mv weaning

7/25/2019 Mv Weaning

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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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5

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

%


Trial


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Criteria Used in Weaning/Discontinuation in different studies


Trial


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Measurements used To Predict the Outcome of a Ventilator

Discontinuation Effort in More Than One Study


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:

((



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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/



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The tolerance of SBTs lasting 6> to 4,>

min should prompt consideration for

permanent entilator discontinuation

(0



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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/



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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

2(

'(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

00

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:

04


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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$

05

$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:

0%


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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&



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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'



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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

mv weaning

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