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