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Weaning Modesand Protocol
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Causes of Ventilator Dependence
Assessment for Discontinuation Trial
Spontaneous Breathing Trial (SBT)
Extubation Criteria
Failure of SBT
eaning !odes
eaning "rotocols
#ole of Tracheostom$
%ong&term Facilities
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Stages of Mechanical Ventilation
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Caus s of V ntilator D p nd nc
ho is the 'entilator dependent*
!echanical entilation + ,- hor
Failure to respond during discontinuation
attemps
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Causes Description
Neurologic controller Central drivePeripheral nerves
Respiratory system Mechanical loadsVentilatory muscle propertiesGas echange properties
Cardiovascular system Cardiac tolerance o! ventilatory muscle "or#peripheral oygen demands
Psychological issues
Caus s of V ntilator D p nd nc
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Assessment for Discontinuation
Trial
Criteria for discontinuation trial.
Eidence for some reersal of theunderl$ing cause for respirator$ failure
Ade/uate ox$genation and p0
0emod$namic stabilit$1 and
The capabilit$ to initiate an inspirator$
effort
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Extubation failure
2&fold higher odds ratio for nosocomial
pneumonia
3&fold to 4,&fold increased mortalit$ ris5
#eported reintubation rates range from -to ,67 for different 8C9 populations
%
Assessment for Discontinuation
Trial
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Criteria Used in Weaning/Discontinuation in different studies
Assessment for Discontinuation
Trial
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Measurements used To Predict the Outcome of a Ventilator
Discontinuation Effort in More Than One Study
Assessment for Discontinuation
Trial
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Formal discontinuation assessmentsshould be performed during spontaneous
breathing
An initial brief period of spontaneous
breathing can be used to assess the
capabilit$ of continuing onto a formal SBT:
()
Spontaneous Breathing Trial
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0o; to assess patient tolerance*
the respirator$ pattern
the ade/uac$ of gas exchange
hemod$namic stabilit$< and sub=ectie comfort:
((
Spontaneous Breathing Trial
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Criteria Used in Several Large Trials To Define
Tolerance of an S BT
*+R heart rate, -po2 hemoglo.in oygen saturation/
Spontaneous Breathing Trial
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The tolerance of SBTs lasting 6> to 4,>
min should prompt consideration for
permanent entilator discontinuation
(0
Spontaneous Breathing Trial
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!re"uenc# of Tolerating an SB T in S elected Patients and
$ate of Perm anent Ventilator Discontinuation
!ollo%ing a Successful SB T
*Values given as No/ 13/ Pts patients/
0)min -67/
8(2)min -67/
Spontaneous Breathing Trial
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Do &ot Wean To '(haustion
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Weaning to '(haustion
## + 6?@min Spo, >7
0# + 4->@min
Sustained ,>7 increase in 0#
SB" + 42> mm 0g< DB" + > mm 0g
Anxiet$
Diaphoresis
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9aily -67
:())
Mechanical Ventilation
RR ; 05niety
9iaphoresis
0)(2) min
Pa?2P 15 cm +2?3=
Fo" levels o! pressure support 15 to % cm +2?3
7pieceH .reathing
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Abilit$ to protect upper air;a$ Effectie cough
Alertness
8mproing clinical condition
Ade/uate lumen of trachea and lar$nx '%ea5 test to identif$ patients ;ho are at ris5for post&extubation stridor
'(tu)ation Criteria
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Post '(tu)ation Stridor
The Cuff lea5 test during !V. Set a tidal Volume 4>&4, ml@5g
!easure the expired tidal olume
Deflated the cuff
#emeasure expired tidal olume (aerage of -&3 breaths)
The difference in the tidal olumes ;ith the
cuff inflated and deflated is the lea5
A alue of 46>ml 2?7 sensitiit$
?7 specificit$
'(tu)ation Criteria
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Post '(tu)ation Stridor
Cough @ %ea5 test in spontaneous breathing Tracheal cuff is deflated and monitored for the
first 6> seconds for cough:
nl$ cough associated ;ith respirator$ gurgling
(heard ;ithout a stethoscope and related tosecretions) is ta5en into account:
The tube is then obstructed ;ith a finger ;hile
the patient continues to breath:
The abilit$ to breathe around the tube isassessed b$ the auscultation of a respirator$
flo;:
'(tu)ation Criteria
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The ris5 of postextubation upper air;a$
obstruction increases ;ith
the duration of mechanical entilation
female gender
trauma< and
#epeated or traumatic intubation
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'(tu)ation Criteria
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!ailure of SBT
Correct reersible causes for failure adeIuacy o! pain control
the appropriateness o! sedation
!luid status
.ronchodilator needs the control o! myocardial ischemia= and
the presence o! other disease processes
Subse/uent SBTs should be performed eer$ ,-h
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!ailure of SBT
#espirator$ 8ncreased resistanceDecreased compliance8ncreased B and exhaustionAuto&"EE"
Cardioascular Bac5;ard failure. %V d$sfunctionFor;ard heart failure
!etablic@Electrol$tes "oor nutritional statuserfeedingDecreased !g and "-leels!etabolic and respirator$ al5alosis
8nfection@feer!a=or organ failure
Stridor
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%eft 0eart Failure. 8ncreased metabolic demands
8ncreases in enous return and pulmonar$edema
Appropriate management ofcardioascular status is necessar$ before;eaning ;ill be successful
!ailure of SBT
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!ailure of SBT
Factors affecting entilator demands
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!ailure of SBTThera!eutic measures to enhance "eaning !rogress
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Weaning Modes
"atients receiing mechanical entilation
for respirator$ failure ;ho fail an SBT
should receie a stable< nonfatiguingP-1P>3 volume assured pressure support 1pressure augmentation3, MMV
mandatory minute ventilation, >PRV air"ay pressure release ventilation/
Weaning Modes
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"SV. "ressure Support radual decrease in the leel of "SV on
regular basis (hours or da$s) to minimum
leel of ?&2 cm 0,
"SV that preents actiation of accessor$
muscles
nce the patient is capable of maintaining the
target entilator$ pattern and gas exchange atthis leel< !V is discontinued
Weaning Modes
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S8!V. s$nchronied intermittent
mandator$ entilation
radual decrease in mandator$ breaths
8t ma$ be applied ;ith "SV
0as the ;orst ;eaning outcomes in
clinical trials
8ts use is not recommended
0)
Weaning Modes
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Ge; !odes
VS< Volume support
Automode
!!V< mandator$ minute entilation
ATC< automatic tube compensation
ASV< adaptie support entilation
0(
Weaning Modes
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ith the assisted modes< to achiee patient
comfort and minimie imposed loads< ;e
should consider.
sensitie@responsie entilator&triggering s$stems
applied "EE" in the presence of a triggering
threshold load from auto&"EE"
flo; patterns matched to patient demand< and
appropriate entilator c$cling to aoid air trapping
are all important to
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Weaning Protocols
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eaning protocols
Deeloped b$ multidisciplinar$ team
8mplemented b$ respirator$ therapists and
nurses to ma5e clinical decisions #esults in shorter ;eaning times and shorter
length of mechanical entilation than
ph$sician&directed ;eaning
Sedation protocols should be deelopedand implemented
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Weaning Protocols
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$ole of Tracheotom#
Candidates for earl$ tracheotom$.
0igh leels of sedation
!arginal respirator$ mechanics "s$chological benefit
!obilit$ ma$ assist ph$sical therap$ efforts:
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The benefits of tracheotom$ include.
improed patient comfort
more effectie air;a$ suctioning
decreased air;a$ resistance enhanced patient mobilit$
increased opportunities for articulated speech
abilit$ to eat orall$< and
more secure air;a$
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$ole of Tracheotom#
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Concerns.
#is5 associated ;ith the procedure
%ong term air;a$ in=ur$
Costs
0$
$ole of Tracheotom#
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Long*term !acilities
9nless there is eidence for clearl$
irreersible disease (e:g:< high spinal cord
in=ur$ or adanced am$otrophic lateral
sclerosis)< a patient re/uiring prolongedmechanical entilator$ ("!V) support for
respirator$ failure should not be
considered permanentl$ entilator&
dependent until 6 months of ;eaningattempts hae failed:
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Critical&care practitioners should
familiarie themseles ;ith specialied
facilities in managing patients ;ho re/uire
prolonged mechanical entilation
"atients ;ho failed entilator
discontinuation attempts in the 8C9 shouldbe transferred to those facilities
0&
Long*term !acilities
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eaning strategies in the "!V patient
should be slo;&paced and should include
graduall$ lengthening SBTs
"s$chological support and careful
aoidance of unnecessar$ muscle
oerload is important for these t$pes ofpatients
0'
Long*term !acilities
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7han# Eou
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+ntroduction
%5 o! mechanically ventilated patients areeasy to .e "eaned o!! the ventilator "ithsimple process
()(5 o! patients reIuire a use o! a
"eaning protocol over a 24%2 hours 5() reIuire a gradual "eaning over longertime
( o! patients .ecome chronically dependent
on MV
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$eadiness To Wean
Dmprovement o! respiratory !ailure
>.sence o! maKor organ system !ailure
>ppropriate level o! oygenation >deIuate ventilatory status
Dntact air"ay protective mechanism 1needed
!or etu.ation3
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,(#genation Status
Pa
?2
A $) mm +g @i?2 )/4)
PBBP 5 cm +2?
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Ventilation Status
Dntact ventilatory driveL a.ility to control theiro"n level o! ventilation
Respiratory rate : 0)
Minute ventilation o! : (2 F to maintain PaC?2
in normal range
@unctional respiratory muscles
+ntact Air%a# Protective
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+ntact Air%a# Protective
Mechanism
>ppropriate level o! consciousness Cooperation
Dntact cough re!le
Dntact gag re!le
@unctional respiratory muscles "ith a.ility to
support a strong and e!!ective cough
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!unction of ,ther ,rgan S#stems
?ptimiJed cardiovascular !unction
>rrhythmias
@luid overload
Myocardial contractility
6ody temperature
( degree increases C?2 production and ?2 consumption .y 5
Normal electrolytes
Potassium= magnesium= phosphate and calcium
>deIuate nutritional status
nder or over!eeding
?ptimiJed renal= >cid.ase= liver and GD !unctions
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Predictors of Weaning ,utcome
PredictorPredictor ValueValueBvaluation o! ventilatory driveLBvaluation o! ventilatory driveL
P )/(P )/( : $ cm +2?: $ cm +2?
Ventilatory muscle capa.ilityLVentilatory muscle capa.ilityL
Vital capacityVital capacity
Maimum inspiratory pressureMaimum inspiratory pressure
; () mF
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Ma(imal +nspirator# Pressure
PmaL Bcellent negative predictive value i!
less than 2) 1in one study ()) !ailure to
"ean at this value3
>n accepta.le Pma ho"ever has a poor
positive predictive value 14) !ailure to "eanin this study "ith a Pma more than 2)3
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!re"uenc#-Volume $atio
Dnde o! rapid and shallo" .reathing RR
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Me asurem ents Performed 'ither hile Patient as $eceiving
Ventilator# Sup port or During a Brief
Period of Spontaneous Breathing That .ave Been Sho%n to .ave
Statisticall# S ignificant L$s To Predict the
,utcom e of a Ventilator Discontinuation 'ffort in M ore T han ,ne
Stud#
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Weaning to '(haustion
RR ; 05niety
9iaphoresis
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Wor/*of*Breathing
PressureO Volume
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Auto*P''P
Dncreases the pressure gradient needed toinspire
se o! CP>P is needed to .alance alveolarpressure "ith the ventilator circuit pressure
-tart at 5 cm +2?= adKust to decrease patientstress
Dnspiratory changes in esophageal pressurecan .e used to titrate CP>P
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)
5
Gradient
5
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)
>uto PBBP ()
5
Gradient
(5
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PBBP
()
>uto PBBP ()
5
Gradient
5
Preparation0 !actors Affecting
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Preparation0 !actors Affecting
Ventilator# Demand
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+ntegrative +ndices Predicting Success
Measured +ndices Must Be Com)ined
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Measured +ndices Must Be Com)ined
With Clinical ,)servations
Three Methods for 1raduall#
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Three Methods for 1raduall#
Withdra%ing Ventilator Support
>lthough the maKority o! patients do not reIuire gradual "ithdra"al o! ventilation=
those that do tend to do .etter "ith graded pressure supported "eaning than"ith a.rupt transitions !rom >ssistP or "ith -DMV used "ith only
minimal pressure support/
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7han# Eou