Optimal pressure support level for beginning weaning in patients with COPD: measurement of diaphragmatic activity with step-by-step decreasing pressure support level

Abstract

Purpose: The study objective was to determine an "optimal" individual pressure support (PS) level for beginning weaning with PS ventilation in patients with chronic obstructive pulmonary disease (COPD).

Materials and methods: Eleven COPD patients intubated and ventilated for acute respiratory failure and judged ready for weaning were studied. The technique consisted of lowering the PS level from a point that was characteristic for each patient and measurable under controlled mechanical ventilation, after setting the ventilator as recommended for COPD patients judged ready for weaning, that is, peak inflation pressure (PIP). This determination was based mainly on exploring the diaphragm with an electromyographic technique by defining the optimal PS level as the lowest PS level associated with no EMG evidence of diaphragmatic stress. Diaphragmatic electromyographic activity (diEMG) was recorded by a bipolar esophageal electrode (Disa-Denmark), and the high-frequency electrical component/low-frequency ratio (H/L) was calculated. The reference H/L was determined during a few spontaneous ventilatory cycles. Muscle stress was defined as a greater than 20% reduction in H/L compared with the reference value.

Results: Optimal PS levels ranged from 4 to 24 cm H2O with a mean of 14+/-6 cm H2O. Two patients with optimal PS level at 4 cm H2O did not require weaning and were quickly extubated. For the nine other patients, optimal PS levels were found to be 70% of PIP; in none was it necessary during weaning to use PS levels higher than individual optimal PS levels.

Conclusions: Optimal PS level established with diEMG monitoring seems to be a useful index for beginning weaning in the PS ventilation mode in COPD patients. The hypothesis of beginning weaning with a PS level equal to 70% of PIP needs to be tested.