Reducing Airway Occlusion Time Without Losing Accuracy to Predict Successful Mechanical Ventilator Liberation During the Measurement of the Timed Inspiratory Effort Index

Abstract

BACKGROUND:

In 2013, a new predictor of successful mechanical ventilation liberation named timed inspiratory effort (TIE) index was devised with the normalization of the maximum inspiratory pressure (obtained within 60 s of unidirectional airway occlusion) with the time at which the value was reached. The aim of this study was to verify whether the presence of a sequence of a certain number of inspiratory effort values between 30–60 s > 1.0 cm H₂O/s could predict weaning success in a performance comparable to the TIE index.

METHODS:

This was a retrospective observational study using 4 databases of previous studies on the TIE index. All patients receiving mechanical ventilation for ≤ 24 h were eligible. Liberation from mechanical ventilation-extubation decisions was made based on performance with spontaneous breathing trials. P < .05 was considered significant. The performance of the TIE index was evaluated by calculating the area under the receiver operating characteristics (AUROC) curve.

RESULTS:

From 349 eligible patients, 165 subjects were selected for analysis. The AUROC for the TIE index in the studied sample was 0.92 (95% CI 0.87–0.97, P < .001). A sequence of ≤ 4 inspiratory efforts > 1.0 cm H₂O/s was found in 51.5% of the subjects, with successful ventilatory liberation occurring in 95.3%. The highest specificity values belonged to the sequence of ≤ 4 and ≤ 5 inspiratory efforts > 1.0 cm H₂O/s; the highest positive predictive value and positive likelihood ratio belonged to the sequence of ≤ 4 inspiratory efforts > 1.0 cm H₂O/s. The mean time that could have been spared if the procedure were interrupted after the first sequence of 4 inspiratory efforts > 1.0 cm H₂O/s was 23 ± 3 s.

CONCLUSIONS:

The presence of a sequence of ≤ 4 inspiratory efforts > 1.0 cm H₂O/s during the TIE index measurement was a reliable predictor of weaning success, which could allow timely interruption of the procedure and entail a substantial reduction in airway occlusion time

Keywords

Mechanical ventilation acute breathing insufficiency weaning from mechanical ventilation weaning predictive index respiratory muscle

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References

Boles

, Bion

, Connors

, Herridge

, Marsh

, Melot

, et al. Weaning from mechanical ventilation. Eur Respir J, 2007; 29(5):1033-1056.

Goldwasser

, Farias

, Freitas

, Saddy

, Amado

, Okamoto

. Desmame e interrupção da ventilação mecânica. In: Carvalho CR, coordinator. J Bras Pneumol, 2007; 33 Suppl 2S(Suppl 2S):S128-S136.

Jubran

, Grant

BJB

, Duffner

, Collins

, Lanuza

, Hoffman

, Tobin

. Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation. A randomized trial. JAMA, 2013; 309(7):671-677.

Béduneau

TPG

, Schortgen

, Piquilloud

, Zogheib

, Jonas

, Brochard

, et al.; WIND (Weaning according to a New Definition) Study Group and the REVA (Réseau Européen de Recherche en Ventilation Artificielle) Network. Epidemiology of weaning outcome according to a new definition. The WIND study. Am J Respir Crit Care Med, 2017; 195(6):772-783.

Thille

, Gacouin

, Coudroy

, Ehrmann

, Quenot

, Nay

, et al.; REVA Research Network. Spontaneous breathing trials with pressure support ventilation or T-piece. N Engl J Med, 2022; 387(20):1843-1854.

Sahn

, Lakshminarayan

. Bedside criteria for discontinuation of mechanical ventilation. Chest, 1973; 63(6):1002-1005.

Marini

, Smith

, Lamb

. Estimation of inspiratory muscle strength in mechanically ventilated patients: the measurement of maximal inspiratory pressure. J Crit Care Med, 1986; 1(1):32-38.

Multz

, Aldrich

, Prezant

, Karpel

, Hendler

. Maximal inspiratory pressure is not a reliable test of inspiratory muscle strength in mechanically ventilated patients. Am Rev Respir Dis, 1990; 142(3):529-532.

Yang

, Tobin

. A prospective study of indices predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med, 1991; 324(21):1445-1450.

10.

Sassoon

, Mahutte

. Airway occlusion pressure and breathing pattern as predictors of weaning outcome. Am Rev Respir Dis, 1993; 148(4 Pt 1):860-866.

11.

Caruso

, Friedrich

, Denari

, Ruiz

SAL

, Deheinzelin

. The unidirectional valve is the best method to determine maximal inspiratory pressure during weaning. Chest, 1999; 115(4):1096-1101.

12.

Nemer

, Barbas

CSV

, Caldeira

, Cárias

, Santos

, Almeida

, et al. A new integrative weaning index of discontinuation from mechanical ventilation. Crit Care, 2009; 13(5):R152-9.

13.

Souza

, Silva

Jr , Almeida

, Lugon

. Comparison of maximal inspiratory pressure, tracheal airway occlusion pressure, and its ratio in the prediction of weaning outcome: impact of the use of a digital vacuometer and the unidirectional valve. Respir Care, 2012; 57(8):1285-1290.

14.

Souza

, Guimarães

, Lugon

. Evaluation of a new index of mechanical ventilation weaning: the timed inspiratory effort. J Intensive Care Med, 2015; 30(1):37-43.

15.

Souza

, Guimarães

, Lugon

. The timed inspiratory effort: a promising index of mechanical ventilation weaning for patients with neurologic or neuromuscular diseases. Respir Care, 2015; 60(2):231-238.

16.

Cordeiro de Souza

, Campos

, Daher

, Furtado da Silva

, Ventura

, do Prado

, et al. Mechanical ventilation weaning in inclusion body myositis: feasibility of isokinetic inspiratory muscle training as an adjunct therapy. Case Rep Crit Care, 2014; 2014:902541.

17.

Souza

, Abreu

, Pinto

, Ribeiro

, Godoy

MDP

, Junior

WAS

, et al. Inspiratory muscle training with isokinetic device to help ventilatory weaning in a patient with Guillain-Barré syndrome by Zika virus. Case Rep Crit Care, 2018; 2018:1-5.

18.

Guimarães

BLS

, Souza

, Guimarães

, Lugon

. Serial weekly measurements of the timed inspiratory effort index can predict successful prolonged weaning. Respir Care, 2019; 64(10):1286-1292.

19.

da Silva Neto

, de Souza

, Costa

, Guimarães

, de Azeredo

, Godoy

MDP

, Lugon

. The timed inspiratory effort index as a weaning predictor: analysis of intra- and Inter-observer reproducibility. Respir Care, 2020; 65(5):636-642.

20.

Godoy

MDP

, de Souza

, da Silva Neto

, Lugon

. Comparison of the timed inspiratory effort index with the T-piece trial as decision making tool for extubation: a randomized controlled non-inferiority trial. Braz J Med Biol Res, 2023; 56:e12824.

21.

Esteban

, Alía

, Tobin

, Gil

, Gordo

, Vallverdú

, 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):512-518.

22.

Epstein

. Routine use of weaning predictors: not so fast. Crit Care, 2009; 13(5):197.

23.

Epstein

. Weaning from ventilatory support. Curr Opin Crit Care, 2009; 15(1):36-43.