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INSPIRATORYMUSCLETRAINING
ADJUNCT INTHETREATMENTOFWEANINGFAILURE?
RikGosselink,Bieke Clerckx,PauloMagelhaes,BregjeFrickx,JohanSegers,Else Merckx,IngeDemeyere,DanielLanger
University Hospitals LeuvenDepartment Rehabilitation SciencesFaculty ofKinesiologyandRehabilitationSciencesKULeuvenBelgium
Weaningfailure:12-50%Jeong etal.Plos One2015.
VentilatoryFailure
InadequateRespiratoryMuscleStrength/Endurance
MalnutritionNeuromuscular
diseaseMetabolicFactors Hyperinflation
Lung1986;164:309-324.
Drugs MetabolicFactors
PrimaryCNSEvents
ObstructiveLungDisease
RestrictiveDisease
CentralRespiratory
Drive
ExcessiveRespiratoryWorkLoad
Inadequate
Excessive
Deconditioning
Levineetal.N.Engl.J.Med.2008;358
Hermansetal.Crit.Care2010;14:R127
Diaphragmweaknessinventilatedpatients
~3%perday
Goligheretal.AJRCCM2015;192:1080
10%
44%
44%
Diaphragmthickness inmechanicallyventilatedpatients
Respiratorymuscle pump
PumpCapacity
Load onthe pump
CNS output Respiratory drive
VentilatoryFailureAfter Moxham J.
l NORMAL
NOFATIGUE
FATIGUE
l RESPIRATORYINSUFFICIENCY¢
DEVELOPMENTOFRESPIRATORYMUSCLEFATIGUE
. . . . .
.
.
.
.
.
Vassilakopoulos etal.Am.J.Respir.Crit.Care Med.1998;158:378-385.
FATIGUE
NOFATIGUE
Rest
Stimulus
ModalityIntensityDuration
Strength trainingregimen:
Intensity:30-50%PImaxperceivedexertion6-8on10pointscale
6à 8breathsperset
3-5setsperday
INSPIRATORYMUSCLETRAINING
Thresholdloadingdevice
-60
-50
-40
-30
-20
-10
0
Sham Experimental
BeforeAfter
Martinetal.Crit.Care15,R842011
PImax(cm
H20)
*
0
10
20
30
40
50
60
70
80
90
100
ShamExperimental
Martinetal.Crit.Care15,R84;2011
Successfullw
eaning(%)
*
IsIMTusefull inall patients onmechanical ventilation
Elkinsetal.JPhysioth.61,125;2015
Elkinsetal.JPhysioth.61,125;2015
PImax
Elkinsetal.JPhysioth.61,125;2015
Duration mechanical ventilation(days)
NS
Elkinsetal.JPhysioth.61,125;2015
Duration mechanical ventilation(days)
NS
Elkinsetal.JPhysioth.61,125;2015
Weaningsucces(%)
Optimization ofthe trainingmodalitiesl Type of loading: Threshold loading – Tapered FlowResistive loading
l Feedback to the patient during the training session
l Control during the training session:l HR/BP/SaO2
l Tidal volume
l Pressure
l Power
l Diaphragm contraction (US)
l Symptoms
MechanicalThresholdLoading
Tapered flowresistive training
Langer et al. Physical Therapy 2015; 95:
MechanicalThresholdLoading TaperedFlowResistiveLoading
Sex: F, Age: 44Y, BMI: 17,8 kg/mDiagnosis: Pulm.valve replacement, Aneurysm pulmonary artery, Bleeding brachiocephalic artery. Ventilatory support: PSV +12, Days on MV: 30
Case
Howdotheseresults affectour clinicalpractice inpatients with weaning failure?
l Inspiratory muscle weakness is associated with weaning failure:Assess muscle strength
lWhen weakness is present: discuss its potential importance inthe weaning failure and the application of IMT
l Apply IMT strength training: limited number of higher intensitycontractions, control of cardiorespiratory response, symptoms,rest period between series allows continuation of mode ofventilatory support
l Support and feedback to the patient during the training sessionis essential and the basis for progressing the training over time.
CONCLUSIONSl Weaning failure is a multifactorial clinical condition
l Inspiratory muscle weakness is associated with weaningfailure
l Inspiratory muscle training is not effective as apreventive measure during mechanical ventilation
l Inspiratory muscle training has been shown, as anadjunct to the treatment of weaning failure, to improveclinical outcome in patients with weaning failure.
l Future challenges: patient selection and assessment,training modality, feedback during the training forpatient and supervisor
ICUPhysical Therapy Team