; 129: 523-529
• 36 Lee W, Koltai P, Harrison AM et al. Indications for tracheotomy in the pediatric intensive care unit population: a pilot study. Arch Otolaryngol Head Neck Surg 2002; 128: 1249-1252
• 37 Da Silva PS, Waisberg J, Paulo CS et al. Outcome of patients requiring tracheostomy in a pediatric intensive care unit. Pediatr Int 2005; 47: 554-559
• 38 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
• 39 Lipovy B, Brychta P, Rihova H et al. Effect of timing of tracheostomy on changes in bacterial colonisation of the lower respiratory tract in burned children. Burns 2013; 39: 255-261
• 40 Mayordomo-Colunga J, Medina A, Rey C et al. Non invasive ventilation after extubation in paediatric patients: a preliminary study. BMC Pediatr 2010; 10: 29-29
• 41 Vianello A, Arcaro G, Braccioni F et al. Prevention of extubation failure in high-risk patients with neuromuscular disease. J Crit Care 2011; 26: 517-524
• 42 James CS, Hallewell CP, James DP et al. Predicting the success of non-invasive ventilation in preventing intubation and reintubation in the paediatric intensive care unit. Intensive Care Med 2011; 37: 1994-2001
• 43 Bengtsson JA, Edberg KE. Neurally adjusted ventilatory assist in children: an observational study. Pediatr Crit Care Med 2010; 11: 253-257
• 44 Lee JH, Rehder KJ, Williford L et al. Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature. Intensive Care Med 2013; 39: 247-257
• 45 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
• 46 Foland JA, Super DM, Dahdah NS, Mhanna MJ. The use of the air leak test and corticosteroids in intubated children: a survey of pediatric critical care fellowship directors. Respir Care 2002; 47: 662-666
• 47 Mhanna MJ, Zamel YB, Tichy CM, Super DM. The „air leak“ test around the endotracheal tube, as a predictor of postextubation stridor, is age dependent in children. Crit Care Med 2002; 30: 2639-2643
• 48 Wratney AT, Benjamin Jr DK, Slonim AD et al. The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients. Pediatr Crit Care Med 2008; 9: 490-496
• 49 Markovitz BP, Randolph AG. Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta-analysis. Pediatr Crit Care Med 2002; 3: 223-226
• 50 Markovitz BP, Randolph AG, Khemani RG. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev CD 001000 2008;
• 51 Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet 1992; 340: 745-748
• 52 Kemper KJ, Ritz RH, Benson MS, Bishop MS. Helium-oxygen mixture in the treatment of postextubation stridor in pediatric trauma patients. Crit Care Med 1991; 19: 356-359
• 53 Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med 1991; 19: 352-355
• 54 Gupta VK, Cheifetz IM. Heliox administration in the pediatric intensive care unit: an evidence-based review. Pediatr Crit Care Med 2005; 6: 204-211