[Show abstract][Hide abstract] ABSTRACT: Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of the respiratory muscles and/or lung parenchymal disease when/after other treatments, i. e. oxygen, body position, secretion management, medication or non invasive ventilation have failed.In the majority of ICU patients weaning is routine and does not present any problems. Nevertheless 40-50 % of the time during mechanical ventilation is spent on weaning. About 20 % of patients need continued MV despite resolution of the conditions which originally precipitated the need for MV.There maybe a combination of reasons; chronic lung disease, comorbidities, age and conditions acquired in ICU (critical care neuromyopathy, psychological problems). According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial. Prolonged weaning is a challenge. An inter- and multi-disciplinary approach is essential for weaning success. Complex, difficult to wean patients who fulfill the criteria for "prolonged weaning" can still be successfully weaned in specialised weaning units in about 50% of cases.In patients with unsuccessful weaning, invasive mechanical ventilation has to be arranged either at home or in a long term care facility.This S2-guideline was developed because of the growing number of patients requiring prolonged weaning. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies engaged in the field.The guideline is based on a systematic literature review of other guidelines, the Cochrane Library and PubMed.The consensus project was chaired by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) based on a formal interdisciplinary process applying the Delphi-concept. The guideline covers the following topics: Definitions, epidemiology, weaning categories, pathophysiology, the spectrum of treatment strategies, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions. Special issues relating to paediatric patients were considered at the end of each chapter.The target audience for this guideline are intensivists, pneumologists, anesthesiologists, internists, cardiologists, surgeons, neurologists, pediatricians, geriatricians, palliative care clinicians, nurses, physiotherapists, respiratory therapists, ventilator manufacturers.The aim of the guideline is to disseminate current knowledge about prolonged weaning to all interested parties. Because there is a lack of clinical research data in this field the guideline is mainly based on expert opinion.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Regional weaning centers play a more and more important role in the weaning process of long-term ventilated patients. The medical center Kloster Grafschaft is one of the oldest and largest centers in Germany. There is very little published data from larger weaning centers in Europe. Methods: From 2007 to 2011 all weaning patients were registered in a database. Additional information of the transferring hospitals was inquired. Prolonged weaning was defined by a period of at least 7 days of mechanical ventilation as well as three unsuccessful weaning trials. Results: Data from 867 of 916 registered patients could be analyzed. 71.1% could be successfully weaned from mechanical ventilation. All patients were suffering from a hypercapnic insufficiency as well as a variety of secondary diagnoses, on average 15.1 per patient. The median of age was 70 years, 62 % were male. Prior to hospital transfer patients had been ventilated for a median of 41 days. Time to successful removal of the artificial airway was 8 days according to the DRG code directive and 13.4 days when non-invasive ventilation (NIV) time was included. Of the 616 patients who could be successfully weaned, 42 % were discharged on NIV. Out of the 251 patients who could not be weaned, 107 were discharged. The remaining 144 (16.7 %) patients died, 33 % due to the primary underlying disease or a complication. 66 % of the deceased patients received palliative care. Patients with successful and unsuccessful weaning did not differ by age, by duration of mechanical ventilation or time until tracheostomy. Postoperative patients could be weaned more often than medical patients (p < 0.05). Discrimination between patients with successful and unsuccessful weaning was not possible by the point in time of the first spontaneous breathing trial in regard to the duration of ventilation but only by the duration of this trial after transfer to our unit (150 vs. 60 min; p < 10-6). The TISS-28 and the SAPS-II-Score did not differ between the two groups. Patients with successful weaning had less agitation according to the RASS-Score (0.47 vs. 0.15; p < 0.005). Conclusion: It becomes apparent that in a specialized weaning center the majority of difficult to wean patients can be liberated in short time from mechanical ventilation.
DMW - Deutsche Medizinische Wochenschrift 11/2013; · 0.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.
BJA British Journal of Anaesthesia 04/2013; · 4.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Oxygen therapy is usually combined with a humidification device to prevent mucosal dryness. Depending of the cannula design oxygen can be administered pre- or intra-nasally (administration of oxygen in front of the nasal ostia versus cannula system inside the nasal vestibulum). The impact of the cannula design on intra-nasal humidity however has not been investigated to date.Objective:First, to develop a system, that samples air from the nasal cavity and analyses the humidity of these samples. Second, to investigate nasal humidity during pre-nasal and intra-nasal oxygen application with and without humidification.Methods:We first developed and validated a sampling and analysis system to measure humidity from air samples. By means of this system we measured inspiratory air samples from 12 individuals who received nasal oxygen with an intra-nasal and pre-nasal cannula at different flows with and without humidification.Results:The sampling and analysis system showed good correlation to a standard hygrometer within the tested humidity range (r = 0.992, p < 0.001).In our subjects intranasal humidity dropped significantly from 40.3 ± 8.7 % to 35.3 ± 5.8 %, 32 ± 5.6 % and 29.0 ± 6.8 % at a flow of one, two and three litres respectively when oxygen was given intra-nasally without humidification (p=0.001, p<0.001 and p<0.001 respectively). We observed no significant change in airway humidity when oxygen was given pre-nasally without humidification. With the addition of humidification we observed no significant change in humidity at any flow rate and independent of pre- or intranasal oxygen administration.Conclusion:Pre-nasal administration of dry oxygen achieves similar levels of intranasal humidity as intranasal administration in combination with a bubble through humidifier. Pre-nasal oxygen simplifies application and may reduce therapy cost.
[Show abstract][Hide abstract] ABSTRACT: To compare the treatment effect of noninvasive positive pressure ventilation (NPPV) and anticyclic servoventilation in patients with continuous positive airway pressure (CPAP)-induced central sleep apnea (complex sleep apnea).
Randomized controlled trial.
Thirty patients who developed complex sleep apnea syndrome (CompSAS) during CPAP treatment.
NPPV or servoventilation.
Patients were randomized to NPPV or servo-ventilation. Full polysomnography (PSG) was performed after 6 weeks. On CPAP prior to randomization, patients in the NPPV and servoventilator arm had comparable apnea-hypopnea indices (AHI, 28.6 ± 6.5 versus 27.7 ± 9.7 events/h (mean ± standard deviation [SD])), apnea indices (AI,19 ± 5.6 versus 21.1 ± 8.6 events/h), central apnea indices (CAI, 16.7 ± 5.4 versus 18.2 ± 7.1 events/h), oxygen desaturation indices (ODI,17.5 ± 13.1 versus 24.3 ± 11.9 events/h). During initial titration NPPV and servoventilation significantly improved the AHI (9.1 ± 4.3 versus 9 ± 6.4 events/h), AI (2 ± 3.1 versus 3.5 ± 4.5 events/h) CAI (2 ± 3.1 versus 2.5 ± 3.9 events/h) and ODI (10.1 ± 4.5 versus 8.9 ± 8.4 events/h) when compared to CPAP treatment (all P < 0.05). After 6 weeks we observed the following differences: AHI (16.5 ± 8 versus 7.4 ± 4.2 events/h, P = 0.027), AI (10.4 ± 5.9 versus 1.7 ± 1.9 events/h, P = 0.001), CAI (10.2 ± 5.1 versus 1.5 ± 1.7 events/h, P < 0.0001)) and ODI (21.1 ± 9.2 versus 4.8 ± 3.4 events/h, P < 0.0001) for NPPV and servoventilation, respectively. Other sleep parameters were unaffected by any form of treatment.
After 6 weeks, servoventilation treated respiratory events more effectively than NPPV in patients with complex sleep apnea syndrome.
Dellweg D; Kerl J; Hoehn E; Wenzel M; Koehler D. Randomized controlled trial of noninvasive positive pressure ventilation (NPPV) versus servoventilation in patients with CPAP-induced central sleep apnea (complex sleep apnea). SLEEP 2013;36(8):1163-1171.
[Show abstract][Hide abstract] ABSTRACT: Homecare for mechanically ventilated patients is complex and challenging for homecare institutions. The framework conditions of homecare are regulated by a likewise complex social legislation. The German Respiratory Society (DGP) and the German Interdisciplinary Society for Home Care Ventilation (DIGAB) have published recommendations on the structure of homecare for ventilated patients in their recent guideline and recommended a certification of homecare nursing services.
Prior to a certification process, the homecare task force of the DIGAB conducted a survey in order to compare the current structures with the guideline recommendations.
Voluntary disclosure of information by means of a written questionnaire consisting of eleven items was requested.
37 homecare institutions with a total of 78 subsidiaries providing service all over Germany returned their questionnaires. While educational standards are mostly in line with the guideline recommendation, it was found that only 43 % of 812 recorded patients followed up with a specialised weaning centre or centre for ventilation. 84 % of these patients were ventilated invasively. In spite of the fact that all homecare institutions took care of invasively ventilated patients, there was a lack of company-owned standards for specific nursing measures.
Homecare for ventilated patients in Germany has reached a decent degree of organisation, while follow-up with specialised centres for ventilation, and with that medical specialist care appears to be underserved. The certification process for homecare institutions should be pursued with emphasis in order to create uniform quality standards. The number of invasively ventilated patients in homecare settings is probably higher than previously estimated and could be the result of a lack of weaning capacity.
[Show abstract][Hide abstract] ABSTRACT: Inhaled bronchodilators are frequently used in patients with chronic obstructive pulmonary disease (COPD). However, there has been no efficient way to administer the long-acting anticholinergic tiotropium to mechanically ventilated patients. The aim of this in vitro study was to compare the fine particle dose (FPD) output of a specifically designed adapter with other accessory devices for the delivery of bronchodilators using the Respimat® (RMT) inhaler by simulating the specific inhalation flow profiles of patients with COPD.
Using characteristic flow profiles from COPD patients being weaned off mechanical ventilation, an in vitro study was performed analyzing the FPD achieved with different accessory devices (connectors, spacers, AeroTrachPlus valved holding chamber), which can be used to deliver drugs from pressurized metered dose inhalers (pMDI) and RMT inhalers to artificial airways. Fenoterol pMDI, tiotropium RMT, and a fixed-dose combination of salbutamol and ipratropium delivered by pMDI or RMT, were used as bronchodilators. Aerosols were collected by a next-generation impactor.
The RMT inhaler, combined with a new in-line adapter, was superior to other inhaler device connector or spacer combinations in FPD delivery during simulated mechanical ventilation (p<0.01). The outcome with the RMT inhaler/RMT adapter combination during simulation of mechanical ventilation was comparable to the measurements with the RMT/AeroTrachPlus valved holding chamber during simulation of spontaneous breathing. The delivery rates of the RMT adapter were not significantly affected by the administered bronchodilators or by the type of artificial airway (endotracheal or tracheostomy tube) employed.
The RMT inhaler combined with the prototype in-line adapter was better than the other accessory device combinations in fine particle deposition of inhaled bronchodilators during mechanical ventilation. Further research is required to determine the clinical relevance of these in vitro findings.
Journal of Aerosol Medicine and Pulmonary Drug Delivery 08/2011; 24(6):285-92. · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Polycythemia is defined by the increase of hematocrit and haemoglobin respectively. Possible causes might be neoplastic diseases like polycythemia vera with proliferation of a cell clone. More often one will find reactive forms resulting from chronic hypoxemia. A physiologic form of polycythemia can be found in highlanders and athletes training at high altitude. With increasing frequency erytrhopoetin and it's analoga are being used as doping substances to induce Polycythemia. Red cell proliferation induced by chronic hypoxemia is the most common form in patients. In this instance the lung itself can be the cause (hypoxemia with hypocapnea in blood gas analysis) or hypoventilation caused by an insufficient respiratory pump (hypercapnea with hypoxemia in blood gas analysis) induces a compensatory Polycythemia. The former form can be treated with long term oxygen therapy and the latter by non-invasive ventilation, either approach corrects hypoxemia and reduces Polycythemia within some weeks.
[Show abstract][Hide abstract] ABSTRACT: The field of mechanical ventilation is highly important in pulmonary medicine. The German Medical Association of Pneumology and Ventilatory Support ["Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)"] therefore has formulated these guidelines for home mechanical non-invasive and invasive ventilation. Non-invasive home mechanical ventilation can be administered using various facial masks; invasive home mechanical ventilation is performed via a tracheostomy. Home mechanical ventilation is widely and increasingly accepted as a treatment option for chronic ventilatory failure which most often occurs in COPD, restrictive lung diseases, obesity-hypoventilation syndrome and neuromuscular disorders. Essential for the initiation of home mechanical ventilation are the presence of symptoms of ventilatory failure and the detection of hypoventilation, most importantly hypercapnia. These guidelines comprise general indication criteria along with disease-specific criteria summarised by treatment algorithms. In addition, the management of bronchial secretions and care of paediatric patients are addressed. Home mechanical ventilation must be organised around a specialised respiratory care centre with expertise in patient selection, the initiation and the control of home mechanical ventilation. In this regard, the guidelines provide detailed information about technical requirements (equipment), control and settings of mechanical ventilation as well as organisation of patient care. A key requirement for home mechanical ventilation is the qualification of specialised home-care services, which is addressed in detail. Independent living and the quality of respiratory care are of highest priority in patients receiving home mechanical ventilation, since home mechanical ventilation can interfere with the integrity of a patient and often marks a life-sustaining therapy. Home mechanical ventilation has been shown to improve health-related quality of life of patients with chronic ventilatory failure. Long-term survival is improved in most patient groups, even though the long-term prognosis is often severely limited. For this reason, ethical issues regarding patient education, communication with ventilated patients at the end of life, living will, testament and medical care during the dying process are discussed.
[Show abstract][Hide abstract] ABSTRACT: There is no published data about mask features that impact skin contact pressure during mask ventilation. To investigate the physical factors of skin contact pressure formation. We measured masks with original and reduced air cushion size and recorded contact pressure. We determined cushion contact and mask areas by planimetric measurements. Contact pressures necessary to prevent air leakage during inspiration exceed inspiratory pressure by 1.01+/-0.41 hPa independent of cushion size. Contact area, ventilator pressure and mask area during inspiration and expiration impact contact pressure. Mask contact pressures are higher during expiration. The contact pressure increases with increase in inspiratory pressures independent of the ventilator cycle. During expiration, the contact pressure will increase in proportion to the expiratory pressure reduction of the ventilator. The mask with reduced air cushion size developed higher contact pressures. Contact pressure can be reduced by selecting masks with a small mask area in combination with a large mask cushion.
Journal of biomechanics 11/2009; 43(4):652-7. · 2.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-invasive ventilation (NIV) has been shown to improve clinical outcomes in acute and chronic hypercapnic respiratory failure. A new timed, automated, auto-adaptive non-invasive ventilatory mode (TA-mode) has been recently introduced.
To investigate the degree of respiratory muscle unloading with this new mode in comparison to assisted (S-mode) NIV in healthy individuals.
Work of breathing, pressure time product and transdiaphragmatic pressure time product were measured during unassisted breathing, assisted and TA-mode-NIV in eight healthy, awake volunteers at inspiratory pressures of 20 and expiratory pressures of 4hPa.
Assisted and TA-mode-NIV reduced the work of breathing by 50 and 89.1%, pressure time product by 61.5 and 72.6% and transdiaphragmatic pressure time product by 77 and 88.7%, respectively when compared to unassisted breathing. The degree of respiratory muscle unloading was higher during TA-mode-NIV when compared to assisted non-invasive ventilation (work of breathing p<0.001, pressure time product p=0.04 and transdiaphragmatic pressure time product p=0,01).
TA-mode-NIV achieved significant higher levels of respiratory muscle unloading in healthy individuals when compared to assisted non-invasive ventilation.
Respiratory medicine 06/2009; 103(11):1706-12. · 2.33 Impact Factor