the art of weaning kuwait

McGill University Health Centre

The Art of WeaningThe Art of WeaningAn Ordered ApproachAn Ordered Approach

Dr. A. Gursahaney MD, FRCPC

Associate Chief Department of Critical Care

McGill University Health Center

Associate Professor of MedicineMcGill University


The Art Of WeaningThe Art Of Weaning

• Supply versus Demand

• Respiratory Capacity versus Ventilatory Loads

• Systematic Approach – Why are they failing?


RESPIRATORY CAPACITYRESPIRATORY CAPACITY

• DEPRESSED DRIVE

Narcotics, Sedative Drugs

Metabolic Alkalosis

Hypothyroidism



IMPAIRED TRANSMISSION

• Spinal Cord Disease Multiple Sclerosis Amyotrophic Lateral Sclerosis Trauma

• Phrenic Nerve Injury Cardiac Surgery Trauma Post Viral Illness Post Central Venous Catheterization

• Peripheral Neuropathy Guillain-Barre ICU Polyneuropathy

• Neuromuscular Junction Myasthenia Gravis



• MUSCLE WEAKNESS

Steroid Myopathy

Malnutrition

Electrolyte Imbalance

Endocrinopathies


VENTILATORY LOADSVENTILATORY LOADS

• INCREASED CENTRAL DRIVE

Sepsis

Fever

Anxiety, Pain, Agitation

Increased CO2 Production



• INCREASED DEAD SPACE VENTILATION

Pulmonary Embolism

ARDS

COPD



• RESISTIVE LOADSBronchospasmSecretionsEndotracheal TubeVentilator Circuit

• LUNG ELASTIC LOADSPulmonary EdemaPneumoniaAtelectasis

• CHEST WALL ELASTIC LOADPleural FluidAbdominal DistensionAscitesObesity



• THRESHOLD LOADS

Ventilator Trigger

Intrinsic PEEP


Weaning SuccessWeaning Success

• Mental status, protect airway

• Secretion management

• Gravity is your friend

• Sleep Wake Cycles


Extubation SuccessExtubation Success

• Oxygenation– PO2 > mmHg on FiO2 < 35%– PO2/FiO2 >200mmHg– PEEP < cmH2O

• Breathing pattern – spontaneous breathing– Ƒ<30 breaths/min– Vt > 5ml/kg– VE < 10 l/min– VC >10 ml/kg

• Neuromuscular capacity/drive– PI max < - 20cmH2O– P 0-1 < 5.5cmH2O

• Integrative indices– Ƒ/t < 105

the art of weaning kuwait

Education

art