Search

Objective: The aim of this study was to investigate a novel standardized protocol in this neurological weaning unit in order to optimize the weaning process for patients subjected to prolonged mechanical ventilation. Of primary interest were the frequency of and reasons for deviating from the protocol as well as risk factors for weaning failure and mortality., Patients and Methods: All patients admitted to the weaning unit were enrolled in this prospective observational study. The weaning protocol consisted of 22 discrete weaning steps. An individual weaning approach was only begun if the standardized protocol failed. Variables for risk analysis included age, body mass index, APACHE II score, reason for initiating mechanical ventilation, total duration of inpatient stay before admission to the weaning unit, extent of mechanical ventilation period before admission, chronic pulmonary diseases and dialysis., Results: Between October 2007 and December 2008 a total of 644 consecutively admitted patients were enrolled in the study. The mean age was 67.6 ± 12.3 years, the mean inpatient stay before admission was 45.8 ± 34.9 days and the mean duration of mechanical ventilation before admission to the unit was 38.1 ± 28.7 days. The mean APACHE II score was 19.0 ± 7.2, 68 % of the patients were male, 98.6  % had a tracheotomy tube, 30.9  % had a history of chronic pulmonary disease and 13.7  % required dialysis. Reasons for initiating ventilation were cerebral 33.1  %, pulmonary 28.7  %, cardiovascular 31.5  %, neuropathic 2.8 %, myopathic 0.9 %, spinal cord injuries 1.9 % and 1.1  % were unclear. Weaning was successful in 77.3 % (498 patients) of all cases with a mean duration of 22.0 ± 33.9 days. Of those successfully weaned, a total of 85.9 % (n = 428) were weaned according to the standard protocol. The weaning process was also shorter (20.8 ± 35.6 versus 29.0 ± 19.9 days) for those patients weaned according to the protocol compared to those patients where the protocol failed. Protocol failure was normally due to complications during the weaning process. Among the patients where the protocol failed, chronic pulmonary disease (41.4 versus 28.3 %; p < 0.02), a longer duration of ventilation (42.3 ± 22.8 versus 35.9 ± 25.3 days; p < 0.01) and a longer in-hospital stay (52.7 ± 41.4 versus 42.4 ± 30.1 days; p < 0.01) prior to admission were significantly more common. A total of 23.0  % (n = 148) of the patients died and 9.8 % (n = 63) of the patients were discharged into a home care ventilation program. Chronic pulmonary disease and the duration of inpatient stay prior to admission were predictors of weaning failure. The APACHE II score, age and acute renal failure with concomitant need for dialysis were the factors best predicting mortality., Conclusions: The majority of patients receiving prolonged mechanical ventilation can be successfully weaned using a standardized protocol. Failures of standardized weaning per protocol occurred most often in patients with chronic pulmonary disease and following longer inpatient stay. These patients also had a higher risk of final weaning failure.

Background: A significant proportion of patients with long-term mechanical ventilation (MV) and difficult or prolonged weaning suffer from primary or secondary neurological conditions and concomitant functional disorders, in addition to respiratory problems. Therefore, these patients are treated in neurological weaning departments., Material and Methods: Using a questionnaire members of the German Working Group for early neurorehabilitation were interviewed with respect to the structure of weaning facilities, weaning strategies, patient characteristics and treatment outcome of patients admitted for weaning in 2009., Results: In the year 2009 a total of 1,486 patients were admitted to 7 participating neurological weaning units. The primary diagnosis was a neurological condition in 97.5% of the patients. In 62.9% of the patients the neurological condition was considered to be primarily responsible for the MV, 22.8% demonstrated pulmonary factors and for 3.0% a cardiac condition was determined to be decisive. In 5.0% of the patients it was not possible to ascertain a single cause or factor. Weaning was successful in 69.8% of all cases, 64.9% (965 patients) were released from the facility without MV, 274 patients (18.4%) were released with MV, 61.3% of these (168 patients) were referred to other rehabilitation facilities or into the care of the family physician and 38.7% (106 patients) were transferred to other hospitals due to special medical problems. The total mortality rate was 16.6% (247 patients deceased)., Conclusions: In this first comprehensive evaluation of German neurological weaning centers for patients with long-term MV, structures and treatment outcomes were compared with recent results from the literature.

A frequent cause of weaning failure and the resultant long-term artificial ventilation is the generalized weakness syndrome in the sense of critical illness polyneuropathy or polymyopathy. However, hardly any information is presently available regarding the necessary intensity of the diagnostic workup for reaching or excluding a diagnosis with certainty in the neurological examination or regarding the additional diagnostic value of electrophysiological studies in patients receiving long-term acute care suspected of having critical illness polyneuropathy and polymyopathy. Therefore, the goal of this investigation was to address these questions. A total of 280 patients with complicated weaning were included in the study. All patients underwent clinical examination by a specialist in neurology and electrophysiological workup performed by another specialist. Among the patients studied, the greatest possible certainty of the diagnosis (positive predictive value) of the clinical examination was 97.9% [95% confidence interval (CI) 69.4-99.9] and the best certainty of excluding the diagnosis (negative predictive value) was 88.9% (95% CI 82.7-93.0). Thus, in difficult-to-wean patients who were considered to probably have the diagnosis of critical illness polyneuropathy or polymyopathy as assessed by a specialist, little additional information is gained from an electrophysiological study, which is hence dispensable in these cases.