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      Application of heart-rate variability in patients undergoing weaning from mechanical ventilation

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          Abstract

          Introduction

          The process of weaning may impose cardiopulmonary stress on ventilated patients. Heart-rate variability (HRV), a noninvasive tool to characterize autonomic function and cardiorespiratory interaction, may be a promising modality to assess patient capability during the weaning process. We aimed to evaluate the association between HRV change and weaning outcomes in critically ill patients.

          Methods

          This study included 101 consecutive patients recovering from acute respiratory failure. Frequency-domain analysis, including very low frequency, low frequency, high frequency, and total power of HRV was assessed during a 1-hour spontaneous breathing trial (SBT) through a T-piece and after extubation after successful SBT.

          Results

          Of 101 patients, 24 (24%) had SBT failure, and HRV analysis in these patients showed a significant decrease in total power ( P = 0.003); 77 patients passed SBT and were extubated, but 13 (17%) of them required reintubation within 72 hours. In successfully extubated patients, very low frequency and total power from SBT to postextubation significantly increased ( P = 0.003 and P = 0.004, respectively). Instead, patients with extubation failure were unable to increase HRV after extubation.

          Conclusions

          HRV responses differ between patients with different weaning outcomes. Measuring HRV change during the weaning process may help clinicians to predict weaning results and, in the end, to improve patient care and outcome.

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          Most cited references 38

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          Weaning from mechanical ventilation.

          Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.
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            Effect of failed extubation on the outcome of mechanical ventilation.

            To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation. Prospective cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital. The failed extubation group consisted of all patients reintubated within 72 h or within 7 days (if continuous ICU care had been required) of extubation. All others were considered to be successfully extubated. Study end points included hospital death vs survival, the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation, the likelihood of requiring > or = 7 or > or = 14 days of ICU care after extubation, and the need for transfer to either a long-term care or rehabilitation facility among the survivors. Of 289 intubated patients, 247 (85%) were successfully extubated, and 42 (15%) required reintubation for failed extubation (time to reintubation 1.5+/-0.2 days). Reintubation for extubation failure resulted in 12 additional days of mechanical ventilation. When compared with successfully extubated patients, reintubated patients were more likely to die in the hospital (43% vs 12%; p or = 14 days in the ICU after extubation, and six times (p<0.001) more likely to need transfer to a long-term care or rehabilitation facility if they survived. After adjusting for severity of illness and comorbid conditions, extubation failure had a significant independent association with increased risk for death, prolonged ICU stay, and transfer to a long-term care or rehabilitation facility. Extubation failure may serve as an additional independent marker of severity of illness. Alternatively, poor outcomes may be etiologically related to extubation failure. If the latter proves to be the case, identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practices may reduce mortality, duration of ICU stay, and need for transfer to a long-term care facility.
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              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.

               ,  R D Hubmayer,  Stephen Hess (2001)
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                Author and article information

                Contributors
                Journal
                Crit Care
                Crit Care
                Critical Care
                BioMed Central
                1364-8535
                1466-609X
                2014
                23 January 2014
                : 18
                : 1
                : R21
                Affiliations
                [1 ]Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
                [2 ]Department of Traumatology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan
                [3 ]Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
                [4 ]School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
                [5 ]Cardiovascular Center, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
                [6 ]Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
                Article
                cc13705
                10.1186/cc13705
                4056081
                24456585
                Copyright © 2014 Huang et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research

                Emergency medicine & Trauma

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