Journal of ISSN: 2376-0060JLPRR

Lung, Pulmonary & Respiratory Research
Opinion
Volume 2 Issue 4 - 2015
Liberation from Mechanical ventilator
Patricia Colgan, Ibrahim Mohd Fawzy M A Hassan, Mohammad Faisal Abdullah Malmstrom, Abdul Aziz Ahmed M. Alhashemi, Thiruppathi Chockalingam*, Ashok Parchani, MP Sujith, Mahesh Chandra, Damodaran CU, Flordevic P Guerra, Talib Yaseen
Hamad Medical Corporation, Qatar
Received: March 12, 2015| Published: April 10, 2015
*Corresponding author: Thiruppathi Chockalingam, Acting Assistant Director of Respiratory Therapy, Hamad Medical Corporation, 3050 Doha, Qatar, Tel: (+974) 55319021; (+974) 44392376; Fax: (+974) 44391829; Email: @
Citation: Colgan P, Hassan IMFMA, Malmstrom MFA, Alhashemi AAAM, Chockalingam T, et al. (2015) Liberation from Mechanical ventilator. J Lung Pulm Respir Res 2(4): 00046. DOI: 10.15406/jlprr.2015.02.00046

Objectives

Discuss the variables that are used to indicate readiness to wean from mechanical ventilation Discuss the use of protocols to wean patients from ventilatory support Discuss the criteria used to indicate readiness for extubation Describe the most common reasons why patients fail to wean from mechanical ventilation.

Predicted Success Rate

75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process 10-15% of patients require a use of a weaning protocol over a 24-72 hours 5-10% require a gradual weaning over longer time 1% of patients become chronically dependent on MV

Assessment criteria for weaning

  1. Neurological: (No sedation,GCS>8,Pain controlled)
  2. Respiratory: (No­WOB ,PS <10,PEEP 5,FIO2-40%,sat >90%, PF >200)
  3. Cardiovascular : (Stable Hemodynamics, Hb >7, Normal ECG)

Ventilation Status

  1. Intact ventilatory drive: ability to control their own level of ventilation
  2. Respiratory rate < 30
  3. Minute ventilation of < 10 L to maintain PaCO2 in normal range
  4. VD/VT < 60% (Vd/Vt = 0.320 + 0.0106 (PaCO2 - end-tidal carbon dioxide measurement) + 0.003 (RR per minute) + 0.0015 (age in years )
  5. Functional respiratory muscles

Intact Airway Protective Mechanism

  1. Appropriate level of consciousness
  2. Cooperation
  3. Intact cough reflex
  4. Intact gag reflex
  5. Functional respiratory muscles with ability to support a strong and effective cough

Approaches to Weaning

  1. Spontaneous breathing trials
  2. Pressure support ventilation (PSV) SIMV
  3. New weaning modes

Maximal Inspiratory Pressure

  1. Negative Expiratory pressure must be more than -20 cmH2o
  2. Assures ability to mobilize secretions

Shallow Breathing Index

Index of rapid and shallow breathing =RR/Vt in litre
Single study results:
  1. RR/Vt>105 95% wean attempts unsuccessful
  2. RR/Vt<105 80% successful
  3. One of the most predictive bedside parameters

Spontaneous Breathing Trial (SBT)

  1. Explore Exclusion Criteria
  2. Assess Readiness for SBT
  3. If passed proceed sedation vacation for 30 min
  4. Initiate SBT for 30 minutes
  5. Assess the tolerance to SBT
  6. If SBT passed assess Readiness for Extubation

Exclusion Criteria for SBT

  1. GCS < 8 unsedated use of Neuro muscular drugs
  2. Neuro Muscular Disease with VC <20 ml /kg or NIP <20
  3. RASS sedation and agitation scale +1 and higher, -3 and lower
  4. Immediate pending Invasive procedure
  5. ICP >20 or needing RX in last 12 hours
  6. Ongoing Cardiac Ischemia
  7. Uncontrolled seizures

     (Figure 1)

Failure to Wean

  1. Weaning to exhaustion
  2. Auto-PEEP
  3. Excessive work of breathing
  4. Poor nutritional status
  5. Overfeeding
  6. Left heart failure
  7. Infection/fever
  8. Major organ failure
  9. Technical limitation

(Appendix)

Spontaneous Breathing Trial(SBT) Guideline

Patient Sticker

Exclusion Criteria

 

GCS <8 Unsedated, use of neuromuscular drugs

Neuromuscular disease -with VC < 20 ML/KG OR NIP < 20

RASS Sedation and Agitation scale +1and higher, -3 and lower

Immediate pending invasive procedure

ICP > 20 or needing  RX in last 12 hours

Weaning protocol can be bypassed if medical team believes timely

Ongoing cardiac ischemia

extubation can be expedited

Uncontrolled Seizures

 

 

 

 

Daily Screening

Date

/       /

/       /

/       /

/       /

/       /

Assesss readiness for SBT (Should be done every morning)

Off pressors (Except Norepinephrine < 0.1MCG/KG/Min or equivalent)

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Temp< 38.4° C

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

FiO2 ( ≤ 40%) and Spo2 > 90%

Yes /No

Yes /No

Yes/ No

Yes/ No

Yes No

PEEP (≤ 8cmH2O)

Yes/ No

Yes/ No

Yes No

Yes /No

Yes/ No

No Physician's order to hold weaning

Yes No

Yes/ No

Yes /No

Yes /No

Yes /No

Dr/ RT Initials

 

 

 

 

 

Dr/RT Comment

 

 

 

 

 

If Yes to All of the above, Sedation Vacation and SBT should be Initiated

On ongoing sedation vacation (for at least 30 minutes if on long acting sedative)?

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

Start Pressure Support (PS) of < 10 and PEEP of 5

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No

If patient passes SBT after 30 minutes, do ABG, check the extubation parameters and inform the physician

DR/RT Initials

 

 

 

 

 

Dr/RT Comment

 

 

 

 

 

Indication to Terminate SBT

Date

/       /

/       /

/       /

/       /

/       /

RR < 8 or > 35 for > 5 min- unless otherwise specified by physician

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

SpO2 < 90% for > 5 min-unless otherwise specified by physician

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

20% HR increase or bradycardia <50 for > 5 min-unless otherwise specified by physician

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Systolic BP > 180 or < 90 unless specified by the physician

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Signs of increased WOB (accessory muscle use, dyssyncrony with ventilator)

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Agitation, anxiety, diaphoresis, chest pain

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

DR/RT Initials

 

 

 

 

 

Dr/RT Comment

 

 

 

 

 

**Please note if patient fails SBT, he or she can remain on pressure support with higher settings as a mode of ventilation

Extubation Parameters

Date

/       /

/       /

/       /

/       /

/       /

Minimal  secretions

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Cough/Gag reflex present

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Positive leak test (>30%)

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

GCS > 8 or tracheostomy

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Acceptable blood gas results

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Dr/RT Initials

 

 

 

 

 

Dr/RT Comment

 

 

 

 

 

If patient passes SBT as well as all the Extubation Parameters, inform ICU physician for possible extubation

If patient passes SBT and has Tracheostomy in place, shift the patient to Humidified Tracheostomy mask

Extubation

Date

/       /

/       /

/       /

/       /

/       /

Extubated?

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

if no- the reason why

 

 

 

 

 

If Yes

 

 

 

 

 

1) Written order by the physician

 

 

 

 

 

2) Humidified oxygen

 

 

 

 

 

3) ABG after 30 minutes of extubation

 

 

 

 

 

If No

 

 

 

 

 

Place patient on settings as directed by physician

 

 

 

 

 

Dr/RT Initials

 

 

 

 

 

Dr/RT Comment

 

 

 

 

 

Failed Extubation

Re-intubated within 48 hours?

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

if yes- the reason why?

 

Appendix

Protocols

  1. Developed by multidisciplinary team
  2. Implemented by respiratory therapists and nurses to make clinical decisions
  3. Results in shorter weaning times and shorter length of mechanical ventilation than physician-directed weaning

Points to Remember

  1. The primary prerequisite for weaning is reversal of the indication of mechanical ventilation
  2. Adequate gas exchange should be present with minimal oxygenation and ventilatory support before weaning is attempted
  3. The function of all organ systems should be optimized, electrolytes should be normal, and nutrition should be adequate before weaning is attempted
  4. The most successful predictor of weaning is RSBI < 100
  5. Maximum inspiratory pressure is the best predictor of weaning failure
  6. Ventilatory discontinuation should be done if patient tolerates SBT for 30-120 minutes
  7. Use of liberation and weaning protocol facilitates the process and decreases the ventilator length of stay.

References

  1. J. bras. pneumol. vol.37 no.5 São Paulo Sept./Oct. 2011
  2. http://dx.doi.org/10.1590/S1806-37132011000500016
  3. Journal  Brasileirode Pneumologia
  4. AARC
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