Download PDF
Pneumologie 2021; 75(02): 113-121
DOI: 10.1055/a-1337-9848
Empfehlungen

Weaning in der Situation einer Pandemie – Ein Positionspapier

Weaning in a Pandemic Situation – A Position Paper
M. Westhoff
 1   Klinik für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Zentrum für Pneumologie und Thoraxchirurgie, Hemer
 2   Universität Witten-Herdecke, Witten
,
J. Geiseler
 3   Medizinische Klinik IV: Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Klinikum Vest GmbH, Paracelsus-Klinik, Marl
,
B. Schönhofer
 4   Pneumologische Praxis und pneumologischer Konsildienst im Klinikum Agnes Karll Laatzen, Klinikum Region Hannover, Laatzen, Germany
,
M. Pfeifer
 5   Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
 6   Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
 7   Krankenhaus Barmherzige Brüder, Klinik für Pneumologie und konservative Intensivmedizin, Regensburg
,
D. Dellweg
 8   Fachkrankenhaus Kloster Grafschaft GmbH, Akademisches Lehrkrankenhaus der Philipps-Universität Marburg, Schmallenberg
,
M. Bachmann
 9   Klinik für Intensiv- und Beatmungsmedizin, Asklepios-Klinik Harburg, Hamburg
,
W. Randerath
10   Institut für Pneumologie an der Universität zu Köln, Köln
11   Klinik für Pneumologie, Krankenhaus Bethanien, Solingen
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Zusammenfassung

Die logistischen und infektiologischen Besonderheiten und Erfordernisse in der Pandemie stellen die intensivmedizinischen Behandlungsteams vor außerordentliche Herausforderungen, die eine erfolgreiche Liberation von Patienten im prolongierten Weaning erschweren können. Gerade in der Pandemie gilt es daher, alle Potenziale zur Beatmungsentwöhnung und Dekanülierung von Patienten im prolongierten Weaning oder in der Langzeitbeatmung auszuschöpfen.

Weaning-Zentren stellen Einheiten der intensivmedizinischen Betreuung mit besonderer Spezialisierung auf prolongiertes Weaning dar und sind integraler Bestandteil eines kontinuierlichen Versorgungskonzeptes dieser Patienten. Ein systematisches Weaning-Konzept in der Pandemie setzt strukturelle, personelle, apparative, infektiologische und hygienische Aspekte voraus.

Im Mittelpunkt dieses Positionspapiers stehen als Ergänzung zur S2k-Leitlinie „Prolongiertes Weaning“ eine neue Klassifikation im prolongierten Weaning und zukünftig erforderliche Organisationsstrukturen für die Pandemie-Situation.

Patienten der Kategorie A mit hohem Weaning-Potenzial bedürfen der strukturierten Respiratorentwöhnung in spezialisierten Weaning-Einheiten, um so die größtmögliche Chance auf erfolgreiches Weaning zu realisieren. Patienten der Kategorie B mit geringem oder aktuell nicht vorhandenem Weaning-Potenzial sollten verzögert nach einer Zwischenphase der weiteren Stabilsierung in einer außerklinischen Beatmungseinrichtung einen Weaning-Versuch erhalten. Patienten der Kategorie C ohne Weaning-Potenzial benötigen eine dauerhafte außerklinische Versorgung, alternativ eine palliativmedizinisch begleitete Beendigung der Beatmung. Die sich aus den 3 Kategorien ergebenden Aufgaben für die Weaning-Zentren werden im Positionspapier vertieft.

Schließlich werden unter perspektivischer Betrachtung im Positionspapier folgende zukünftig denkbare Netzwerke und Register benannt: 1. lokal organisierte regionale Netzwerke von zertifizierten Weaning-Zentren, 2. ein zentrales, bundesweites Register der Weaning-Kapazitäten entsprechend dem DIVI-Register und 3. eine Registrierung der Patienten im schwierigen oder prolongierten Weaning.

Abstract

The logistical and infectious peculiarities and requirements challenge the intensive care treatment teams aiming at a successful liberation of patients from long-term mechanical ventilation.

Especially in the pandemic, it is therefore important to use all potentials for weaning and decannulation, respectively, in patients with prolonged weaning.

Weaning centers represent units of intensive medical care with a particular specialization in prolonged weaning. They are an integral part of a continuous care concept for these patients.

A systematic weaning concept in the pandemic includes structural, personnel, equipment, infectiological and hygienic issues.

In addition to the S2k guideline “Prolonged weaning” this position paper hightlights a new classification in prolonged weaning and organizational structures required in the future for the challenging pandemic situation. Category A patients with high weaning potential require a structured respiratory weaning in specialized weaning units, so as to get the greatest possible chance to realize successful weaning. Patients in category B with low or currently nonexistent weaning potential should receive a weaning attempt after an intermediate phase of further stabilization in an out-of-hospital ventilator unit. Category C patients with no weaning potential require a permanent out-of-hospital care, alternatively finishing mechanical ventilation with palliative support.

Finally, under perspective in the position paper the following conceivable networks and registers in the future are presented: 1. locally organized regional networks of certified weaning centers, 2. a central, nationwide register of weaning capacities accordingly the already existing DIVI register and 3. registration of patients in difficult or prolonged weaning.



Publication History

Article published online:
22 December 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literaturverzeichnis

  • 1 Tolksdorf K, Buda S, Schuler E. et al. Eine höhere Letalität und lange Beatmungsdauer unterscheiden COVID-19 von schwer verlaufenden Atemwegsinfektionen in Grippewellen. Epidemiol Bulletin 2020; 41: 3-10
    PubMedGoogle Scholar
  • 2 Schönhofer B, Geiseler J, Dellweg D. et al. Prolongiertes Weaning. S2k-Leitlinie herausgegeben von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. Pneumologie 2019; 73: 723-814
    PubMedGoogle Scholar
  • 3 Esteban A, Alía I, Tobin MJ. et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999; 159, S. 512-518
    PubMedGoogle Scholar
  • 4 Epstein SK, Nevins ML, Chung JE. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161: 1912-1916
    CrossrefPubMedGoogle Scholar
  • 5 Funk GC, Anders S, Breyer MK. et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 2010; 35: 88-94
    CrossrefPubMedGoogle Scholar
  • 6 Windisch W, Dreher M, Geiseler J. et al. 2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz – Revision 2017. Pneumologie 2017; 71: 722-795
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Huttmann SE, Magnet FS, Karagiannidis C. et al. Quality of life and life satisfaction are severely impaired in patients with long-term invasive ventilation following ICU treatment and unsuccessful weaning. Ann Intensive Care 2018; 8: 38
    CrossrefPubMedGoogle Scholar
  • 8 Karagiannidis C, Kluge S, Riessen R. et al. Intensivmedizin: Intensivpflegemangel führt zu drohender Unterversorgung. Dtsch Arztebl 2018; 115: A467-A469
    PubMedGoogle Scholar
  • 9 Arabi YM, Fowler R, Hayden FG. Critical care management of adults with community-acquired severe respiratory viral infection. Intensive Care Med 2020; 46: 315-328
    CrossrefPubMedGoogle Scholar
  • 10 Kluge S, Janssens U, Welte T. et al. S2k-Leitlinie – Empfehlungen zur stationären Therapie von Patienten mit COVID-19. AWMF-Register-Nr. 113/001. 2020 Verfügbar unter: https://www.awmf.org/uploads/tx_szleitlinien/113-001l_S2k_Empfehlungen_stationäre_Therapie_Patienten_COVID-19_2020-11.pdf
    Google Scholar
  • 11 https://www.intensivregister.de/#/aktuelle-lage/reports
  • 12 Karagiannidis C, Mostert C, Hentschker C. et al. Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study. Lancet Respir Med 2020; 8: 853-862
    CrossrefPubMedGoogle Scholar
  • 13 Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020; 323: 1239-1242
    CrossrefPubMedGoogle Scholar
  • 14 South AM, Diz DI, Chappell MC. COVID-19, ACE2, and the cardiovascular consequences. Am J Physiol Heart Circ Physiol 2020; 318: H1084-H1090
    CrossrefPubMedGoogle Scholar
  • 15 Guan WJ, Liang WH, Zhao Y. et al. Comorbidity and its impact on 1590 patients with CoViD-19 in China: A Nationwide Analysis. Eur Respir J 2020; 55: 2000547
    CrossrefPubMedGoogle Scholar
  • 16 Cheung KS, Hung IF, Chan PP. et al. Cheung KS, HGastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples from the Hong Kong Cohort and Systematic Review and Meta-analysis. Gastroenterology 2020; 159: 81-95
    CrossrefPubMedGoogle Scholar
  • 17 Yanga J, Zhenga Y, Goua X. et al. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis 2020; 94: 91-95
    CrossrefPubMedGoogle Scholar
  • 18 Zheng Z, Peng F, Xu B. et al. Risk factors of critical and mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect 2020; 85: e16-e25
    CrossrefPubMedGoogle Scholar
  • 19 Aggarwal S, Garcia-Telles N, Aggarwal G. et al. Clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19): Early report from the United States. Diagnosis (Berl) 2020; 7: 91-96
    CrossrefPubMedGoogle Scholar
  • 20 Pei G, Zhang Z, Peng J. et al. Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. J Am Soc Nephrol 2020; 31: 1157-1165
    CrossrefPubMedGoogle Scholar
  • 21 Da BL, Kushner T, El Halabi M. et al. Liver Injury in Hospitalized Patients with COVID-19 Correlates with Hyper Inflammatory Response and Elevated IL-6. Hepatol Commun 2020; DOI: 10.1002/hep4.1631. [Epub ahead of print]
    CrossrefPubMedGoogle Scholar
  • 22 Cai Q, Huang D, Yu H. et al. COVID-19: Abnormal liver function tests. J Hepatol 2020; 73: 566-574
    CrossrefPubMedGoogle Scholar
  • 23 Wei JF, Huang FY, Xiong TY. et al. Acute myocardial injury is common in patients with CoViD-19 and impairs their prognosis. Heart 2020; 106: 1154-1159
    CrossrefPubMedGoogle Scholar
  • 24 Mao L, Jin H, Wang M. et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol 2020; 77: 683-690
    CrossrefPubMedGoogle Scholar
  • 25 Chen R, Liang W, Jiang M. et al. Medical Treatment Expert Group for COVID-19. Risk Factors of fatal Outcome in Hospitalized Subjects With Coronavirus Disease 2019 from a Nationwide Analysis in China. Chest 2020; 158: 97-105
    CrossrefPubMedGoogle Scholar
  • 26 Ackermann M, Verleden SE, Kuehnel M. et al. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med 2020; 383: 120-128
    CrossrefPubMedGoogle Scholar
  • 27 Wichmann D, Sperhake JP, Lütgehetmann M. et al. Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study. Ann Intern Med 2020; 173: 268-277
    CrossrefPubMedGoogle Scholar
  • 28 Poissy J, Goutay J, Caplan M. et al. Lille Hemostasis Group. Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence. Circulation 2020; 142: 184-186
    CrossrefPubMedGoogle Scholar
  • 29 Zhang Y, Xiao M, Zhang S. et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med 2020; 382: e38
    CrossrefPubMedGoogle Scholar
  • 30 Ruan Q, Yang K, Wang W. et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020; 6: 1294-1297
    CrossrefPubMedGoogle Scholar
  • 31 Zhou F, Yu T, Du R. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet 2020; 395: 1054-1062
    CrossrefPubMedGoogle Scholar
  • 32 Kollef MH, Shapiro SD, Silver P. et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 1997; 25: 567-574
    CrossrefPubMedGoogle Scholar
  • 33 Uhlig S, Frerichs I. Lung Protective Ventilation –’Pathophysiology and Diagnostics. Anasthesiol Intensivmed Notfallmed Schmerzther 2008; 43: 438-455
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Ibrahim EH, Ward S, Sherman G. et al. A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting. Chest 2000; 117: 1434-1442
    CrossrefPubMedGoogle Scholar
  • 35 Quinnell TG, Pilsworth S, Shneerson JM. et al. Prolonged invasive ventilation following acute ventilatory failure in COPD: weaning results, survival, and the role of noninvasive ventilation. Chest 2006; 129: 133-139
    CrossrefPubMedGoogle Scholar
  • 36 Pinsky MR. Cardiovascular issues in respiratory care. Chest 2005; 128: 592S-597S
    CrossrefPubMedGoogle Scholar
  • 37 Buda AJ, Pinsky MR. Effect of intrathoracic pressure on left ventricular performance. N Engl J Med 1979; 301: 453-459
    CrossrefPubMedGoogle Scholar
  • 38 Dres M, Teboul JL, Monnet X. et al. Weaning the cardiac patient from mechanical ventilation. Curr Opin Crit Care 2014; 20: 493-498
    CrossrefPubMedGoogle Scholar
  • 39 Gamberini L, Tonetti T, Spadaro S. et al. Factors influencing liberation from mechanical ventilation in coronavirus disease 2019: multicenter observational study in fifteen Italian ICUs. J Intensive Care 2020; 8: 80
    CrossrefPubMedGoogle Scholar
  • 40 Ji Y, Ma Z, Peppelenbosch MP. et al. Potential association between COVID-19 mortality and health-care resource availability. Lancet Glob Health 2020; 8: e480
    CrossrefPubMedGoogle Scholar
  • 41 Rollnik JD, Adolphsen J, Bauer J. et al. [Prolonged weaning during early neurological and neurosurgical rehabilitation: S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. Nervenarzt 2017; 88: 652-674
    CrossrefPubMedGoogle Scholar
  • 42 Bingold T, Bickenbach J, Coburn M. et al. DGAI-Zertifizierung anästhesiologische Intensivmedizin: Entwöhnung von der Beatmung Modul 1. Anästh Intensivmed 2013; 54: 212-216
    PubMedGoogle Scholar
  • 43 Bingold T, Bickenbach J, Coburn MD. et al. Modulares Zertifikat Intensivmedizin der DGAI. Anästh Intensivmed 2014; 55: 316-329
    Google Scholar
  • 44 Schönhofer B, Geiseler J, Pfeifer M. et al. WeanNet: a network of weaning units headed by pneumologists. Pneumologie 2014; 68: 737-742
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Wean Net Study Group. WeanNet: The network of weaning units of the DGP (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin) - results to epidemiology an outcome in patients with prolonged weaning]. Dtsch Med Wochenschr 2016; 141: e166-e172
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 https://www.dimdi.de/static/de/klassifikationen/ops/kode-suche/opshtml2021/block-8-70...8-72.htm
  • 47 Levy J, Lʼeotard A, Lawrence C. et al. A model for a ventilator-weaning and early rehabilitation unit to deal with post-ICU impairments with severe COVID-19. Ann Phys Rehabil Med 2020; 63: 376-378
    CrossrefPubMedGoogle Scholar
  • 48 Darwiche K, Ross B, Gesierich W. et al. Empfehlungen zur Durchführung einer Bronchoskopie in Zeiten der COVID-19-Pandemie. Pneumologie 2020; 74: 260-262
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Pfeifer M, Ewig S, Voshaar T. et al. Positionspapier zur praktischen Umsetzung der apparativen Differenzialtherapie der akuten respiratorischen Insuffizienz. Pneumologie 2020; 74: 337-357
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Baker JG, Sovani M. Case for continuing community NIV and CPAP during the COVID-19 epidemic. Thorax 2020; 75: 368
    CrossrefPubMedGoogle Scholar
  • 51 https://brit-thoracic.org.uk/media/455095/advice-on-acute-niv-technical-aspects-final-16-march-2020.pdf
  • 52 Ferioli M, Cisternino C, Leo V. et al. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev 2020; 29: 200068
    CrossrefPubMedGoogle Scholar
  • 53 Bundesanstalt für Arbeitsschutz und. Bundesanstalt für Arbeit. Arbeitsmedizin. Verfügbar unter: https://www.baua.de/DE/Angebote/Rechtstexte-und-Technische-Regeln/Regelwerk/TRBA/pdf/Beschluss-609.pdf
    Google Scholar
  • 54 Windisch W, Dellweg D, Geiseler J. et al. Prolonged Weaning from Mechanical Ventilation. Dtsch Arztebl Int 2020; 117: 197-204
    Google Scholar
  • 55 Schönhofer B, Pfeifer M, Köhler D. Protrahierte respiratorische Insuffizienz – Epidemiologie und Netzwerk zur Respiratorentwöhnung (Weaning) nach prolongierter Beatmung. Pneumologie 2010; 64: 595-599
    Article in Thieme ConnectPubMedGoogle Scholar
  • 56 Bornitz F, Ewert R, Knaak C. et al. Weaning from Invasive Ventilation in Specialist Centers Following Primary Weaning Failure. Dtsch Arztebl Int 2020; 117: 205-210
    CrossrefPubMedGoogle Scholar
  • 57 Herridge MS, Tansey CM, Matté A. et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364: 1293-1304
    CrossrefPubMedGoogle Scholar
  • 58 Hermans G, van Mechelen H, Clerckx B. et al. Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2014; 190: 410-420
    CrossrefPubMedGoogle Scholar
  • 59 Davydow DS, Desai SV, Needham DM. et al. Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review. Psychosom Med 2008; 70: 512-519
    CrossrefPubMedGoogle Scholar
  • 60 Wilcox ME, Brummel NE, Archer K. et al. Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41: S81-S98
    CrossrefPubMedGoogle Scholar
  • 61 Baron R, Binder A, Biniek R. et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version. German Med Sci 2015; 13: Doc19
    PubMedGoogle Scholar
  • 62 Pandharipande PP, Girard TD, Ely EW. Long-term cognitive impairment after critical illness. N Engl J Med 2014; 370: 185-186
    PubMedGoogle Scholar
  • 63 Kirchner GI, Rümmele P. Update on Sclerosing Cholangitis in Critically Ill Patients. Viszeralmedizin 2015; 31: 178-184
    PubMedGoogle Scholar
  • 64 Bein T, Weber-Carstens S, Apfelbacher C. et al. The quality of acute intensive care and the incidence of critical events have an impact on health-related quality of life in survivors of the acute respiratory distress syndrome - a nationwide prospective multicenter observational study. Ger Med Sci 2020; 18: Doc1
    PubMedGoogle Scholar
  • 65 Schenk M. Neurologische Manifestationen: Wie COVID-19 die Nerven tangiert. Dtsch Arztebl International 2020; 117: A1001-A1004
    PubMedGoogle Scholar
  • 66 Poyiadji N, Shahin G, Noujaim D. et al. Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology 2020; 296: E119-E120
    CrossrefPubMedGoogle Scholar
  • 67 Moriguchi T, Harii N, Goto J. et al. A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2. Int J Infect Dis 2020; 94: 55-58
    CrossrefPubMedGoogle Scholar
  • 68 Zhao H, Shen D, Zhou H. et al. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence?. Lancet Neurol 2020; 19: 383-384
    CrossrefPubMedGoogle Scholar
  • 69 Toscano G, Palmerini F, Ravaglia S. et al. Guillain-Barre Syndrome Associated with SARS-CoV-2. N Engl J Med 2020; 382: 2574-2576
    CrossrefPubMedGoogle Scholar
  • 70 Alberti P, Beretta S, Piatti M. et al. Guillain-Barré syndrome related to COVID-19 infection. Neurology: Neuroimmunology and Neuroinflammation 2020; 7: e741
    PubMedGoogle Scholar
  • 71 https://www.intensivregister.de/#/index
  • 72 Gräsner JT, Zill M, Alpers B. et al. COVID-19-Intensivpatienten: Innerdeutsche Verlegungen. Dtsch Arztebl 2020; 117: A2321-A2323
    PubMedGoogle Scholar