Advertisement

Weaning pp 21-32 | Cite as

Strategien in der Respiratorentwöhnung

  • Bernd Schönhofer
  • Steffen Weber-Carstens
Chapter
  • 73k Downloads

Zusammenfassung

Nicht selten resultieren aus einer komplexen, intensivmedizinischen Behandlung mit Beatmung immer älter werdender Patienten eine Langzeitabhängigkeit von Beatmungsmedizin. Nur etwa die Hälfte langzeitbeatmeter Patienten (>14 Tage) ist vor Entlassung aus dem Krankenhaus vom Respirator entwöhnt. Und nur etwa 41 % der Patienten nach Langzeitbeatmung leben noch ein Jahr nach Entlassung aus dem Krankenhaus. Die Ursachen für eine Langzeitbeatmung und ein Scheitern der Respiratorentwöhnung sind vielfältig und reichen von iatrogenen Verursachungen, wie z. B. Übersedierung, Fehlen eines protokollbasierten Managements zur Erfassung des Weaningpotentials, einer unzureichenden Adaption der Beatmungsunterstützung an die klinische Situation des Patienten, über Folgezustände einer protrahierten Intensivtherapie mit Entwicklung z. B. eines Delirs oder Ausbildung eines schwerwiegenden neuromuskulären Organversagens, bis hin zu Problemen, die durch die respiratorische Grunderkrankung begründet sind.

Literatur

  1. [1]
    Damuth E, Mitchell JA, Bartock JL, Roberts BW, Trzeciak S (2015) Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med 3(7):544–553CrossRefPubMedGoogle Scholar
  2. [2]
    Fried TR, Bradley EH, Towle VR, Allore H (2002) Understanding the treatment preferences of seriously ill patients. N Engl J Med 346(14):1061–1066CrossRefPubMedGoogle Scholar
  3. [3]
    Geiseler J, Kelbel C (2016) Weaning from mechanical ventilation: weaning categories and weaning concepts. Med Klin Intensivmed Notfmed 111(3):208–214CrossRefPubMedGoogle Scholar
  4. [4]
    Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C et al (2007) Weaning from mechanical ventilation. Eur Respir J 29(5):1033–1056CrossRefPubMedGoogle Scholar
  5. [5]
    Funk GC, Anders S, Breyer MK, Burghuber OC, Edelmann G, Heindl W et al (2010) Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 35(1):88–94CrossRefPubMedGoogle Scholar
  6. [6]
    Béduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E, Jonas M et al (2017) Epidemiology of weaning outcome according to a new definition. The WIND study. Am J Respir Crit Care Med 195(6):772–783CrossRefPubMedGoogle Scholar
  7. [7]
    American Psychiatric Association (1980) Diagnostic and statistical manual of mental disordersGoogle Scholar
  8. [8]
    Brummel NE, Jackson JC, Pandharipande PP, Thompson JL, Shintani AK, Dittus RS et al (2014) Delirium in the ICU and subsequent long-term disability among survivors of mechanical ventilation. Crit Care Med 42(2):369–377CrossRefPubMedPubMedCentralGoogle Scholar
  9. [9]
    Luetz A, Heymann A, Radtke FM, Chenitir C, Neuhaus U, Nachtigall I et al (2010) Different assessment tools for intensive care unit delirium: which score to use? Crit Care Med 38(2):409–418CrossRefPubMedGoogle Scholar
  10. [10]
    Veiga D, Luis C, Parente D, Fernandes V, Botelho M, Santos P, Abelha F (2012) Postoperative delirium in intensive care patients: risk factors and outcome. Rev Bras Anestesiol 62(4):469–483CrossRefPubMedGoogle Scholar
  11. [11]
    Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE et al (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291(14):1753–1762CrossRefPubMedGoogle Scholar
  12. [12]
    Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T et al (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27(12):1892–1900CrossRefPubMedGoogle Scholar
  13. [13]
    Zhang Z, Pan L, Ni H (2013) Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry 35(2):105–111CrossRefPubMedGoogle Scholar
  14. [14]
    Lat I, McMillian W, Taylor S, Janzen JM, Papadopoulos S, Korth L et al (2009) The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 37(6):1898–1905CrossRefPubMedGoogle Scholar
  15. [15]
    Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT et al (2013) Long-term cognitive impairment after critical illness. N Engl J Med 369(14):1306–1316CrossRefPubMedPubMedCentralGoogle Scholar
  16. [16]
    Jeon K, Jeong BH, Ko MG, Nam J, Yoo H, Chung CR, Suh GY (2016) Impact of delirium on weaning from mechanical ventilation in medical patients. Respirology 21(2):313–320CrossRefPubMedGoogle Scholar
  17. [17]
    Jackson DL, Proudfoot CW, Cann KF, Tim Walsh T (2010) A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care 14:R59Google Scholar
  18. [18]
    DAS-Taskforce 2015; Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G (2015) Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version. Ger Med Sci 13:Doc19Google Scholar
  19. [19]
    Windisch W (2008) Pathophysiology of respiratory muscle weakness. Pneumologie 62(Suppl 1):S18–S22CrossRefPubMedGoogle Scholar
  20. [20]
    Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C et al (2011) Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med 183(3):364–371CrossRefPubMedGoogle Scholar
  21. [21]
    Jaber S, Jung B, Matecki S, Petrof BJ (2011) Clinical review: ventilator-induced diaphragmatic dysfunction––human studies confirm animal model findings! Crit Care 15(2):206CrossRefPubMedPubMedCentralGoogle Scholar
  22. [22]
    Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P et al (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358(13):1327–1335CrossRefPubMedGoogle Scholar
  23. [23]
    Wollersheim T, Woehlecke J, Krebs M, Hamati J, Lodka D, Luther-Schroeder A et al (2014) Dynamics of myosin degradation in intensive care unit-acquired weakness during severe critical illness. Intensive Care Med 40(4):528–538CrossRefPubMedGoogle Scholar
  24. [24]
    Hooijman PE, Beishuizen A, Witt CC, de Waard MC, Girbes AR, Spoelstra-de Man AM et al (2015) Diaphragm muscle fiber weakness and ubiquitin-proteasome activation in critically ill patients. Am J Respir Crit Care Med 91(10):1126–1138CrossRefGoogle Scholar
  25. [25]
    Powers SK, Kavazis AN, Levine S (2009) Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med 37(10):S347CrossRefPubMedPubMedCentralGoogle Scholar
  26. [26]
    Pickerodt PA, Francis RC, Weber-Carstens S (2013) Monitoring of the respiratory muscle function during weaning from mechanical ventilation. Anasthesiol Intensivmed Notfallmed Schmerzther 48(10):634–639CrossRefPubMedGoogle Scholar
  27. [27]
    Orozco-Levi M, Lloreta J, Minguella J, Serrano S, Broquetas JM, Gea J (2001) Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 164(9):1734–1739CrossRefPubMedGoogle Scholar
  28. [28]
    Laghi F, Topeli A, Tobin MJ (1998) Does resistive loading decrease diaphragmatic contractility before task failure? J Appl Physiol (1985) 85(3):1103–1112CrossRefGoogle Scholar
  29. [29]
    Laghi F, D'Alfonso N, Tobin MJ (1995) Pattern of recovery from diaphragmatic fatigue over 24 hours. J Appl Physiol (1985) 79(2):539–546CrossRefPubMedGoogle Scholar
  30. [30]
    Kollef MH, Shapiro SD, Silver P, St John RE, Prentice D, Sauer S et al (1997) A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 25(4):567–574CrossRefPubMedGoogle Scholar
  31. [31]
    Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF (1999) Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 159:439–446CrossRefPubMedGoogle Scholar
  32. [32]
    Blackwood B, Burns KE, Cardwell CR, O'Halloran P (2014) Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev 6(11):CD006904Google Scholar
  33. [33]
    Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet 371(9607):126–134CrossRefPubMedGoogle Scholar
  34. [34]
    Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL et al (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373(9678):1874–1882CrossRefPubMedGoogle Scholar
  35. [35]
    Morandi A, Brummel NE, Ely EW (2011) Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care 17(1):43–49CrossRefPubMedGoogle Scholar
  36. [36]
    Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S (2014) Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 7:CD009176Google Scholar
  37. [37]
    Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA, Spronk P et al (2016) Comfort and patient-centred care without excessive sedation: the ecash concept. Intensive Care Med 42(6):962–971CrossRefPubMedPubMedCentralGoogle Scholar
  38. [38]
    Balas MC, Devlin JW, Verceles AC, Morris P, Ely EW (2016) Adapting the ABCDEF bundle to meet the needs of patients requiring prolonged mechanical ventilation in the long-term acute care hospital setting: historical perspectives and practical implications. Semin Respir Crit Care Med 37(1):119–135CrossRefPubMedGoogle Scholar
  39. [39]
    Schönhofer B, Dellweg D, Geiseler J, Moerer O, Weber-Carstens S, Sitter H (2014) S2k-Leitlinie Prolongiertes Weaning. Peumologie 68:19–75Google Scholar
  40. [40]
    Schönhofer B, Euteneuer S, Nava S, Suchi S, Köhler D (2002) Survival of mechanically ventilated patients admitted to a specialised weaning centre. Intensive Care Med 28(7):908–916CrossRefPubMedGoogle Scholar
  41. [41]
    Yang KL, Tobin MJ (1991) A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 324(21):1445–1450CrossRefPubMedGoogle Scholar
  42. [42]
    MacIntyre NR, Cook DJ, Ely, W. E, Jr., Epstein SK et al (2001) Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the american college of chest physicians; the american association for respiratory care; and the american college of critical care medicine. Chest 120(6 Suppl):375S–95SGoogle Scholar
  43. [43]
    Savi A, Teixeira C, Silva JM, Borges LG, Pereira PA, Pinto KB et al (2012) Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care 27(2):221.e1–e8CrossRefPubMedGoogle Scholar
  44. [44]
    Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN, Epstein SK (2006) A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med 34(10):2530–2535CrossRefPubMedGoogle Scholar
  45. [45]
    Sahn SA, Lakshminarayan S (1973) Bedside criteria for discontinuation of mechanical ventilation. Chest 63(6):1002–1005CrossRefPubMedGoogle Scholar
  46. [46]
    Jubran A, Grant BJ, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, Tobin MJ (2013) Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA 309(7):671–677CrossRefPubMedPubMedCentralGoogle Scholar
  47. [47]
    Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N et al (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150(4):896–903CrossRefPubMedGoogle Scholar
  48. [48]
    Moerer O (2012) Effort-adapted modes of assisted breathing. Curr Opin Crit Care 18(1):61–69PubMedGoogle Scholar
  49. [49]
    Bein T (2014) Current concepts of augmented spontaneous breathing: new modes of effort-adapted weaning. Anaesthesist 63(4):279–286CrossRefPubMedGoogle Scholar
  50. [50]
    Di Mussi R, Spadaro S, Mirabella L, Volta CA, Serio G, Staffieri F et al (2016) Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV. Crit Care 20:1CrossRefPubMedPubMedCentralGoogle Scholar
  51. [51]
    Schönhofer B, Kuhlen R (2004) Beatmung als Therapie der akuten respiratorischen Insuffizienz. Dtsch med Wschr 129:517–522Google Scholar
  52. [52]
    Westhoff M, Schönhofer B, Neumann P, Bickenbach J, Barchfeld T, Becker H et al (2015) Noninvasive mechanical ventilation in acute respiratory failure. Pneumologie 69(12):719–756CrossRefPubMedGoogle Scholar
  53. [53]
    Burns KE, Meade MO, Premji A, Adhikari NK (2014) Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a cochrane systematic review. CMAJ 186(3):E112–E122CrossRefPubMedPubMedCentralGoogle Scholar
  54. [54]
    Burns KE, Lellouche F, Lessard MR, Friedrich JO (2014) Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults. Cochrane Database Syst Rev 2:CD008639Google Scholar
  55. [55]
    Brower RG (2009) Consequences of bed rest. Crit Care Med 37(10):S422CrossRefPubMedGoogle Scholar
  56. [56]
    TEAM Study Investigators (2015) Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 19(1):81CrossRefGoogle Scholar
  57. [57]
    Nydahl P, Ewers A, Brodda D (2014) Complications related to early mobilization of mechanically ventilated patients on intensive care units. Nurs Crit Care.  https://doi.org/10.1111/nicc.12134
  58. [58]
    Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ et al (2014) Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med 42(5):1178–1186CrossRefPubMedGoogle Scholar
  59. [59]
    Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I et al (2016) Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet 388(10052):1377–1388CrossRefPubMedGoogle Scholar
  60. [60]
    Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM (2011) Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med 39(12):2627–2630CrossRefPubMedGoogle Scholar
  61. [61]
    Kabitz HJ, Windisch W, Schönhofer B (2013) Understanding ventilator-induced diaphragmatic dysfunction (VIDD): progress and advances. Pneumologie 67(8):435–441CrossRefPubMedGoogle Scholar
  62. [62]
    Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM (2012) Diaphragm muscle thinning in patients who are mechanically ventilated. Chest 142(6):1455–1460CrossRefPubMedGoogle Scholar
  63. [63]
    DiNino E, Gartman EJ, Sethi JM, McCool FD (2014) Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax 69(5):423–427CrossRefPubMedGoogle Scholar
  64. [64]
    Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D et al (2015) Evolution of diaphragm thickness during mechanical ventilation. Impact of inspiratory effort. Am J Respir Crit Care Med 192(9):1080–1088CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Deutschland, ein Teil von Springer Nature 2018

Authors and Affiliations

  • Bernd Schönhofer
    • 1
  • Steffen Weber-Carstens
    • 2
  1. 1.KRH Klinikum SiloahKlinik für Pneumologie, Intensiv- und SchlafmedizinHannoverDeutschland
  2. 2.Charité-Universitätsmedizin BerlinKlinik für Anästhesiologie mit Schwerpunkt operative IntensivmedizinBerlinDeutschland

Personalised recommendations