Résumé
Le processus décisionnel visant à séparer les patients de la ventilation mécanique repose, entre autres éléments, sur l’interprétation de la tolérance clinique du patient à un test de sevrage, communément désigné comme épreuve de ventilation spontanée. Plusieurs modalités dans la réalisation de l’épreuve de ventilation spontanée s’offrent au clinicien (maintien d’une aide inspiratoire et/ou d’une pression expiratoire positive minimale, aucune aide inspiratoire ni pression expiratoire positive sur le ventilateur, pièce en T). D’un point de vue physiologique, l’épreuve de ventilation spontanée réalisée en pièce en T reproduit le plus fidèlement les conditions de ventilation spontanée en comparaison aux autres modalités, et la situation sans support sur le ventilateur semble être équivalente. Toute addition de support sur les ventilateurs modernes sous-estime le travail respiratoire. Dans la population tout venant ou la probabilité de succès est élevée, le choix du premier test peut prendre en compte plusieurs aspects (faisabilité, choix de ne pas sous-estimer la possibilité de succès, etc.). Dans une population sélectionnée par un premier échec de sevrage, le choix de réaliser les épreuves en pièce en T (ou sans support sur le ventilateur) semble la plus logique dans l’objectif de ne pas sous-estimer le risque d’échec.
Abstract
Decision making process aiming at separate patients from mechanical ventilation relies with others issues, on the interpretation of patient’s clinical tolerance during a weaning attempt, so-called spontaneous breathing trial. Several modalities of spontaneous breathing trial are available for clinicians (T piece, minimal pressure support with/without positive end expiratory pressure, no pressure support, no positive end expiratory pressure). From a physiological point of view, T piece reflects better spontaneous breathing without assistance as compared to others methods and ventilation without any support seems equivalent. Any support provided by modern ventilators underestimates work of breathing. In a non-selected population where the weaning success probability is high, the choice of the first spontaneous breathing trial modality takes into account several issues (feasibility, decision not to underestimate the probability success). In a population selected by a first weaning attempt failure, it is logical to repeat further trial with T piece (or without ventilatory support) in order to avoid underestimation of a potential next failure.
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Dres, M., Sklar, M. & Brochard, L. Sevrage de la ventilation mécanique : quel test de sevrage utiliser chez les patients de réanimation ?. Méd. Intensive Réa 26, 3–10 (2017). https://doi.org/10.1007/s13546-016-1236-x
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DOI: https://doi.org/10.1007/s13546-016-1236-x