• Table E-1
  • Table E-2
  • Noninvasive ventilation during the weaning proccess in chronically critically ILL patients




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    NONINVASIVE VENTILATION DURING THE WEANING PROCCESS IN CHRONICALLY CRITICALLY ILL PATIENTS

    Online Supplemental Material

    Jesus Sancho1, Emilio Servera1,2, Luis Jara-Palomares3, Emilia Barrot3, Raquel Sanchez-Oro-Gómez3, F Javier Gómez de Terreros4,5, M Jesús Martín-Vicente4,5, Isabel Utrabo4,5, M Belen Núñez5,6, Alicia Binimelis5,6, Ernest Sala5,6, Enrique Zamora7, Gonzalo Segrelles7, Angel Ortega-Gonzalez8, Fernando Masa4,5. Spanish Respiratory Intermediate Care Units Group

    1Respiratory Care Unit. Respiratory Medicine Department. Hospital Clínico Universitario, Valencia. Spain. INCLIVA Institute of Health Reasearch. Valencia. Spain

    2Universitat de Valencia. Spain

    3Unidad Médico-Quirurgica de Enfermedades Respiratorias. Hospital Virgen del Rocio. Sevilla. Spain

    4Servicio de Neumología. Hospital San Pedro Alcántara. Cáceres. Spain

    5Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES). IS CIII. Madrid. Spain

    6Servicio de Neumología. Hospital Son Espases. Palma de Mallorca. Spain

    7Intermediate Care Unit. Pulmonology Department. La Princesa Institute for Health Research. Hospital Universitario de La Princesa. Madrid. Spain

    8Servicio de Neumología. Hospital Nuestra Señora del Prado. Talavera de la Reina. Spain

    Conflict of Interest: authors have no financial relationship with any commercial entity that has an interest in the subject of this manuscript.

    Corresponding Author:

    Jesus Sancho

    Respiratory Care Unit. Respiratory Medicine Department

    Hospital Clínico Universitario

    Blasco Ibañez 17

    46010 Valencia. Spain

    jesus.sancho@uv.es



    Key words: noninvasive ventilation, prolonged mechanical ventilation, chronic critical illness, weaning, respiratory failure.

    MATERIAL AND METHOD

    Those patients whose weaning process could not be completed due to the need for MV during the night were transferred to NIV. The criteria for transfer to NIV were: when it proved impossible to increase the duration of SBT beyond 18 hours during 5 consecutive days.5 Two different techniques were used to effect the transfer to NIV. In some RCUs, the tracheostomy was replaced by a tracheal button and NIV was initiated; in others, NIV was applied with the tracheostomy tube having been capped, its cuff deflated, and using a fenestrated inner cannula. A tracheal button (Figure S-1) is a stoma maintenance device that fits from the skin to just inside the anterior wall of the trachea; with this device the patient breaths through the upper airway, when is capped, and when necessary a catheter can be passed through the button for secretions removal. In both cases, NIV was applied through a nasal or oronasal mask in pressure support mode and with oxygen added if necessary. The ventilator was initially set up so as to attain a tidal volume of about 8-10 mL/Kg. The back-up respiratory rate was set at 12 to 16 bpm and the inspiratory trigger sensitivity at –1 cmH2O. The ventilatory parameters were then readjusted in order to achieve effective ventilation (PaCO2 <45mmHg and time spent with SpO2 below 90% at night using NIV <5%). Once NIV was tolerated by the patient and effective ventilation had been achieved the tracheal button or tracheostomy tube was removed and the tracheostomy was closed.



    RESULTS

    In 24 patients a capped tracheostomy tube was used to transfer to NIV and in 16 a tracheal button; no statistical differences were found between the two groups in hospital mortality (8.33% vs 6.25%, p=0.760), stay at RCU (34.43+19.81 vs 56.64+43.81 days, p=0.096) and time from NIV initiation to tracheostomy closure (1.42+1.13 vs 2.30+2.18 days, p=0.307). (Table E1, E2)

    Legends:

    Figure S-1: Tracheal button




    Tracheal button

    n=16

    Capped tracheostomy tube

    n=24

    p

    Gender (Male/Female)

    8/8

    13/19

    0.265

    Age (years)

    67.53+12.04

    63.60+15.47

    0.972

    Cause of Critical illness (medical/surgical)

    11/5

    19/5

    0.549

    Charlson Index

    1.73+1.22

    2.09+1.30

    0.087

    APACHE II

    15.00+3.27

    13.11+2.80

    0.164

    Intensive care stay (days)

    43.54+22.46

    38.57+20.63

    0.643

    MV in intensive care (days)

    34.81+18.45

    35.96+20.69

    0.606

    Weaning time at RCU (days)

    31.33+18.93

    43.00+21.73

    0.087

    pH

    7.39+0.04

    7.39+0.08

    0.972

    PaO2 (mmHg)

    105.50+28.33

    78.28+19.64

    0.006

    PaCO2 (mmHg)

    49.50+0.04

    53.60+7.09

    0.288

    FiO2

    0.36+0.07

    0.39+0.09

    0.413

    Leukocytes (per L)

    10034.66+2878.06

    9810.00+3832.71

    0.850

    Neutrophils (%)

    72.54+12.74

    71.75+11.12

    0.886

    Hemoglobin (g/dL)

    9.38+1.54

    10.27+1.60

    0.205

    Hematocrit (%)

    28.13+4.92

    30.87+5.33

    0.230

    Platelets (per L)

    300600.00+15800.00

    234000.00+76967.52

    0.278

    Sodium (mmol/L)

    138.53+6.61

    140.62+4.90

    0.442

    Potassium (mmol/L)

    4.08+0.39

    4.17+0.77

    0.718

    Blood urea nitrogen (mg/dL)

    53.53+40.99

    75.25+35.06

    0.375

    Creatinine (mg/dL)

    0.91+0.85

    0.87+0.69

    0.908

    Serum albumin (g/dL)

    3.06+0.69

    3.30+0.51

    0.347

    C-reactive protein (mg/L)

    45.66+44.21

    22.31+20.80

    0.175



    Table E-1


    Demographic and clinical data at RCU admission

    of the CCI patients who need NIV during weaning process.

    APACHE: Acute Physiology and Chronic Health Evaluation; CCI: Chronically critically Ill; MV: Mechanical ventilation; NIV: Noninvasive ventilation; RCU: Respiratory Care Unit




    Tracheal button

    n=15

    Capped tracheostomy tube

    n=22

    p

    pH

    7.42+0.04

    7.43+0.03

    0.701

    PaO2 (mmHg)

    80.46+19.98

    71.90+10.47

    0.209

    PaCO2 (mmHg)

    41.60+4.32

    44.72+6.92

    0.169

    FiO2

    0.21+0.1

    0.21+0.01

    0.880



    Table E-2


    Arterial Blood Gases at Hospital discharge of the Chronically CritilalIy Ill patients who need noninvasive ventilation to achieve weaning success.


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    Noninvasive ventilation during the weaning proccess in chronically critically ILL patients

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