Respiratory muscles and weaning failure

Vassilakopoulos, T.; Zakynthinos, Spyros; Roussos, Ch.

doi:10.1183/09031936.96.09112383

Cited by 118 publications

(94 citation statements)

References 111 publications

(153 reference statements)

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“…Although controversy exists, it has been predicted that depressed strength and endurance of respiratory muscles can play a key role in weaning difficulties (26,34,115). However, direct evidence demonstrating cause and effect that VIDD is primarily responsible for weaning problems is lacking due to the difficulty of performing these experiments in humans.…”

Section: Contribution Of Vidd To Weaning Failurementioning

confidence: 99%

“…The causes of weaning failure can be multifactorial and include aspects such as medications (e.g., neuromuscular blockers), confounding morbidities (e.g., sepsis), psychological factors (i.e., anxiety), neurological disorders, and an imbalance between respiratory load and the respiratory muscle capacity (26,43,71,115). Although controversy exists, it has been predicted that depressed strength and endurance of respiratory muscles can play a key role in weaning difficulties (26,34,115).…”

Section: Contribution Of Vidd To Weaning Failurementioning

confidence: 99%

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Ventilator-induced diaphragm dysfunction: cause and effect

Powers

Wiggs

Sollanek

et al. 2013

American Journal of Physiology-Regulatory, Integrative and Comp

143

156

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Powers SK, Wiggs MP, Sollanek KJ, Smuder AJ. Ventilator-induced diaphragm dysfunction: cause and effect. Am J Physiol Regul Integr Comp Physiol 305: R464 -R477, 2013. First published July 10, 2013 doi:10.1152/ajpregu.00231.2013 is used clinically to maintain gas exchange in patients that require assistance in maintaining adequate alveolar ventilation. Common indications for MV include respiratory failure, heart failure, drug overdose, and surgery. Although MV can be a life-saving intervention for patients suffering from respiratory failure, prolonged MV can promote diaphragmatic atrophy and contractile dysfunction, which is referred to as ventilator-induced diaphragm dysfunction (VIDD). This is significant because VIDD is thought to contribute to problems in weaning patients from the ventilator. Extended time on the ventilator increases health care costs and greatly increases patient morbidity and mortality. Research reveals that only 18 -24 h of MV is sufficient to develop VIDD in both laboratory animals and humans. Studies using animal models reveal that MV-induced diaphragmatic atrophy occurs due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, autophagy, and the ubiquitin-proteasome system as key proteases that participate in MV-induced diaphragmatic proteolysis. The challenge for the future is to define the MV-induced signaling pathways that promote the loss of diaphragm protein and depress diaphragm contractility. Indeed, forthcoming studies that delineate the signaling mechanisms responsible for VIDD will provide the knowledge necessary for the development of a pharmacological approach that can prevent VIDD and reduce the incidence of weaning problems. respiratory muscle; atrophy; mechanical ventilation; weaning; muscle wasting MECHANICAL VENTILATION (MV) is used clinically to achieve sufficient pulmonary gas exchange in patients unable to sustain adequate alveolar ventilation on their own. Common indications for MV include respiratory failure due to chronic obstructive pulmonary disease, status asthmaticus, and/or heart failure. In addition, MV is often an essential intervention in patients suffering from acute drug overdose, neuromuscular diseases, sepsis, and during surgery along with postsurgical recovery.The number of patients receiving prolonged MV in the United States exceeds more than 300,000 each year in the intensive care unit (ICU) (20). Although MV can be a lifesaving measure, prolonged MV results in the rapid development of diaphragmatic weakness due to both atrophy and contractile dysfunction. This detrimental impact of prolonged MV on the diaphragm has been termed ventilator-induced diaphragmatic dysfunction (VIDD) and VIDD is predicted to be a major contributor to problems in weaning patients from the ventilator (26, 114). Although previous reports describing the impact of prolonged MV on the diaphragm have appeared in the literature, advances in our understanding of the mechanisms responsible for VIDD h...

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Section: Contribution Of Vidd To Weaning Failurementioning

confidence: 99%

Section: Contribution Of Vidd To Weaning Failurementioning

confidence: 99%

Ventilator-induced diaphragm dysfunction: cause and effect

Powers

Wiggs

Sollanek

et al. 2013

American Journal of Physiology-Regulatory, Integrative and Comp

143

156

View full text Add to dashboard Cite

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“…Factors predisposing to respiratory muscle fatigue are those that increase inspiratory muscle energy demands and/or decrease energy supplies [7]. Energy demands are determined by the work of breathing and the strength and efficiency of the inspiratory muscles ( fig.…”

Section: Hypercapnic (Type Ii) Respiratory Failurementioning

confidence: 99%

Respiratory failure

Roussos¹,

Koutsoukou²

2003

Eur Respir J

382

182

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Respiratory failure occurs due mainly either to lung failure resulting in hypoxaemia or pump failure resulting in alveolar hypoventilation and hypercapnia. Hypercapnic respiratory failure may be the result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers.Hypercapnic respiratory failure may occur either acutely, insidiously or acutely upon chronic carbon dioxide retention. In all these conditions, pathophysiologically, the common denominator is reduced alveolar ventilation for a given carbon dioxide production.Acute hypercapnic respiratory failure is usually caused by defects in the central nervous system, impairment of neuromuscular transmission, mechanical defect of the ribcage and fatigue of the respiratory muscles.The pathophysiological mechanisms responsible for chronic carbon dioxide retention are not yet clear. The most attractive hypothesis for this disorder is the theory of “natural wisdom”. Patients facing a load have two options, either to push hard in order to maintain normal arterial carbon dioxide and oxygen tensions at the cost of eventually becoming fatigued and exhausted or to breathe at a lower minute ventilation, avoiding dyspnoea, fatigue and exhaustion but at the expense of reduced alveolar ventilation. Based on most recent work, the favoured hypothesis is that a threshold inspiratory load may exist, which, when exceeded, results in injury to the muscles and, consequently, an adaptive response is elicited to prevent and/or reduce this damage. This consists of cytokine production, which, in turn, modulates the respiratory controllers, either directly through the blood or probably the small afferents orviathe hypothalamic-pituitary-adrenal axis. Modulation of the pattern of breathing, however, ultimately results in alveolar hypoventilation and carbon dioxide retention.

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“…Gas exchange, respiratory central drive, respiratory muscle capacity, and respiratory muscle workload are the 4 most important indicators of respiratory function in determining patients' ability to tolerate weaning from mechanical ventilation. 10,25 Therefore, we use them as indicators of respiratory function.…”

Section: A Pavlovian-inspired Approach For Repeated Ventilator Weaninmentioning

confidence: 99%

Psychophysiological Determinants of Repeated Ventilator Weaning Failure: An Explanatory Model

Chen¹,

Jacobs²,

Quan³

et al. 2011

American Journal of Critical Care

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BackgroundThe adverse effects of a failed ventilator weaning trial on the subsequent weaning attempts are not well understood. Objectives To examine physiological and psychological factors that may be predictive of risk for repeated weaning failures and prolonged mechanical ventilation. Methods A prospective predictive study of 102 subjects, age 34 to 91 years, whose first ventilator weaning trial was unsuccessful but who were physiologically ready for another weaning attempt. Subjects were recruited from intensive care units and a respiratory care center of a tertiary medical center. Validated self-report scales and a Bicore monitoring system were used to measure ventilator patients' psychophysio log ical performance during the second weaning trial. Structural equation modeling was used to analyze the data and test the model. Results Significant causal pathways were found between fear and anxiety (r = 0.77; P < .001), anxiety and respiratory function (r = 0.24; P < .05), and respiratory function and weaning outcomes (r = 0.42; P < .001). The overall model predicted that both physiological and psychological factors were important in determining repeated failure of ventilator weaning, and the data were in support of the model (χ 2 = 29.49, P > .05). Conclusions Patients whose first ventilator weaning trial is unsuccessful may be markedly fearful. Left unaddressed, these fears cause high anxiety levels that significantly compromise respiratory function and contribute to subsequent weaning failures. Thus begins a vicious cycle of repeated failure of ventilator weaning and prolonged mechanical ventilation. (American Journal of Critical Care. 2011;20:292-302) Unfortunately, we know little about why ventilator weaning is repeatedly unsuccessful in 1 in 5 patients, causing the patients to continue receiving mechanical ventilation longer than is physiologically necessary.8 Using an interdisciplinary approach for this study, incorporating psychological and physiological determinants, we developed an explanatory model of repeated ventilator weaning failure to advance knowledge in this field. Literature Review Physiological Weaning Indicators Are Predominant in Contemporary StudiesSahn and Lakshminarayan 9 documented important physiological predictors of successful ventilator weaning 4 decades ago. Currently, 3 of the most important predictors are gas exchange, neuromuscular competence of the respiratory system, and severity of respiratory workload.10 These physiological indicators, however, have shown poor value as predictors of ventilator weaning. More recently, in an effort to improve overall weaning success, the field has concentrated on identifying the causes that underlie failure of ventilator weaning and identifying other useful predictors of successful ventilator weaning. Owing to the differences among studies in the population of patients studied, the prevalence of weaning success, the duration of mechanical ventilation before weaning, and the applied thresholds, it is difficult to find one predictive indicat...

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Respiratory muscles and weaning failure

Cited by 118 publications

References 111 publications

Ventilator-induced diaphragm dysfunction: cause and effect

Ventilator-induced diaphragm dysfunction: cause and effect

Respiratory failure

Psychophysiological Determinants of Repeated Ventilator Weaning Failure: An Explanatory Model

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