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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Etiologies of the difficult-to-wean patient

Etiologies of the difficult-to-wean patient
Etiologies Investigations Treatment
Respiratory/ventilatory
Increased ventilatory demand Hypoxemia (eg, atelectasis, morbid obesity, abdominal distension, lung disease, sepsis), elevated dead space (eg, hyperinflation, pulmonary embolism, dehydration), excess carbon dioxide production (eg, fever, infection, overfeeding [refer to nutritional below], metabolic acidosis, or neuropsychiatric factors [eg, delirium, anxiety, pain]). Clinical examination including neurologic examination, chest radiograph, arterial blood gases, routine chemistries, thyroid function tests, nutrition assessment, and occasionally CT chest and/or abdomen or CT angiography. Rarely, nerve conduction studies or bronchoscopy.
  • Treat underlying etiology (eg, bronchodilation, antibiotics, pulmonary toilet, fluids, diuresis). Administer oxygen.
  • Adjust mechanical ventilator settings, when indicated (eg, for auto-PEEP).
  • Correct feeding or metabolic disturbances.
  • Optimize sedative analgesics.
  • Rarely, ETT change, physical therapy, thoracocentesis.
Increased resistive load Bronchoconstriction (eg, COPD, asthma), airway edema (eg, lower respiratory infection), secretions (eg, tracheobronchitis, pneumonia), equipment issues (refer to ventilator circuit below).
Increased elastic load Dynamic hyperinflation (eg, COPD, asthma, increased minute ventilation), alveolar filling (eg, pulmonary edema), atelectasis, pleural disease (eg, pleural effusion, pneumothorax), chest wall disease, or abdominal distension (eg, morbid obesity, ileus, ascites).
Reduced neuromuscular capacity Electrolyte abnormalities (eg, hypophosphatemia, hypomagnesemia, hypocalcemia, hypokalemia), medications (eg, steroids, neuromuscular blocking agents), malnutrition (refer to nutritional below), hypothyroidism, systemic inflammation (eg, sepsis), neuropathy (eg, Guillain-Barré syndrome, critical illness polyneuropathy), and myopathy (eg, critical illness myopathy).
Decreased ventilatory drive Excess sedation, metabolic alkalosis (eg, nasogastric suctioning, volume depletion, diuretics and other causes of chloride depletion), central nervous system disease (eg, stroke, encephalopathy), central sleep apnea, or obesity hypoventilation syndrome.
Cardiac
  Weaning may induce myocardial ischemia in susceptible patients. A continuous multi-lead EKG during SBTs or EKG pre- and post-weaning trial. BNP or N-terminal pro-BNP pre- and post-weaning trial. Transthoracic echocardiography. Rarely, cardiac catheterization.
  • Maximize cardiac medications (eg, beta blockade, diuresis, ACE inhibition, or vasodilators before or during SBT).
  • Rarely, coronary re-perfusion interventions or inotropic agents.
  Pulmonary edema may develop in patients with cardiac dysfunction or ischemia.
  Fluid overload may present similarly in patients with normal cardiac function.
Psychological
  Psychological issues (eg, depression, anxiety, delirium, pain) and oversedation may limit ventilation and impede cooperation with an SBT. Clinical history and examination including pain assessment.
  • Patient education, optimize sedative analgesia medications, which may involve increasing, adjusting, or weaning psychoactive medications.
Ventilator circuit
  Equipment dead space, circuit compliance, gas compression volume, exhalation valve dysfunction, and increased resistance (eg, ETT luminal narrowing due to inspissated secretions and debris or small-sized ETT). Examine waveforms (eg, ventilator asynchrony), ventilator pressures (eg, peak inspiratory pressure, plateau pressure), and equipment (eg, blocked exhalation valve, excess condensation).
  • Equipment modifications (eg, change tubing, ventilator, ETT, etc), pulmonary toilet.
Nutritional
  Protein catabolism and underfeeding leading to respiratory muscle weakness. Overfeeding leading to increased carbon dioxide production and increased ventilatory load. Calculate nutrition needs.
  • Administer adequate nutrition.
COPD: chronic obstructive pulmonary disease; CT: computed tomography; PEEP: positive end-expiratory pressure; ETT: endotracheal tube; EKG: electrocardiogram; SBT: spontaneous breathing trial; BNP: brain natriuretic peptide; ACE: angiotensin converting enzyme.
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