SCCM Resource Library-Association of Maximal Inspiratory Pressure and Weaning in Patients Undergoing Diaphragm Pacing

Video Transcription

Hello everyone, my name is Martin Dress, I am very happy to have this opportunity to present this work and I would really like to thank the  organizing committee for giving me this opportunity. The title of this work is the association of maximum inspiratory pressure and  victorious for patients experiencing diaphragmatic pressure. There is my conflict of interest, I think it is important to mention that  This studio was funded and sponsored by the Medical Ombudsman.  The context of the work is diaphragmatic dysfunction which is very prevalent in patients in the ICU when they are exposed to mechanical ventilation.  It has been established that diaphragmatic dysfunction is present in more than 60% of patients,  especially at the hour of victory, and that can be a problem in releasing  ventilation patients.  Here in this studio, we wanted to address the following hypothesis that we could  mitigate and correct the diaphragmatic dysfunction of VIDD ventilation with a new technique which is temporary transvenus-diaphragmic neurostimulation.  For this, we used a new tool which is the intravenous intestinal catheter,  the living catheter, which is a type of catheter that we can use every day in our ICU,  but which has some electrodes on the central part and at the end which can  provide stimulation directly to the phrenic nerves when the catheter is inserted into the  left subclavian of the intestine. And then, this catheter, which can be used to administer  fluids or drugs to the patient, is also connected to a controller that can  stimulate, provide stimulation to the phrenic nerves and then generate diaphragmatic contraction.  Therefore, the eligibility criteria and assessment of the results of our study were as follows.  Key study eligibility criteria where the patient has been mechanically ventilated for more than  four days and, obviously, who had met the eligibility criteria and who failed at least  two attempts at victory. And on the other part, the assessment of the results where the measurement of the  proportion of patients who managed to have been taken off the ventilator by day 30. And we also  had some eligibility criteria regarding safety and change in maximum inspiratory pressure.  This is the study design. This was a multicenter, prospective, randomized, controlled study,  studied on the open screen. It was conducted in France and Germany. It was a randomized study,  one on one, with a group with a standard of care, with a protocolized victory  on all centers. And on the other group, the intervention group, the treatment group,  patient had victory standard of care, plus cathedral insertion and stimulation  which were carried out twice a day, in the morning and in the evening, 120 stimulations per day.  So, we randomized 112 patients, 55 into the victory care group and 57 into the treatment group,  because some patients could not have the cathedral in place or because in  in certain situations it was not possible to do the stimulation. At the end, we compared 43 patients  in the treatment group and 55 in the victory care group. Therefore, the statistical analysis that  I will show you now is the analysis based on the baseline value of maximum inspiratory pressure.  The low maximum inspiratory pressure when it was below 30 centimeters of water and the pressure  maximum inspiratory high when it was higher than 30 centimeters of water.  Here you have the main baseline patient characteristic on inclusion.  In particular, it is important to note that the BMI was quite high, 27 in the treatment group and  25 in the victory care group and there was a small imbalance for this variable and also  the maximum inspiratory pressure which was significantly unfortunate, but significantly  low in the treatment group, 25 versus 33. It is also important to take into account that almost  50% of patients were customized for inclusion and duration of mechanical ventilation  before recording was 26 days in the treatment group and 29 in the victory care group.  These are the main results here, the proportion of successful wins on studio day 30 defined by the MIP base.  In red, these are the patients who were registered in the treatment group.  In blue, patients in the control group. So as you can see, if we look  on the left, the top victory care group, there were 100% of patients who had the treatment  who eventually had a successful victory and 82% of the control group of patients in the  control group and in patients with low PID, as experienced, the proportion of  Victory success was lower, but it was higher in the treatment group, 73% compared to 60%.  in the control group, but it is also important to say that the differences are not significant.  We also look at the duration of mechanical ventilation over studio day 30,  once again defined by the MIP base. Here you can see that, as experienced, again, the patient with  the highest level of MIP had reduced duration of mechanical ventilation. It was 10 days,  say 11 days for patient in treatment group  with a high MIP, compared to 11 days also for the patient in the control group.  And on the other hand, for the patient with a low level of MIP, there was a higher difference,  although it was not significant, with 14 days in the group of patients who had the treatment  and almost 19 days in the control group. We also looked at the safety assessment.  There was a similar proportion of serious adverse events in both groups, with no adverse device effects anticipated in the study. The most common event  was septic shock. And we also had an equivalent proportion of non-motorized effects  in both groups. So, our conclusions are as follows. TDDN, the stimulation technique  nervous phenic with this cathedral, is visible and safe in the difficulty of overcoming the patient  on mechanical ventilation. Our analysis confirms the association between MIP and defeat success  and MIP and days on mechanical ventilation. And what's more, TDDN appears to improve the success of defeating  and reduce days on mechanical ventilation, even in safe patients with a low MIP based on it.  But here the results are not statistically significant and we need more studies  to obtain a more conclusive conclusion. Thank you very much for your attention.

Video Summary

The study presented by Martin Dress focused on diaphragmatic dysfunction in patients in the ICU who are on mechanical ventilation. The goal was to investigate whether a new technique called temporary transvenus-diaphragmic neurostimulation (TDDN) could improve diaphragmatic function and reduce the duration of mechanical ventilation. The study used an intravenous intestinal catheter with electrodes to stimulate the phrenic nerves. The results showed that TDDN had a positive impact on successful extubation and reduced the duration of mechanical ventilation, especially in patients with low maximum inspiratory pressure. However, more studies are needed to confirm these findings.

Asset Subtitle

Pulmonary, Procedures, 2022

Asset Caption

INTRODUCTION: The relative effects of transvenous diaphragm neurostimulation (TTDN) on the association of Maximal Inspiratory Pressure (MIP) with weaning and duration of mechanical ventilation (MV) in difficult-to-wean patients have not been reported. METHODS: We conducted a multicenter, open label, randomized controlled trial of TTDN using a multi-electrode stimulating central venous catheter (Lungpacer Diaphragm Pacing Therapy System) in patients on MV for >96 hours with at least two failed spontaneous breathing trials and satisfying readiness to wean criteria. A total of 98 subjects were randomized (1:1) to TTDN (up to 120 stimulations per day; up to 30 days) or standard of care (SoC) in the modified intent to treat population. Clinical outcomes of the proportion of patients successfully weaned and MV duration were assessed in patients categorized by the median baseline absolute MIP into two cohorts – LowMIP (≤30 cmH2O, Nf49) or HighMIP ( >30 cmH2O, Nf49). RESULTS: TTDN patients had a poorer average baseline MIP than the SoC patients (25.2 ±12 TTDN vs 32.8 ±14 SoC, p=0.005) resulting in more TTDN subjects in the LowMIP (28/49, 57%) than the HighMIP cohort (15/49, 31%). Weaning success was greater in the HighMIP vs the LowMIP cohort confirming the association with baseline MIP (p=0.007). There was a greater weaning success in the TTDN group compared to SoC, with the difference being more pronounced in the HighMIP cohort (HighMIP: 100% (TTDN) vs 81.8% (SoC), difference 18.2% (p=0.597); LowMIP: 72.7% (TTDN) vs 61.9% (SoC), difference 10.8% (p=0.335)).HighMIP subjects spent fewer days on MV than LowMIP subjects (11.15 vs 15.85 days). In either the HighMIP or LowMIP cohorts, the TTDN group spent fewer days on MV than the SoC group (HighMIP: 10.7 (TTDN) vs 11.3 (SoC) days, difference -0.6 days (p=0.827); LowMIP: 13.7 (TTDN) vs 18.6 (SoC) days, difference -4.8 days (p=0.335)), with the difference between groups being markedly better in the LowMIP cohort. CONCLUSION: TTDN is feasible and safe in difficult to wean patients on MV. This analysis confirms the association of MIP with weaning success and days on MV. Moreover, TTDN appears to improve weaning success and reduce days on MV even in sicker patients with low baseline MIP.

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Area Procedures

Knowledge Level Advanced

Membership Level Select

Tag Respiratory Failure

Tag Weaning

Tag Mechanical Ventilation

Tag Acute Lung Injury

Year 2022

Keywords

diaphragmatic dysfunction

ICU patients

mechanical ventilation

temporary transvenus-diaphragmic neurostimulation

phrenic nerves

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