Neuromuscular disorders associated with failure to wean from the ventilator

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Abstract
To determine, by retrospective chart analysis, the frequency, type and significance of neuromuscular disorders in patients whose clinical features suggested a neuromuscular cause of failure to wean. Failure to wean is a common and difficult problem in critical care units. While a neuromuscular cause may be suspected in some patients, the frequency and type has not been determined utilizing comprehensive electrophysiological studies of limbs and the respiratory system. Such knowledge may aid in patient management and prognosis. The clinical setting was a critical care/trauma centre that admits 1500 patients per year, approximately 500 being on ventilators for longer than five days. We analyzed the hospital charts of 40 patients admitted to the unit during three years, whose respiratory assessment suggested a neuromuscular cause for failure to wean from the ventilator. To investigate this possibility, we performed electrophysiological studies of the limbs and also of the respiratory system by phrenic nerve conduction and needle electromyography of the chest wall and diaphragm. The results were compared to 25 healthy controls. 38 of 40 patients (95%) had a neuromuscular disorder: 25 — critical illness polyneuropathy, 2 — Guillain-Barré syndrome, 4 — diabetic and critical illness polyneuropathy, 2 — uremic and critical illness polyneuropathy, 10 — an abnormality of central drive, 5 — unilateral phrenic nerve palsy, 3 — a neuromuscular transmission defect, and 5 — a primary myopathy. Fifteen (38%) had a combination of disorders. Patients with more severe polyneuropathy took longer to wean, a mean of 136 versus 52 days (p=0.007). The severity of the polyneuropathy had no effect on mortality. Electrophysiological studies of limbs and the respiratory system are together valuable in confirming the presence, and identifying the specific type of neuromuscular cause for difficulty in weaning from the ventilator. This information is important in patient management and prognosis.

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