Advanced, cost-effective diagnostic, therapeutic, and adaptive modalities, combined with a multidisciplinary approach, help successfully wean a patient with COPD.
A 75-year-old male ex-smoker (of 35 pack-years) affected by chronic obstructive pulmonary disease and arterial hypertension for 5 years, and by chronic respiratory failure for 2 years, presented on April 10, 2001, at the emergency department of Spedali Civile Brescia (Italy) with a severe episode of acute respiratory failure. There was radiographic evidence of pneumonia. The patient was admitted to an ICU for intubation and mechanical ventilation. He was tracheotomized after 10 days in the ICU. After 5 days with a tracheostomy in place, he was transferred to Gussago, Italy, to a weaning center in a pulmonary rehabilitation division, where he underwent weaning from mechanical ventilation.
Upon admission, the patient was ventilated for the first 4 hours using the same mode that had been in use at discharge from the ICU, which was pressure-support ventilation (PSV) at 20 cm H2O plus 5 cm H2O of positive end-expiratory pressure (PEEP). He was also treated medically, and his airway secretions were removed frequently using suction. At the end of this brief period, the patient underwent evaluation by our RT, who performed triage daily to evaluate possible changes and adjust the patient’s rehabilitation program accordingly. Associated with triage was an evaluation intended to define specific bronchial-hygiene and/or pulmonary-expansion treatments that would complement the program. The patient’s admission triage score was 17, reflecting these parameters: he could maintain a sitting position with assistance, he needed complete assistance in performing activities of daily living (ADL), he was unable to walk, he experienced shortness of breath at rest without mechanical ventilation, and he was confined to his house before admission to the hospital. For these reasons, the patient required individual treatment consisting of assisted passive and active mobilization, sitting and standing balance work, and strengthening exercises. Moreover, in the complementary evaluation, the RT underscored the need for bronchial hygiene assistance consisting of forced expiration, postural drainage, and suction. The time required was an hour per day, in one or two sessions.
Weaning Trial
On his second day at the center, the patient was assigned to the weaning protocol: based on his indications, a T-piece weaning trial was carried out. The RT noted the respiratory-function parameters daily and recorded the attainment of the minimum criteria for weaning. The patient exhibited satisfactory neurological status, no agitation, a body temperature of 36°C, a minute ventilation of 13.5 L, respiratory rate on tidal volume ratio (f/VT) =100, a maximal inspiratory pressure (MIP) of 25 cm H2O, a respiratory rate of 18 breaths per minute, a pH of 7.4, a ratio of PaO2 to fraction of inspired oxygen (FIO2) of 160, hemodynamic stability (without the need for a vasopressor), and an oxygen saturation of 94% (with an FIO2 of 40% with 5 cm H2O of PEEP). For these reasons, the patient was allowed to perform the T-piece trial; it failed, however, because the patient showed signs of distress (a respiratory rate of 40 breaths per minute, an oxygen saturation of 86% with an FIO2 of 40%, and a heart rate of 130 beats per minute) an hour after withdrawal from mechanical ventilation. The patient was returned to the same level of mechanical ventilatory support used before withdrawal.
On the third day, the patient was assigned to a weaning protocol using decreasing levels of assistance of PSV, starting from PSV at 14 cm H2O and PEEP at 5 cm H2O. This level of support was decreased by 4 cm H2O per day. On the fourth day, the patient had one episode of respiratory distress, which was interpreted as failure in one weaning step. The patient was reconnected to the ventilator and returned to the previous weaning step until he showed no signs of distress. He maintained 8 consecutive hours at 8 cm H2O of PSV on the fifth day.
On the sixth day, using a portable manometer, the RT measured a MIP of 30 cm H2O and a maximal expiratory pressure (MEP) of 45 cm H2O. Weaning was considered successful on the seventh day because mechanical ventilation was not required within 48 hours of suspension of the protocol.
On the patient’s eighth day at the weaning center, his triage score was 13: he maintained upright posture with assistance, needed moderate assistance for ADLs, walked with assistance, and experienced shortness of breath with light activities. Individual treatment remained most appropriate, with assisted walking and the possibility of upper-limb cycling. Accordingly, the patient underwent a program of endurance training with upper-limb cycling.
On the ninth day, the patient’s cuffed tracheostomy cannula was changed to a type allowing speech. The triage score dropped to 12 on the 10th day; the patient began group treatment in a gym near the weaning room and underwent individual assisted-walking sessions. The group treatment consisted of exercises for respiratory coordination, reinforcement exercises for upper and lower limbs, stretching of the respiratory accessory muscles, active mobilization of the limbs and trunk, and educational sessions. On the 11th day, the patient underwent baseline incremental testing using an upper-limb cycle ergometer with these results: a maximal workload of 17.5 W, a final Borg dyspnea score of 7, a final Borg muscular-fatigue score of 9, and oxygen saturation of 92% at the end of the test (with an FIO2 of 32%).
Rehabilitation
Twelve days after admission to the weaning center, the patient’s baseline endurance test indicated a workload of 9 W, a work time of 10 minutes, and an end-of-test oxygen saturation of 93% at an FIO2 of 32%. The patient began rehabilitation with the training program the next day. On the 14th day, he was discharged from the center to the pulmonary rehabilitation department. His blood-gas levels had been stable for 48 hours (with a pH of 7.42, a PaO2 of 70 mm Hg, and a PaCO2 of 44 mm Hg). He required neither mechanical ventilation nor intravenous therapy.
On the 16th day, however, the patient exhibited signs of thrombosis of the left great saphenous vein. This made it necessary to undertake oral anticoagulant therapy and to suspend group treatment and assisted walking for a week. On the 22nd day, overnight saturation monitoring (without supplemental oxygen use) indicated significant desaturation and confirmed the need for supplemental oxygen therapy at a flow rate of 1 L per minute.
On the 28th day, the patient performed a final incremental test. Maximal workload was 22.5 W (an increase of 28%), isowatt and final Borg dyspnea scores were both 3, isowatt and final Borg muscular-fatigue scores were 4, and oxygen saturation was 92% at the end of the test at an FIO2 of 28%. On the following day, a final endurance test indicated a workload of 9 W, a work time of 19 minutes (a 90% increase), and an oxygen saturation of 92% at the end of the test (the FIO2 was 28%). The figure shows trends for the 15 arm-training sessions. On the 30th day after admission, the patient underwent tracheotomy closure, having met the criteria set for the procedure (first ICU admission, clinical stability, no therapy changes in the past week, 72 hours’ closing of a fenestrated cannula without clinical worsening, expiratory tidal volume of more than 200 mL, MIP of more than 20 cm H2O, MEP of more than 40 cm H2O, suitable cough and efficient expectoration, suitable neurological state, no dysphagia, and no tracheal anatomic alterations).
On the 35th day, the patient’s 6-minute walking test showed a good recovery of exercise tolerance (340 m), a reduced oxygen saturation (87%) during the walk, and light dyspnea and muscular fatigue at the end of exercise. On the next day, he performed an assisted walking test to identify the quantity of oxygen needed during exercise. After that, the 6-minute walking test was repeated with the addition of oxygen at a flow rate of 2 L per minute. There was a good final arterial saturation (93%) with a small increase in distance walked (355 m).
On the 43rd day, the patient’s triage score was 7. He could maintain upright posture without assistance, he was performing ADLs independently, he walked without assistance with pauses, and he experienced shortness of breath during moderate activity performed with pauses (walking uphill and climbing fewer than three flights of stairs). On the following day, he was discharged home after confirmation of greatly reduced dynamic pulmonary volumes and hyperinflation, as well as exercise and nocturnal oxygen demands. His forced expiratory volume in 1 second was 1.2 L (40% of the predicted value), his forced vital capacity was 2.7 L (70% predicted), his residual volume was 222% of the predicted value, and his MIP was 50 cm H2O (46% predicted).
M. Paneroni, RT, is therapist coordinator in the Weaning Center, Fondazione S. Maugeri IRCCS, Gussago, Italy. M. Sarvà, MD, is a doctor in charge at the center. M. Vitacca, MD, is the medical coordinator at the center.
References:
1. Stoller JK, Haney DJ, Burkhart J, et al. Physician-ordered respiratory care versus physician-ordered use of a respiratory therapy consult service: early experience at Cleveland Clinic Foundation. Respir Care. 1993;38:1143-1154.
2. Vitacca M, Vianello A, Colombo D, et al. Comparison of two methods for weaning COPD patients requiring mechanical ventilation for more than 15 days. Am J Respir Crit Care Med. 2001;164:225-230.
