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Clinical Investigations in Critical CareCriteria for Extubation and Tracheostomy Tube Removal for Patients With Ventilatory Failure: A Different Approach to Weaning
Section snippets
Materials and Methods
A ventilator unit accepted 49 consecutive patients primarily with neuromuscular ventilatory impairment with endotracheal or tracheostomy tubes for ventilator weaning and extubation or decannulation. Forty-three of the 49 had thus far failed to respond to conventional weaning and the remaining 6 were weaned, but still had tracheostomy tubes that could not be removed during the acute hospitalization. All of the ventilator users arrived using some combination of either assist/control mode
Results
Forty-nine tracheostomy tube decannulation attempts were made on 37 patients with the following diagnoses: 22 with SCI; 15 with global alveolar hypoventilation, including 11 with progressive neuromuscular disease; 2 with Guillain-Barré syndrome; 1 with obesity hypoventilation syndrome; and 1 with partial lung resection and chronic alveolar hypoventilation. Initial decannulation attempts were successful for 25 patients, 12 initial attempts failed, and on subsequent attempts, 7 succeeded and 5
Discussion
A normal cough requires a precough inspiration or insufflation to about 85 to 90% of total lung capacity.9 Glottic closure follows for about 0.2 s and sufficient intrathoracic pressures are generated to obtain peak transient expiratory flows or PCFs upon glottic opening that are normally 360 to 1000 L/min.10 Total expiratory volume during normal coughing is about 2.3± 0.5 L.9
For patients with paralytic conditions, PCFs are reduced by the inability to adequately inflate the lungs (reduced VC),
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revision accepted June 18.