Algorithm for weaning from mechanical ventilation in children with different types of acute respiratory failure
Keywords:weaning from mechanical ventilation, children, acute respiratory failure
AbstractBackground. Important problem of pediatric intensive care is successful weaning from mechanical ventilation. However, there is no consensus on the basic physiological parameters that have to be achieved during the weaning process for successful patient’s extubation. The purpose of the study was to describe and evaluate the clinical effectiveness of our algorithm for weaning from mechanical ventilation in children with different forms of acute respiratory failure. The study hypothesis was that the duration of weaning from mechanical ventilation does not depend on gas exchange rates (paO2/FiO2 ratio, SpO2/FiO2 ratio, oxygenation index), cardiovascular function (stroke volume index, cardiac index), diaphragm function (amplitude of both hemidiaphragms movement, thickening fraction) and patient’s nutritional status (transthyretin level and transthyretin/C-reactive protein ratio), phosphorus, calcium, and magnesium serum levels. Materials and methods. We conducted a prospective cohort single-center study at the Department of Anesthesiology and Intensive Care of Lviv Regional Children’s Clinical Hospital “OHMATDYT”. We included patients with acute respiratory failure who were mechanically ventilated via endotracheal tube for more than 3 days. Exclusion criteria in this study were: the refusal of the patient’s legal representatives to participate in the study at any of its stages, the patient’s agonizing state upon admission, and initiation of mechanical ventilation in less than 48 h after prior weaning. The study included 89 people aged 1 month — 18 years. All patients were randomly divided into 2 groups (using random.org). Eighty-one individuals were included in the data analysis. We analyzed the frequency of successful weaning from mechanical ventilation (no need in mechanical ventilation for more than 48 h from the moment of patient’s extubation and discontinuation of any mechanical support), as well as the duration of mechanical ventilation and the length of stay in the intensive care unit. Results. During weaning from mechanical ventilation, in addition to the standard clinical examination of patient, we proposed the use of an algorithm, which includes the following steps: transition of the patient into support mode of mechanical ventilation, ultrasound examination of diaphragm function; evaluation of pulmonary shunt and oxygen cost of breathing with paO2/FiO2 ratio or SpO2/FiO2 ratio, oxygenation index; improvement of hemodynamics (achieving normalization of trends of cardiac index and stroke index); optimization of nutritional status and regression of the systemic inflammation response syndrome (by transthyretin level and transthyretin/C-reactive protein ratio); normalization of inorganic phosphorus, magnesium and serum calcium levels. We found that 72.1 % of patients were successfully weaned from mechanical ventilation in group I, while in group II — 86.8 % (p = 0.05). The duration of mechanical ventilation was higher in group II compared to group I: 23.1 ± 2.2 days and 19.4 ± 2.6 days, respectively (p = 0.12). The length of stay in the intensive care unit was higher among patients of group I in comparison with group II: 29.2 ± 3.1 days and 26.5 ± 3.6 days, respectively (p = 0.06). Conclusions. The comprehensive approach, which includes correction of hemodynamic parameters, achievement of optimal gas exchange level, improvement of nutritional status and correction of electrolyte balance with diaphragm-protective mechanical ventilation, allows us to increase the likelihood of successful weaning from mechanical ventilation in children.
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