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Der schwer entwöhnbare Patient

Difficult to wean patients

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Zusammenfassung

Bei etwa einem von zehn beatmeten Patienten verläuft die Entwöhnung vom Respirator (Weaning) prolongiert. Dies geht mit einer erhöhten Morbidität und Mortalität einher. Nach einem gescheiterten Spontanatemversuch sollte daher geklärt werden, durch welche Organdysfunktion(en) die erfolgreiche Entwöhnung verhindert wird. Die konkrete Ursache von prolongierter Entwöhnung kann am besten während eines gescheiterten Spontanatemversuches festgestellt werden, anhand der klinischen Untersuchung, der arteriellen und venösen Blutgase, der Echokardiographie u. a. Pathologische Atemmechanik, schwache bzw. überlastete Atemmuskulatur, Herzinsuffizienz und Myokardischämie sowie psychiatrische Probleme können anhand bestimmter Befundkonstellationen erkannt werden. Reduktion der Atemarbeit, Training der Atemmuskulatur sowie Senkung von Vor- und Nachlast sind die entscheidenden Schritte zur Überwindung einer respiratorisch bzw. kardial limitierten Entwöhnbarkeit. Erfolgreiche Strategien zur Vermeidung von Entwöhnungsproblemen sind eine kooperative Sedierung, der frühe Beginn mit einer strukturierten Entwöhnung und die Frührehabilitation schwacher Patienten.

Abstract

Approximately 10% of patients with mechanical ventilation experience prolonged weaning and also have an increased morbidity and mortality. Once spontaneous breathing trials have failed the organ systems responsible should be identified. This can be accomplished during the spontaneous breathing trial using clinical examination, measurement of blood gases, echocardiography and imaging techniques. Specific patterns allow the diagnosis of pathological respiratory mechanisms, weak ventilatory muscles, heart failure, myocardial ischemia and psychiatric problems. Respiratory and cardiac limitations of weaning can be overcome by reducing the ventilatory load, training of the ventilatory muscles and reducing cardiac workload. A cooperative sedation strategy as well as an early start of weaning and rehabilitation can prevent prolonged weaning in critically ill patients.

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Literatur

  1. Boles JM, Bion J, Connors A et al (2007) Weaning from mechanical ventilation. Eur Respir J 29:1033–1056

    Article  PubMed  Google Scholar 

  2. Jones DP, Byrne P, Morgan C et al (1991) Positive end-expiratory pressure vs T-piece. Extubation after mechanical ventilation. Chest 100:1655–1659

    Article  PubMed  CAS  Google Scholar 

  3. Tobin MJ, Jubran A (2006) Variable performance of weaning-predictor tests: role of Bayes‘ theorem and spectrum and test-referral bias. Intensive Care Med 32:2002–2012

    Article  PubMed  Google Scholar 

  4. Ferrer M, Sellares J, Valencia M et al (2009) Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 374:1082–1088

    Article  PubMed  Google Scholar 

  5. Nava S, Gregoretti C, Fanfulla F et al (2005) Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 33:2465–2470

    Article  PubMed  Google Scholar 

  6. Vassilakopoulos T, Zakynthinos S, Roussos C (2006) Bench-to-bedside review: weaning failure — should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care 10:204

    Article  PubMed  Google Scholar 

  7. Funk GC, Anders S, Breyer MK et al (2010) Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 35:88–94

    Article  PubMed  Google Scholar 

  8. Girard TD, Kress JP, Fuchs BD 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 371:126–134

    Article  PubMed  Google Scholar 

  9. Seneff MG, Zimmerman JE, Knaus WA et al (1996) Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest 110:469–479

    Article  PubMed  CAS  Google Scholar 

  10. Penuelas O, Frutos-Vivar F, Fernandez C et al (2011) Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med

  11. Bigatello LM, Stelfox HT, Berra L et al (2007) Outcome of patients undergoing prolonged mechanical ventilation after critical illness. Crit Care Med 35:2491–2497

    Article  PubMed  Google Scholar 

  12. Martin AD, Smith B, Davenport P et al (2011) Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial. Critical Care 15:R84

    Article  PubMed  Google Scholar 

  13. Beuret P, Roux C, Auclair A et al (2009) Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med 35:1090–1093

    Article  PubMed  Google Scholar 

  14. Pinsky MR (1994) Cardiovascular effects of ventilatory support and withdrawal. Anesth Analg 79:567–576

    Article  PubMed  CAS  Google Scholar 

  15. Jubran A, Mathru M, Dries D et al (1998) Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof. Am J Respir Crit Care Med 158:1763–1769

    PubMed  CAS  Google Scholar 

  16. Zapata L, Vera P, Roglan A et al (2011) B-type natriuretic peptides for prediction and diagnosis of weaning failure from cardiac origin. Intensive Care Med 37:477–485

    Article  PubMed  CAS  Google Scholar 

  17. Lamia B, Maizel J, Ochagavia A et al (2009) Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 37:1696–1701

    Article  PubMed  Google Scholar 

  18. Adrogue HJ, Madias NE (1998) Management of life-threatening acid-base disorders. Second of two parts. N Engl J Med 338:107–111

    Article  PubMed  CAS  Google Scholar 

  19. Moviat M, Pickkers P, Voort PH van der et al (2006) Acetazolamide-mediated decrease in strong ion difference accounts for the correction of metabolic alkalosis in critically ill patients. Crit Care 10:R14

    Article  PubMed  Google Scholar 

  20. Chiang LL, Wang LY, Wu CP et al (2006) Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther 86:1271–1281

    Article  PubMed  Google Scholar 

  21. Vassilakopoulos T, Petrof BJ (2004) Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 169:336–341

    Article  PubMed  Google Scholar 

  22. Ely EW, Shintani A, Truman B et al (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762

    Article  PubMed  CAS  Google Scholar 

  23. Jubran A, Lawm G, Kelly J et al (2010) Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med 36:828–835

    Article  PubMed  Google Scholar 

  24. Holliday JE, Hyers TM (1990) The reduction of weaning time from mechanical ventilation using tidal volume and relaxation biofeedback. Am Rev Respir Dis 141:1214–1220

    PubMed  CAS  Google Scholar 

  25. Schonhofer B, Wenzel M, Geibel M et al (1998) Blood transfusion and lung function in chronically anemic patients with severe chronic obstructive pulmonary disease. Crit Care Med 26:1824–1828

    Article  PubMed  CAS  Google Scholar 

  26. Hebert PC, Blajchman MA, Cook DJ et al (2001) Do blood transfusions improve outcomes related to mechanical ventilation? Chest 119:1850–1857

    Article  PubMed  CAS  Google Scholar 

  27. Girault C, Daudenthun I, Chevron V et al (1999) Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med 160:86–92

    PubMed  CAS  Google Scholar 

  28. Ferrer M, Esquinas A, Arancibia F et al (2003) Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med 168:70–76

    Article  PubMed  Google Scholar 

  29. Terragni PP, Antonelli M, Fumagalli R et al (2010) Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult icu patients: a randomized controlled trial. JAMA 303:1483–1489

    Article  PubMed  CAS  Google Scholar 

  30. Gracey DR, Hardy DC, Koenig GE (2000) The chronic ventilator-dependent unit: a lower-cost alternative to intensive care. Mayo Clin Proc 75:445–449

    PubMed  CAS  Google Scholar 

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung/en hin: GC Funk ist als Referent für die Firmen Dräger, Maquet, Orion Pharma & Roche Diagnostics tätig.

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  1. Erste Interne Lungenabteilung, Intensivstation, Otto Wagner Spital, Sanatoriumstr. 2, 1140, Wien, Österreich

    G.-C. Funk

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  1. G.-C. Funk
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Correspondence to G.-C. Funk.

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Funk, GC. Der schwer entwöhnbare Patient. Med Klin Intensivmed Notfmed 107, 622–628 (2012). https://doi.org/10.1007/s00063-012-0134-x

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  • DOI: https://doi.org/10.1007/s00063-012-0134-x

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