Criteria for Extubation and Tracheostomy Tube Removal for Patients With Ventilatory Failure: A Different Approach to Weaning

doi:10.1378/chest.110.6.1566

Chest

Volume 110, Issue 6, December 1996, Pages 1566-1571

https://doi.org/10.1378/chest.110.6.1566 Get rights and content

The purpose of this study was to prospectively compare parameters that might predict successful translaryngeal extubation and tracheostomy tube decannulation. Irrespective of ventilatory function, 62 extubation/decannulation attempts were made on 49 consecutive patients with primarily neuromuscular ventilatory insufficiency who satisfied criteria. Thirty-four patients required 24-h ventilatory support. Noninvasive intermittent positive pressure ventilation (IPPV) was substituted as needed for IPPV via translaryngeal or tracheostomy tubes. Successful decannulation was defined as extubation or decannulation and site closure with no consequent respiratory symptoms or blood gas deterioration for at least 2 weeks. Failure was defined by the appearance of respiratory distress and decreases in vital capacity and oxyhemoglobin saturation despite use of noninvasive IPPV and assisted coughing. The independent variables of age, extent of predecannulation ventilator use, vital capacity, and peak cough flows (PCF) were studied to determine their utility in predicting successful extubation and decannulation. Only the ability to generate PCF greater than 160 L/min predicted success, whereas inability to generate 160 L/min predicted the need to replace the tube. All 43 attempts on patients with PCF greater than 160 L/min succeeded; all 15 attempts on patients with PCF below 160 L/min failed; and of 4 patients with PCF of 160 L/min, 2 succeeded and 2 failed. We conclude that the ability to generate PCF of at least 160 L/min is necessary for the successful extubation or tracheostomy tube decannulation of patients with neuromuscular disease irrespective of ability to breathe.

Section snippets

Materials and Methods

A ventilator unit accepted 49 consecutive patients primarily with neuromuscular ventilatory impairment with endotracheal or tracheostomy tubes for ventilator weaning and extubation or decannulation. Forty-three of the 49 had thus far failed to respond to conventional weaning and the remaining 6 were weaned, but still had tracheostomy tubes that could not be removed during the acute hospitalization. All of the ventilator users arrived using some combination of either assist/control mode

Results

Forty-nine tracheostomy tube decannulation attempts were made on 37 patients with the following diagnoses: 22 with SCI; 15 with global alveolar hypoventilation, including 11 with progressive neuromuscular disease; 2 with Guillain-Barré syndrome; 1 with obesity hypoventilation syndrome; and 1 with partial lung resection and chronic alveolar hypoventilation. Initial decannulation attempts were successful for 25 patients, 12 initial attempts failed, and on subsequent attempts, 7 succeeded and 5

Discussion

A normal cough requires a precough inspiration or insufflation to about 85 to 90% of total lung capacity.⁹ Glottic closure follows for about 0.2 s and sufficient intrathoracic pressures are generated to obtain peak transient expiratory flows or PCFs upon glottic opening that are normally 360 to 1000 L/min.¹⁰ Total expiratory volume during normal coughing is about 2.3± 0.5 L.⁹

For patients with paralytic conditions, PCFs are reduced by the inability to adequately inflate the lungs (reduced VC),

References (16)

BachJR et al.
Management of chronic alveolar hypoventilation by nasal ventilation
Chest
(1990)
BachJR et al.
Intennittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users
Chest
(1993)
BachJR et al.
Noninvasive options for ventilatory support of the traumatic high level quadriplegic
Chest
(1990)
BachJR et al.
Sleep fragmentation in kyphoscoliotic individuals with alveolar hypoventilation treated by nasal IPPV
Chest
(1995)
BachJR.
Mechanical insufflation-exsufflation: comparison of peak expiratory flows with manually assisted and unassisted coughing techniques
Chest
(1993)
BachJR.
Update and perspectives on noninvasive respiratory muscle aids: II
The expiratory muscle aids. Chest
(1994)
BachJR.
Amyotrophic lateral sclerosis: predictors for prolongation of life by noninvasive respiratory aids
Arch Phys Med Rehabil
(1995)
MasseryM.
Manual breathing and coughing aids
Phys Med Rehabil Clin North Am
(1996)

There are more references available in the full text version of this article.

Cited by (472)

Mechanical Insufflation-Exsufflation: When the “Art of Coughing” Becomes Science
2024, Chest
The Effect of Pressure Changes During Mechanical Insufflation-Exsufflation on Respiratory and Airway Physiology
2024, Chest
Respiratory muscle weakness can impair cough function, leading to lower respiratory tract infections. These infections are an important contributor to morbidity and mortality in patients with neuromuscular disease. Mechanical insufflation-exsufflation (MIE) is used to augment cough function in these patients. Although MIE is widely used, there are few data to advise on the optimal technique. Since the introduction of MIE, the recommended pressures to be delivered have increased. There are concerns regarding the use of higher pressures and their potential to cause lung derecruitment and upper airway closure.
What is the impact of high-pressure MIE (HP-MIE) on lung recruitment, respiratory drive, upper airway flow, and patient comfort, compared with low-pressure MIE (LP-MIE), in patients with respiratory muscle weakness?
Clinically stable patients using domiciliary MIE with respiratory muscle weakness secondary to Duchenne muscle dystrophy, spinal cord injury, or long-term tracheostomy ventilation received LP-MIE (30/–30 cm H₂O) and HP-MIE (60/–60 cm H₂O) in a random sequence. Lung recruitment, neural respiratory drive, and cough peak expiratory flow were measured throughout, and patients reported comfort and breathlessness following each intervention.
A total of 29 patients (10 with Duchenne muscle dystrophy, eight with spinal cord injury, and 11 with long-term tracheostomy ventilation) were included in this study. HP-MIE augmented cough peak expiratory flow compared with LP-MIE (mean cough peak expiratory flow HP-MIE 228 ± 81 L/min vs LP-MIE 179 ± 67 L/min; P = .0001) without any significant change in lung recruitment, neural respiratory drive, or patient-reported breathlessness. However, in patients with more pronounced respiratory muscle weakness, HP-MIE resulted in an increased rate of upper airway closure and patient discomfort that may have an impact on clinical efficacy.
HP-MIE did not lead to lung derecruitment or breathlessness compared with LP-MIE. However, it was poorly tolerated in individuals with advanced respiratory muscle weakness. HP-MIE generates more upper airway closure than LP-MIE, which may be missed if cough peak expiratory flow is used as the sole titration target.
ClinicalTrials.gov; No.: NCT02753959; URL: www.clinicaltrials.gov
Neuromuscular Disorders in Pediatric Respiratory Disease
2024, Clinics in Chest Medicine
Update on manual bronchial clearance techniques (adults and adolescents)
2024, Revue des Maladies Respiratoires
Chez l’adulte et l’adolescent, les techniques de désencombrement bronchique sont nombreuses et variées. Cependant, le niveau de preuve de ces traitements est faible. Parmi celles-ci, l’Expiration lente glotte ouverte en décubitus latéral (ELTGOL), le drainage autogène (DA) et la technique de respiration cyclique active (ACBT) atteignent un niveau de preuve grade B avec un niveau de force faible. Ces manœuvres sont adoptées dans le monde entier. Cependant, une description exacte des techniques de kinésithérapie respiratoire (KR) fait souvent défaut dans la littérature scientifique. Il semble donc difficile de standardiser leur mise en pratique et de reproduire les résultats. La validation scientifique de la plupart des techniques de KR est problématique en raison du manque de fidélité dans leur exécution. Cet article vise à décrire chaque méthode avec exactitude. Pour chacune des trois techniques de KR, une modélisation graphique des exercices respiratoire est proposée afin d’en faciliter l’apprentissage et également améliorer leur reproductibilité d’application par les kinésithérapeutes.
In adults and teenagers, airway clearance physiotherapy techniques (ACPT) are various and numerous. However, they for still awaiting scientific validation. Among ACPTs, Slow Expiration with the Glottis Opened in the Lateral Posture (ELTGOL), Autogenic Drainage (DA), and Active Cycling Breathing Technique (ACBT) present a Grade B level of evidence with weak recommendations. Even though these maneuvers are widely applied, precise description of chest physiotherapy (CP) is largely absent from the scientific literature; it is difficult to standardize its implementation and reproduce the results; scientific validation and faithful execution of the techniques are consequently problematic. In this paper, the authors aim to depict each of the three CP techniques as precisely as possible; with this in mind, graphic modeling of the different respiratory exercises is presented in such a way that they can be easily learned, applied and reproduced by physiotherapists.
Peak expiratory flow and the single-breath counting test as markers of respiratory function in patients with myasthenia gravis
2023, Neurologia
La miastenia gravis (MG) es una enfermedad autoinmune mediada por anticuerpos. El cuadro clínico se caracteriza por debilidad muscular fluctuante y fatigable, con frecuente afectación de músculos fonodeglutorios y respiratorios. Dada la severidad que implica el compromiso respiratorio en la MG, su evaluación rutinaria es esencial.
Nuestro objetivo fue identificar un marcador semiológico útil en la pesquisa del compromiso respiratorio en pacientes con MG.
Se realizó un trabajo observacional en pacientes con diagnóstico de MG. Los pacientes fueron evaluados con test de cuenta máxima, pico flujo espiratorio (PEF), cuestionario de disnea modificado (mMRC) y valoración de fuerza del cuello. Los resultados de estos parámetros fueron correlacionados con la medición de CVF (capacidad vital forzada) y presiones bucales estáticas máximas (Pi_Máx y Pe_Máx).
Cuarenta y cinco pacientes con MG fueron incluidos, dos pacientes tenían MGFA grado I, 35 grado II, siete grado III y uno grado IV al momento de la evaluación. Se halló una correlación positiva entre el test de cuenta máxima y la CVF (r = 0,57, p = 0,000), y entre el PEF y la CVF (r = 0,76, p = 0,000). El grado de disnea, según el mMRC, mostró una correlación negativa con la CVF (r =-0,31 p = 0,03). A su vez, el PEF correlacionó con la Pe_Máx de forma positiva, estadísticamente significativa (r = 0,51, p = 0,002).
El PEF, el test de cuenta máxima y el mMRC fueron útiles para evaluar la función respiratoria en pacientes con MG.
Myasthenia gravis (MG) is an antibody-mediated autoimmune disease characterised by fluctuating, fatigable muscle weakness, frequently involving bulbar and respiratory muscles. Considering the severity of respiratory involvement in MG, routine evaluation of respiratory function is essential.
The aim of this study was to identify a useful clinical marker of respiratory involvement in patients with MG.
We performed an observational study of patients with MG. All cases were evaluated with the single-breath counting test, peak expiratory flow (PEF), a modified Medical Research Council dyspnoea scale (mMRC), and a neck strength assessment. The results of these parameters were correlated with forced vital capacity (FVC), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP).
The study included 45 patients with MG: 2 patients classified as grade I on the Myasthenia Gravis Foundation of America classification at the time of evaluation, 35 classified as grade II, 7 classified as grade III, and one classified as grade IV. Positive correlations were found between single-breath counting test scores and FVC values (r = 0.57, p = .000), and between PEF and FVC values (r = 0.76, p = .000). Severity of dyspnoea according to the mMRC scale showed a negative correlation with FVC values (r = -0.31, p = .03). PEF also showed a significant correlation with MEP (r = 0.51, p = .002).
PEF, the single-breath counting test, and the mMRC scale are useful measures for evaluating respiratory function in patients with MG.
Key4OI Recommendations for Lung Function Guidance in Osteogenesis Imperfecta: Based on an Internationally Performed Comprehensive International Consortium for Health Outcomes Measurement Procedure
2023, Chest
Pulmonary involvement in Osteogenesis Imperfecta (OI) can be severe but may be overlooked in milder cases. The Care4BrittleBones Foundation initiated this project to develop a set of global outcome measures focusing on respiratory-related issues in patients with OI. The objective was to reach an international consensus for a standardized set of outcomes and associated measuring instruments for the pulmonary care of individuals with OI. Based on the initial tests and questionnaires, we suggest parameters for when pulmonologists should seek guidance from the growing literature on OI pulmonary care and/or recognized experts in the field.
The project team consisted of a multidisciplinary mix of 12 people from six countries, including an OI patient representative, and facilitated by the Care4BrittleBones Foundation director. The International Consortium for Health Outcomes Measurement (ICHOM) process was followed, which includes the Delphi method, used to collect the opinions of the expert team. Patient input was present in each meeting due to the inclusion of a patient representative. In addition, online focus groups were held. They consisted of adults with OI from different countries, and they determined which questions matter the most to the OI community worldwide.
After three Delphi rounds, the expert team reached a consensus on the final set of measuring instruments, which included pulmonary function testing and patient self-reporting of symptoms related to breathing and sleep. Two questionnaires were decided upon: St. George’s Respiratory Questionnaire (shortened version) and four questions regarding sleep. Patients should be screened for a history of pneumonia. Advanced testing for select patients by a pulmonologist would include further pulmonary function tests and a chest radiograph.
A standardized set of outcome measures related to pulmonary care of individuals with OI was determined based on what is important to both experts and patients. This included patient-reported outcome measures and basic pulmonary function testing. Using these outcome measures, it can be determined which patients are at high risk for pulmonary complications.

View all citing articles on Scopus

: revision accepted June 18.

View full text

Chest

Clinical Investigations in Critical CareCriteria for Extubation and Tracheostomy Tube Removal for Patients With Ventilatory Failure: A Different Approach to Weaning

Section snippets

Materials and Methods

Results

Discussion

Chest

Chest

Chest

Chest

Chest

The expiratory muscle aids. Chest

Arch Phys Med Rehabil

Phys Med Rehabil Clin North Am

Clinical Investigations in Critical Care
Criteria for Extubation and Tracheostomy Tube Removal for Patients With Ventilatory Failure: A Different Approach to Weaning