Table 2.

Future potential suggestions to evaluation in VM weaning for ARDS.

WEANING IN ARDS
(1) Control of the Illness (reducing inflammation)
(2) PaO2/FiO2>200 and PEEP≤10 cmH2O
(3) Evaluate:
(a) Pulmonary mechanics during the spontaneous ventilation test:
(i) Measure TV e DP – caution TV>8ml/kg and/or DP>13 [56]
(ii) If available – monitoring Pes [42, 57]
(iii) Bedside alternative for the evaluation of pulmonary mechanics: Administration of small doses of sedatives and short-acting NMB (propofol 10mg IV and if necessary succinylcholine 2-4mg IV) and change to VCV to measurements [58]
(b) Asynchrony and Ventilatory Drive:
(i) Asynchrony Index (failure if>10%)[59]
(ii) P0.1 (consider high drive if>3.0)[44, 45]
(c) Imaging Monitoring:
(i) EIT (tidal variation of impedance (TIV), the changes in end-expiratory lung impedance (ΔEELI) – failure if global inhomogeneity index (GI) value>40 [53]
(ii) US (lung score >17 is predictive of postextubation distress [49, 60])
(iii) Echocardiography (qualitative right ventricular failure and diastolic dysfunction)[49]
(4) Management with High TV, DP, Asynchrony Index, P0.1 or worse of regional aeration:
(i) Eliminate stress factors (pain, anxiety and delirium) and sedation adjustment – try dexmedetomidine or propofol. Avoid bolus of fentanyl (can lower RR and increase TV)
(ii) Test increment in PEEP to 12cmH2O
(iii) Alternative ventilatory modes to improve asynchronies – PAV [61] or NAVA [62]
(iv) Patients with refractory weaning: use partial NMB [63] and ECMO [64]

ARDS: acute respiratory distress syndrome; MV: mechanical ventilator; PEEP: positive end-expiratory pressure; TV: tidal volumes; DP: driving pressure; Pes: esophageal pressure; P0.1: pressure 100 ms after the onset of an inspiratory effort; EIT: electrical impedance tomography; VCV: volume control ventilation; US: ultrasound; lPAV: proportional-assist ventilation; NAVA: neurally adjusted ventilator assist; NMB: neuromuscular blockade; ECMO: extracorporeal membrane oxygenation.