Destete en una UCI polivalente
Incidencia y factores de riesgo de fracaso. Valoración de índices predictivos
Palabras clave:
DESCONEXIÓN DEL VENTILADOR, FACTORES DE RIESGO, INCIDENCIA
Resumen
Introducción: la desvinculación de la ventilación mecánica (VM) es controversial. Su fracaso genera morbimortalidad.
Objetivos: determinar incidencia de destete, factores de riesgo de fracaso: necesidad de reintubación antes de 48 horas posextubación, valoración de índices predictivos.
Material y método: estudio prospectivo. Cohorte abierta, adultos destetados de VM por 24 horas o más, período mayo de 2010 a junio de 2011. Excluidos: traqueostomizados. Evaluados diariamente con parámetros clínico-gasométricos para prueba de ventilación espontánea, medición previa: presión inspiratoria máxima (Pimax), presión-oclusión en primeros 100 milisegundos de inicio de inspiración (P0.1), cociente P0.1/ Pimax. Previo a extubar: medida del índice de Yang-Tobin (frecuencia respiratoria/volumen corriente en litros).
Resultados: 78 pacientes, 58,7 años ± 21,4 (edad media ± 1 desvío estándar), 59% hombres; 61,5%, destete simple en tubo T. Fracaso de destete: 12,8%. Fracción de eyección del ventrículo izquierdo (FEVI) < 45% determinó riesgo relativo de destete dificultoso o prolongado = 3,08, intervalo de confianza (IC) 95%, 1,72-5,51 (p = 0,0001) y fue el único factor de riesgo independiente de fracaso (regresión logística), Odds Ratio = 6,01, IC 95%, 1,40-25,72, (p=0,01). Fueron estadísticamente significativas las diferencias en grupos éxito y fracaso de: balance hídrico en últimas 24 horas, p = 0,002; Pimax, p = 0,006; P0.1, p = 0,04; P0.1/Pimax, p = 0,0001; índice Yang-Tobin, p = 0,03. Mortalidad 30% en fracaso y 4,4% en éxito, p = 0,03. Áreas bajo la curva ROC ("receiver operating characteristic") de significación estadística para Pimax: 0,77, IC 95%, 0,62-0,92; P0.1: 0,70, IC 95%, 0,51-0,90; P0.1/Pimax: 0,85, IC 95%, 0,73-0, 97.
Conclusiones: incidencia de destete simple menor a los reportes. Fracaso connota mayor mortalidad. FEVI < 45%: factor de riesgo independiente de fracaso. Índices predictivos P0.1, Pimax, P0.1/Pimax significativos.
Citas
(1) Alía I, Esteban A. Weaning from mechanical ventilation. Crit Care 2000; 4(2):72-80.
(2) MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120(6 Suppl):375S-95S.
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(4) Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29(5):1033-56.
(5) Brochard L, Thille AW. What is the proper approach to liberating the weak from mechanical ventilation? Crit Care Med 2009; 37(10 Suppl):S410-5.
(6) Eskandar N, Apostolakos MJ. Weaning from mechanical ventilation. Crit Care Clin 2007; 23(2):263-74.
(7) Goldstone J. The pulmonary physician in critical care. 10: difficult weaning. Thorax 2002; 57(11):986-91.
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(18) Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN, et al. A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med 2006; 34(10):2530-5.
(19) El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care 2008; 12(4):221.
(20) De Bast Y, De Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002; 28(9):1267-72.
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(26) Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care 2003; 9(1):59-66.
(27) Seymour CW, Martinez A, Christie JD, Fuchs BD. The outcome of extubation failure in a community hospital intensive care unit: a cohort study. Crit Care 2004; 8(5):R322-7.
(28) Frutos-Vivar F, Esteban A. When to wean from a ventilator: an evidence-based strategy. Cleve Clin J Med 2003; 70(5):389, 392-3, 397.
(29) Esteban A, Alía I, Gordo F, Fernández R, Solsona JF, Vallverdú I, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1997; 156(2 Pt 1):459-65.
(30) Smyrnios NA, Connolly A, Wilson MM, Curley FJ, French CT, Heard SO, et al. Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation. Crit Care Med 2002; 30(6):1224-30.
(31) Esteban A, Alía I, Tobin MJ, Gil A, Gordo F, Vallverdú I, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999; 159(2):512-8.
(32) Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120(4):1262-70.
(33) Hurtado FJ, Berón M, Olivera W, Garrido R, Silva J, Caragna E, et al. Gastric intramucosal pH and intraluminal PCO2 during weaning from mechanical ventilation. Crit Care Med 2001; 29(1):70-6.
(34) Segal LN, Oei E, Oppenheimer BW, Goldring RM, Bustami RT, Ruggiero S, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med 2010; 36(3):487-95.
(35) Epstein CD, Peerless JR. Weaning readiness and fluid balance in older critically ill surgical patients. Am J Crit Care 2006; 15(1):54-64.
(36) Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med 2005; 31(12):1643-7.
(37) Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998; 158(2):489-93.
(38) Schifelbain LM, Vieira SR, Brauner JS, Pacheco DM, Naujorks AA. Echocardiographic evaluation during weaning from mechanical ventilation. Clinics (Sao Paulo) 2011; 66(1):107-11.
(39) Voga G. Hemodynamic changes during weaning: can we assess and predict cardiac-related weaning failure by transthoracic echocardiography? Crit Care 2010; 14(4):174.
(2) MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120(6 Suppl):375S-95S.
(3) Epstein SK. Weaning from ventilatory support. Curr Opin Crit Care 2009; 15(1):36-43.
(4) Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29(5):1033-56.
(5) Brochard L, Thille AW. What is the proper approach to liberating the weak from mechanical ventilation? Crit Care Med 2009; 37(10 Suppl):S410-5.
(6) Eskandar N, Apostolakos MJ. Weaning from mechanical ventilation. Crit Care Clin 2007; 23(2):263-74.
(7) Goldstone J. The pulmonary physician in critical care. 10: difficult weaning. Thorax 2002; 57(11):986-91.
(8) Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150(4):896-903.
(9) Esteban A, Frutos F, Tobin MJ, Alía I, Solsona JF, Valverdú I, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med 1995; 332(6):345-50.
(10) Meade M, Guyatt G, Griffith L, Booker L, Randall J, Cook DJ. Introduction to a series of systematic reviews of weaning from mechanical ventilation. Chest 2001; 120(6 Suppl):396S-9S.
(11) Vallverdú I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 1998; 158(6):1855-62.
(12) Foti G, Cereda M, Banfi G, Pelosi P, Fumagalli R, Pesenti A. End-inspiratory airway occlusion: a method to assess the pressure developed by inspiratory muscles in patients with acute lung injury undergoing pressure support. Am J Respir Crit Care Med 1997; 156(4 Pt 1):1210-6.
(13) Krieger BP, Isber J, Breitenbucher A, Throop G, Ershowsky P. Serial measurements of the rapid-shallow-breathing index as a predictor of weaning outcome in elderly medical patients. Chest 1997; 112(4):1029-34.
(14) Tobin MJ, Jubran A. Variable performance of weaning-predictor tests: role of Bayes' theorem and spectrum and test-referral bias. Intensive Care Med 2006; 32(12):2002-12.
(15) Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324(21):1445-50.
(16) Capdevila XJ, Perrigault PF, Perey PJ, Roustan JP, d'Athis F. Occlusion pressure and its ratio to maximum inspiratory pressure are useful predictors for successful extubation following T-piece weaning trial. Chest 1995; 108(2):482-9.
(17) Conti G, Montini L, Pennisi MA, Cavaliere F, Arcangeli A, Bocci MG, et al. A prospective, blinded evaluation of indexes proposed to predict weaning from mechanical ventilation. Intensive Care Med 2004; 30(5):830-6.
(18) Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN, et al. A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med 2006; 34(10):2530-5.
(19) El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care 2008; 12(4):221.
(20) De Bast Y, De Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002; 28(9):1267-72.
(21) Frutos-Vivar F, Ferguson ND, Esteban A, Epstein SK, Arabi Y, Apezteguía C, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130(6):1664-71.
(22) Caille V, Amiel JB, Charron C, Belliard G, Vieillard Baron A,Vignon P. Echocardiography: a help in the weaning process. Crit Care 2010; 14(3):R120.
(23) Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342(20):1471-7.
(24) Meade MO, Guyatt GH, Cook DJ, Sinuff T, Butler R. Trials of corticosteroids to prevent postextubation airway complications. Chest 2001; 120(6 Suppl):464S-8S.
(25) Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13(10):818-29.
(26) Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care 2003; 9(1):59-66.
(27) Seymour CW, Martinez A, Christie JD, Fuchs BD. The outcome of extubation failure in a community hospital intensive care unit: a cohort study. Crit Care 2004; 8(5):R322-7.
(28) Frutos-Vivar F, Esteban A. When to wean from a ventilator: an evidence-based strategy. Cleve Clin J Med 2003; 70(5):389, 392-3, 397.
(29) Esteban A, Alía I, Gordo F, Fernández R, Solsona JF, Vallverdú I, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1997; 156(2 Pt 1):459-65.
(30) Smyrnios NA, Connolly A, Wilson MM, Curley FJ, French CT, Heard SO, et al. Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation. Crit Care Med 2002; 30(6):1224-30.
(31) Esteban A, Alía I, Tobin MJ, Gil A, Gordo F, Vallverdú I, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999; 159(2):512-8.
(32) Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120(4):1262-70.
(33) Hurtado FJ, Berón M, Olivera W, Garrido R, Silva J, Caragna E, et al. Gastric intramucosal pH and intraluminal PCO2 during weaning from mechanical ventilation. Crit Care Med 2001; 29(1):70-6.
(34) Segal LN, Oei E, Oppenheimer BW, Goldring RM, Bustami RT, Ruggiero S, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med 2010; 36(3):487-95.
(35) Epstein CD, Peerless JR. Weaning readiness and fluid balance in older critically ill surgical patients. Am J Crit Care 2006; 15(1):54-64.
(36) Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med 2005; 31(12):1643-7.
(37) Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998; 158(2):489-93.
(38) Schifelbain LM, Vieira SR, Brauner JS, Pacheco DM, Naujorks AA. Echocardiographic evaluation during weaning from mechanical ventilation. Clinics (Sao Paulo) 2011; 66(1):107-11.
(39) Voga G. Hemodynamic changes during weaning: can we assess and predict cardiac-related weaning failure by transthoracic echocardiography? Crit Care 2010; 14(4):174.
Publicado
2013-06-30
Cómo citar
1.
França AG, Ebeid A, Formento C, Loza D. Destete en una UCI polivalente. Rev. Méd. Urug. [Internet]. 30 de junio de 2013 [citado 24 de noviembre de 2024];29(2):85-6. Disponible en: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/285
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