Prolonged Invasive Ventilation Following Acute Ventilatory Failure in COPD: Weaning Results, Survival, and the Role of Noninvasive Ventilation

doi:10.1378/chest.129.1.133

Chest

Volume 129, Issue 1, January 2006, Pages 133-139

https://doi.org/10.1378/chest.129.1.133 Get rights and content

Background

Invasive ventilation for COPD has significant mortality, and weaning can be difficult. At Papworth Hospital, we provide a specialist weaning service using noninvasive ventilation (NIV) for patients requiring prolonged invasive ventilation after recovery from acute illness. We analyzed our results for patients with COPD to identify factors associated with weaning outcome and survival.

Methods

A retrospective analysis was conducted of COPD patients admitted for weaning from invasive ventilation, from 1992 to 2003. Weaning success and survival were assessed. Associations were sought between these outcomes and age, sex, spirometry, arterial blood gas levels, APACHE (acute physiology and chronic health evaluation) II score, length of stay (LOS), and the use of NIV and long-term oxygen therapy.

Results

Sixty-seven patients were identified, all of whom were receiving tracheostomy ventilation on transfer to the Respiratory Support and Sleep Centre (RSSC). Sixty-four patients (95.5%) were weaned, and 62 patients survived to hospital discharge. NIV was used in weaning 40 patients and in the long term in 25 patients. Median survival was 2.5 years (interquartile range, 0.7 to 4.6 years). One-year, 2-year, and 5-year survival rates were 68%, 54%, and 25%, respectively. Long-term survival was inversely associated with age and LOS in the ICU and the RSSC. The provision of maintenance NIV after weaning was associated with better long-term survival, independent of age and LOS (hazard rate, 0.48; p = 0.03).

Conclusions

These results demonstrate that a specialist multidisciplinary approach, including the use of NIV, can be successful in weaning most COPD patients from prolonged invasive ventilation. The data also suggest that long-term NIV may improve survival in selected patients.

Section snippets

Materials and Methods

Patients are referred to the PCP when weaning has failed at the referring ICU. Those accepted for transfer to the RSSC have recovered from the acute illness that precipitated their intubation. Most receive ventilation via tracheostomy and are hemodynamically stable without need of inotropic support.

General Care

Following transfer to our unit, sedating drugs are withdrawn at the first opportunity, and a normal diurnal routine is reinforced. Respiratory function is optimized with bronchodilators and corticosteroids as indicated. Respiratory tract secretions are actively managed with physiotherapy, tracheal suctioning, and the appropriate use of antibiotics. The management of coexisting medical problems is reviewed, and metabolic abnormalities are corrected. Tube enteral feeding is used to optimize

Weaning from IMV

On arrival, IMV is continued, using pressure support ventilation (PSV) with positive end-expiratory pressure aiming to normalize arterial blood gas (ABG) levels. Ventilatory weaning involves the introduction of unsupported spontaneous breathing (USB). Initial brief episodes (up to 30 min) are lengthened according to individual patient progress. This is guided by close clinical observation for respiratory distress, and the use of pulse oximetry, transcutaneous Pco₂ (Ptco₂) monitoring, and ABG

Laryngeal Function and Tracheostomy Management

Effective laryngeal function is a priority. Speaking is encouraged as soon as self-ventilation via a one-way tracheostomy speaking valve is possible without risk of aspiration. Swallowing safety is first assessed with the tracheostomy tube cuff inflated, using oropharyngeal administration of blue food dye followed by tracheal suctioning. If there is no aspiration, dyed fluids and food are tried. Once successful, these steps are repeated with the cuff deflated. Mild aspiration usually improves

Patient Selection

Patients with a discharge diagnosis of COPD were sought from a database of all patients entered into the PCP. The diagnosis was reviewed on the basis of patient history, referring hospital notes, clinical assessment, spirometry, and radiography. Coexisting pulmonary, neuromuscular, or chest wall disorders, or obstructive sleep apnea were exclusion criteria.

Data Collection

A retrospective case note review was performed, and the following data were extracted: age at PCP admission; sex; length of stay (LOS) at referring ICU; LOS in the RSSC; FEV₁; FVC; ABG levels at intubation, at transfer to, and discharge from the PCP; APACHE (acute physiology and chronic health evaluation) II score at ICU admission; ventilation mode and inspired oxygen concentration at RSSC discharge; and discharge destination. The most recent ventilator settings were sought for patients

Outcomes

Weaning success was defined as complete withdrawal of IMV, with or without continuing requirement for nocturnal NIV. Hospital and long-term survival were also measured. Patients with a tracheostomy retained solely for suction were regarded as weaned. Failure to wean was defined as death during the weaning process, or discharge from the RSSC with a continuing requirement for IMV. Long-term survival was assessed using case notes, the hospital computerized patient administration system, and the

Statistical Analysis

Data were analyzed using statistical software (SPSS version 12.0 for Windows; SPSS; Chicago, IL). Long-term survival was assessed with Kaplan-Meier charts and life tables. Associations with survival were sought using Cox regression, with grouped data used when statistically significant but nonlinear relationships were found for continuous variables. Normally distributed data were compared using independent t tests, and nonparametric data were compared with the Mann-Whitney U test.

Results

We accepted 436 patients into the PCP between June 1992 and December 2003, 97 of whom had a discharge diagnosis of COPD. Thirty patients were excluded from the analysis due to coexisting pulmonary, chest-wall or neuromuscular disorders, or obstructive sleep apnea. Demographics, ICU, and weaning data of the remaining 67 patients (36 male) are presented in Table 1.

All 67 patients were receiving tracheostomy ventilation on arrival to the RSSC. Three patients died in the RSSC while receiving IMV,

Patient Characteristics and Correlation With Long-term Survival

Neither weaning success nor hospital survival were associated with age; sex; FEV₁; FVC; APACHE II score on ICU admission; ABG levels at ICU or PCP admission; LOS in the ICU; or use of NIV during weaning. Long-term survival was inversely associated on univariate analysis with age and LOS in the ICU and the RSSC. Patients aged ≥ 70 years on entry to the PCP had a 2.7-fold hazard of dying subsequently, compared to those < 70 years old (95% confidence interval [CI], 1.5 to 4.9; p = 0.001). Patients

Discussion

Exacerbations of COPD requiring hospitalization are associated with substantial hospital and longer-term mortality.³⁴⁶⁷⁸⁹¹⁴ Those cases complicated by acute ventilatory failure frequently require IMV, and weaning can be difficult.¹²¹⁰¹⁵ We report a 95.5% success rate for weaning COPD patients from IMV and 92.5% survival to hospital discharge. These subjects had recovered from the acute illness that precipitated their intubation, were hemodynamically stable, and received ventilation via

ACKNOWLEDGMENT

The authors thank the Intensive Care National Audit and Research Centre for their help in providing APACHE II data, and Fay Cafferty for statistical input.

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The role of interventional bronchoscopy in the management of post-intubation tracheal stenosis: A 20-year experience
2021, Pulmonology
Citation Excerpt :
According to our data, difficult-to-wean patients may be at higher risk of developing complex tracheal stenosis. Evidence has shown that non-invasive ventilation (NIV) may be helpful during the weaning process in specific cases.17–19 A prospective study suggested that NIV may be helpful in achieving weaning in critically ill chronic patients who have hypercapnia after 24 h of spontaneous breathing or are unable to increase the duration of spontaneous breathing beyond 18 h.20 Similarly, a more recent prospective study showed that in tracheostomised patients partially dependent on mechanical ventilation, decannulation is feasible and safe after switching to NIV.21
Benign tracheal stenosis management is still controversial, and there is no international consensus on the best treatment option. Thus, we aimed to look into the history of PITS and the different strategies used in its treatment. The importance of bronchoscopic treatment was also defined, and its effectiveness and safety were assessed.
Retrospective study of patients diagnosed with PITS, who were referred to the Bronchology Department between January 1996 and December 2016.
Of 115 patients enrolled (mean age 48.5 ± 17.6 years, 53% males), 66.1% had complex stenosis. The most common causes of intubation were respiratory (29.9%), neurological (26.8%) and surgical (19.6%). Complex stenosis was caused by longer intubation, and was more frequent among previously tracheostomized patients. The most common location was the upper third of trachea (60.9%). Most cases were initially treated by interventional bronchoscopy, and although serial dilations were effective in some complex PITS, a higher proportion of simple stenosis was successfully managed with this treatment option. Long-term recurrence after serial dilation was observed in 25.0% of cases. Stent placement was required (19.1%) only for complex PITS. Stent-related complications were frequent (61.9%) and linked to the stenting time (p < 0.001). Overall, there were no procedure-related complications. Surgical intervention was also performed (30.0%), always with complex PITS. Post-surgical recurrences were observed in 24.2% of cases.
Interventional bronchoscopy is an efficient and safe modality in PITS management. Further studies are needed for better classification and improved knowledge of PITS pathogenesis, and to achieve international consensus of definition to guide clinicians in their practice.
The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature
2021, Pulmonology
Citation Excerpt :
No data was presented on the percent undergoing successful decannulation, but it was clear that NIV was fundamental in maintaining independent ventilation to permit discharge home. In a similar report, Quinnell et al.23 described a nine-year experience in their weaning centre, focusing on 67 COPD patients with prolonged mechanical ventilation and tracheostomy tubes. They were able to wean 65 (96%) with 62 surviving to discharge, of which NIV was initiated in patients who were unable to tolerate unsupported spontaneous breathing trials without developing respiratory distress or hypercapnia, defined as PaCO2 > 56 mmHg.
Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation.
We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) “non-invasive ventilation”, “tracheostomy” and “weaning”. We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation.
In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge.
The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning.
Predictors of survival after prolonged weaning from mechanical ventilation
2020, Journal of Critical Care
Citation Excerpt :
In the current study, the lost to follow-up rate was only 9.1% (n = 54). In 62 patients with COPD the one-, two-, and five-year survival rates were 68%, 54%, and 25%, respectively [25]. Among 457 patients with prolonged weaning the one-, three-, and five-year survival rates post-discharge were 65%, 41%, and 29%, respectively [18].
Weaning from mechanical ventilation is a key component of intensive care treatment; however, this process may be prolonged as some patients require care at specialised centres. Current data indicate that weaning from invasive mechanical ventilation is successful in approximately 65% of patients; however, data on long-term survival after discharge from a weaning centre are limited.
We analysed predictors of survival among 597 patients (392 men, mean age 68 ± 11) post-discharge from a specialised German weaning centre.
Complete weaning from mechanical ventilation was achieved in 407 (57.8%) patients, and 106 patients (15.1%) were discharged with non-invasive ventilation; thus, prolonged weaning was successful in 72.9% of the patients. The one-year and five-year survival rates post-discharge were 66.5% and 37.1%, respectively. Age, duration of mechanical ventilation, certain clusters of comorbidities, and discharged with mechanical ventilation significantly influenced survival (p < .001). Completely weaned patients who were discharged with a tracheostomy had a significantly reduced survival rate than did those who were completely weaned and discharged with a closed tracheostomy (p = .004).
The identified predictors of survival after prolonged weaning could support therapeutic strategies during patients' intensive care unit stay. Patients should be closely monitored after discharge from a weaning centre.
Weaning from mechanical ventilation. Role of conventional methods and non-invasive ventilation for weaning
2017, Revue des Maladies Respiratoires
Hospital outcomes and long-term survival after referral to a specialized weaning unit
2017, British Journal of Anaesthesia
Citation Excerpt :
Within our service, we use NIV to facilitate decannulation for patients with limited respiratory reserve. In the event of continued ventilatory failure after decannulation, we continue nocturnal NIV on discharge in keeping with evidence of benefit for selected patients with chronic ventilatory failure attributable to neuromuscular,14 COPD,15 or chest wall disorders,16 or after weaning from prolonged IMV.17–19 Compared with the complex and expensive community care requirements for domiciliary tracheostomy ventilation, the relative simplicity of NIV may enable more patients to be discharged home.
Prolonged invasive mechanical ventilation (IMV) is a frequent challenge, and an increasing number of patients are transferred from intensive care units to long-term acute care hospitals or specialized weaning units. There are few published data for discharge home rates, use of noninvasive ventilation (NIV), or long-term survival.
A case-note and database review was conducted of patients admitted to a UK national specialized weaning unit for weaning from IMV between 1992 and 2012. Patients were grouped into diagnostic categories according to the predominant cause of weaning failure. Weaning outcomes and long-term survival were assessed according to diagnostic group and mode of ventilation on discharge.
Four hundred and fifty-eight patients were transferred for weaning from IMV. Four hundred and seventeen (91%) survived to hospital discharge, of whom at least 343 (82%) were ultimately discharged to their own home. Three hundred and thirty (72%) weaned from IMV, of whom 142 weaned from all ventilation and 188 weaned to nocturnal NIV. Weaning success was highest for patients with chronic obstructive pulmonary disease and chest wall disorders. Median survival from unit discharge was 25 months (interquartile range 5–74), with the longest survival seen for patients discharged with nocturnal NIV [37 (12–81) months].
These results confirm successful weaning outcomes for patients transferred to a specialized weaning and long-term ventilation service. In contrast to other service models, most patients achieved discharge to their own home.
Tracheotomy and high-flow oxygen therapy for mechanical ventilation weaning
2017, Revue des Maladies Respiratoires

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Chest

Original Research: Acute Ventilatory FailureProlonged Invasive Ventilation Following Acute Ventilatory Failure in COPD: Weaning Results, Survival, and the Role of Noninvasive Ventilation

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

General Care

Weaning from IMV

Laryngeal Function and Tracheostomy Management

Patient Selection

Data Collection

Outcomes

Statistical Analysis

Results

Patient Characteristics and Correlation With Long-term Survival

Discussion

ACKNOWLEDGMENT

Lancet

Chest

Chest

Chest

Mayo Clin Proc

Br J Anaesth

Chest

Chest

Chest

Respir Med

Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

N Engl J Med

Outcome and function following prolonged mechanical ventilation

Arch Intern Med

Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation

Arch Intern Med

Survival of mechanically ventilated patients admitted to a specialised weaning centre

Intensive Care Med

Mechanically assisted ventilation in a community hospital

Arch Intern Med

Original Research: Acute Ventilatory Failure
Prolonged Invasive Ventilation Following Acute Ventilatory Failure in COPD: Weaning Results, Survival, and the Role of Noninvasive Ventilation