Difficult-to-wean Adult Patients
Conditions
Keywords
Weaning, Mechanical Ventilation, Lung Ultrasound
Brief summary
Daily lung ultrasound can help weaning from mechanical ventilation in difficult-to-wean adult patients. In this randomized trial, standardized lung ultrasound will be performed daily asssociated with standardized interventions aiming to decrease the total time in mechanical ventilation.
Detailed description
This trial will be performed in two intensive care units (ICUs). After randomization, all patients in the intervention group will undergo daily lung ultrasounds before the next spontaneous breathing trial. The results from the lung ultrasound will indicate specific interventions to facilitate weaning: * No sign of lung sliding (ultrasound finding suggestive of pleural movement): prompt evaluation for pneumothorax or mainstream intubation will be indicated; * normal lung ultrasound (ultrasound A profile): the patient will be evaluated for deep vein thrombosis / pulmonary embolism and/or for reversible airway obstruction (e.g. uncontrolled asthma or COPD \[Chronic Obstructive Pulmonary Disease\] exacerbation)- followed by appropriate treatment. If the patient has COPD, non invasive mechanical ventilation must be used as mode of discontinuing mechanical ventilation; * lung ultrasound shows pulmonary edema (ultrasound B profile): cardiogenic pulmonary edema will be differentiated from acute Respiratory Distress Syndrome (ARDS) - followed by appropriate treatment (e.g. a negative fluid balance of, at least, 1000 ml before the next spontaneous breathing trial); * lung ultrasound shows asymmetrical patterns (ultrasound AB profile or Pulmonary Consolidation): the possibility of an uncontrolled infection will be investigated; * presence of simple pleural effusion: diuretics will be indicated (for a negative fluid balance of, at least, 1000 ml before the next spontaneous breathing trial) or thoracocentesis at description of the assistant team; * presence of complex pleural effusion: other image exam will be performed, and will be evaluated by the surgical team.
Interventions
OTHERAbolish Lung Sliding
If there is no lung sliding, the patient will be promptly evaluated for pneumothorax or mainstream intubation.
OTHERNormal Lung Ultrasound
If the patient fails the spontaneous breathing trial and the lung ultrasound examination is normal - researchers will investigate venous thrombosis (deep vein thrombosis and/or pulmonary embolism) and rule out reversible airway obstruction. If the patient has the previous diagnosis of COPD, non invasive mechanical ventilation is indicated for facilitate weaning.
OTHERPulmonary Interstitial Syndrome
If lung ultrasound shows B pattern - cardiogenic pulmonary edema will be differentiated from Acute Respiratory Distress Syndrome (ARDS). If cardiogenic edema is a possibility, diuretics will be administrated (at least 40 mg of furosemide) or ultrafiltration will be performed. The main target is a negative fluid balance of, at least, 1000 ml before the next spontaneous breathing trial. Another possibility is to titrate vasodilators (at least a 20% reduction in the systolic blood pressure) before the next spontaneous breathing trial.
OTHERAsymmetrical Lung Ultrasound
If lung ultrasound shows asymmetrical findings, the occurence of new or uncontrolled infection (pulmonary or extrapulmonary) will be investigated.
OTHERSimple Pleural Effusion
If the patient has pleural effusion without ultrasonographic signs of complications (any hyperechoic pattern or complex septated pattern), researchers will administrate diuretics (at least 40 mg of furosemide in 24 hours) or increase ultrafiltration - to achieve a negative fluid balance of, at least, 1000 ml before the next spontaneous breathing trial. Another possibility is to perform pleural drainage.
OTHERComplex Pleural Effusion
If there is pleural effusion with hyperechoic or septated pattern, another image exam will be performed and evaluated by the surgical team.
Sponsors
Hospital Moinhos de Vento
Federal University of Rio Grande do Sul
Hospital Ernesto Dornelles
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Difficult to Wean; * 1 failure in the spontaneous breathing trial or 1 extubation failure * Adult patients (over 18 years old);
Exclusion criteria
* Palliative Care; * Life expectancy under 90 days; * COPD Gold IV, Cirrhosis Child C, Metastatic Cancer with low performance, etc * Other weaning method than institutional protocol
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Time in mechanical ventilation | from intubation until extubation success (defined as weaning from mechanical support for, at least, 48 hours) or death (days) |
Secondary
| Measure | Time frame |
|---|---|
| Length of ICU stay | from icu admition until icu discharge, up to 2 months |
| Incidence of ventilation-associated pneumonia | until icu discharge, up to 2 months |
| ICU's, Hospital's and 28-days mortality | until ICU's and hospital's discharge and 28th day from ICU admisson, with an expected average of 4 weeks |
| Number of tracheostomies performed | patients follow-up will continue until weaning from mechanical support, up to 2 months |
| Correlation between findings from ultrasound and other image techniques | after data collection (1 year) - retrospective review |
| Duration of Weaning | From first failed spontaneous breathing trial or failed extubation until weaning from mechanical ventilation support, up to 4 weeks |
| Performance status at ICU's and Hospital's discharge | at icu's and hospital discharge, with an expected average of 4 weeks |
Countries
Brazil
Contacts
Primary ContactFelippe L Dexheimer Neto, MD
Outcome results
None listed