Mechanical Ventilation Weaning Protocol

Education for Nurses, Respiratory Therapists and PhysiciansThe SLRH Ventilator Weaning Protocol Workgroup

Objectives of this programProvide education about ventilator weaning in the Critical Care Units and Medical Progressive Care and Step down UnitsProvide rationale and benefits for using a ventilator weaning protocolReview the assessment tool for ventilator weaning in critically ill patientsReview SLRH vent weaning protocol:

◦Revised acute vent weaning protocol◦New chronic vent weaning protocol

Explain tracheostomy decisions and careDemonstrate how weaning is integrated into the total care of the patient

A Weaning Protocol:Promotes a standardized assessment of each patient’s readiness to wean as part of the

daily assessment by the nurse and respiratory therapistEmpowers the nurse and respiratory therapist to initiate the process of early weaning from the ventilator by identifying patients who are readyFacilitates collaboration between the RN/RT and physician or nurse practitionerThe Physician can order the weaning protocol based on the assessment by the RN/RT and MD/DO

Benefits of a Weaning ProtocolStudies have shown that weaning

protocols lead to a DECREASE IN:◦Duration of mechanical ventilation◦ICU and hospital length of stay◦Number of tracheostomies performed◦Complications associated with

mechanical ventilation Ventilator-associated pneumonia and lung

injury Venous thromboembolic disease Gastrointestinal hemorrhage

Improving weaning from mechanical ventilationEarly morning daily awakening and

daily spontaneous breathing trial decrease duration of mechanical ventilation

Both nurse-driven and respiratory therapist-driven weaning protocols lead to earlier weaning and extubation, compared to physician-driven protocols

Wesley,E et al; N Engl J Med 1996; 335:1864-1869

Kollef,Marin et al;Crit Care Med 1997; 25:567-574

Why do we need a weaning protocol in our critical care units?

Weaning Protocols are the Standard of Care in Intensive Care Units

We can REDUCE: ◦ Duration of mechanical ventilation◦ ICU and hospital length of stay◦ ICU and hospital mortality◦ Sedation◦ ICU complications such as ventilator-

associated pneumonia (VAP), ventilator-associated lung injury venous thromboembolism and GI hemorrhage

◦ Neuromuscular dysfunction, delirium, and cognitive dysfunction

◦ Weakness due to delay in mobilization

We need to standardize our goals and management of mechanically ventilated patients in order to provide the best care for our patients.

W.E.A.N.! at SLRHWork together – RN, RT, NP, PA,

MD/DOEarly identification – Early in the

day, early in the courseAssessment by RN and RT in

daily screen and protocolNotify physician to start protocol

and how patient tolerates weaning

Weaning: working together - clinicians and patients

The ICU and stepdown nurse and the respiratory therapist for the patient have the important role of timely assessment of weaning readiness

The Physician needs to make the overall decision about whether the patient should undergo the weaning protocol

There are different ways of weaning and this process is individualized. So different modes of weaning may be chosen based on the patient’s disease and course.

Weaning protocols in different unitsOur protocols will take into

account the resources of the different units – critical care and stepdown units - so that the presence and support of nursing and respiratory care are optimal.

In addition to the early morning protocol, weaning assessment can be done at any time during the day.

Acute and Chronic WeaningWhat is the difference?

Acute generally refers to patients with an endotracheal tube who have been on the ventilator for less than 2-3 weeks

Chronic generally refers to patients who have been on the ventilator for longer periods and who have a tracheostomy ◦ Patients with a tracheostomy may require

a more prolonged process◦ However, even some patients with a

tracheostomy may be weaned in a short period of time

The weaning protocolsThe protocols are found on Forms

on DemandWe will go through the steps of

the protocols for acute and chronic weaning

Step 1: Assessment for Weaning ReadinessInitial assessment is the “screening” based

on patient factors, ventilator factors and sometimes ABG. This is the daily screening to be done by the RN and RT to see if the patient is ready for a weaning trial.

This screening does not involve any ventilator changes.

Screening facilitates early morning weaning trial and extubation and does not have to wait for physician rounds

This assessment ties in with the sedation policy: using the sedation protocol to achieve a RASS of 0 or a daily interruption of sedation is appropriate for weaning patients

Early assessment for weaningThe screening is done in the ICU

daily by the night shift (between 5:30 and 7 am) so that, if the patient passes, weaning can be started early◦ Document readiness on ICU

flowsheetIf a barrier is found, such as the

patient is too sedated, this is the opportunity to reduce/stop sedatives to achieve the RASS goal and score◦ The screening can be repeated at

any point if the condition changes

STEP 1: Assessment for weaning readinessThe patient meets the following criteria:

PATIENT FACTORS□ Hemodynamically stabilizing: □ Vital signs acceptable ( BP ≥ 90 systolic, HR ≈ 55 to 135 bpm) □ Tapering/low doses of vasopressors□ Sp02 > 92%□ Can follow simple commands

□ Adequate cough on command□ Initiate good inspiratory effort □ Patient is not expected to follow commands

VENTILATOR PARAMETERS □ FiO2 < 50% □ PEEP ≤ 5 cm H20ABG PARAMETERS □ PaO2 ≥ 75 mmHg □ pH > 7.25

STEP 2: Criteria met, Notify Physician for initiation of protocol

RN and RT communicate the weaning readiness with the MD/DO ( fellow/housestaff/attending)

Physician decides whether weaning should be initiated. Some situations in which the patient meets criteria but weaning will not be done include – procedure or test that will require ventilation, concerning lab test or change in stability.

Physician decides on the vent weaning mode, completes orders and places order in Prism to initiate weaning protocol

Feedings heldSedation goal RASS of 0 achieved or hold

sedationExplain to the patient

Physician Order for WeaningThe MD/NP needs to place the

order for weaning only onceThis order will remain active for

daily weaning unless cancelled due to change in patient condition

Please note…There are some patients who

have a neurologic injury or baseline dysfunction – who are not expected to follow commands, but who still may be able to wean from the ventilator.

The clinicians may decide to proceed with a trial of weaning in patients who do not pass all readiness criteria.

Start weaning protocol earlyBetween 5:30 and 7 am in the

ICUsBy 9 am for chronically-ventilated

patients in the stepdown units

STEP 3: Method of weaningchosen by physician

PRESSURE SUPPORT VENTILATION METHOD (PSV)□ Set PS___ □ FiO2___ %□ Decrease PS by ___q ___h□ ABG ( ) Y ( ) NGOAL : PS ≤ 5 for ____ min

SICU METHOD □ CPAP = 5, PS=0 □ FI02 21% □ Tolerates 20 min □ Then ABG:GOAL: Pa02 >50mmHg PaC02 <50 mmHg RR < 35/min

SIMV METHOD□ Set IMV___ PS___□ FiO2___%□ Decrease IMV rate by __ q __ h □ Decrease PS by ___ q ___ h □ ABG needed ( ) Y ( ) N

GOAL: IMV ≤ 4 AND PS ≤ 8 for ___min

SPONTANEOUS BREATHINGTRIAL METHOD (SBT)□ PS=____□ CPAP = ___□ FI02 ___%□ T-piece □ Duration ___minutes□ ABG needed ( )Y( ) N GOAL : ____ min

Acute weaning – Spontaneous Breathing Trial “SBT”The most common method is the SBT:

CPAP mode, pressure support 5-8 cm H20. Duration 30-120 minutes.

Other methods include:◦ SIMV with gradual reduction in respiratory

rate◦ Pressure support with gradual reduction in

amount of pressure supportFor SICU patients, CPAP trial for 20

minPhysician Order: must complete

method, settings, and duration

STEP 4: Assessing patient tolerance of weaning

• Respiratory Rate <35 breaths per minute• Heart rate between 50 and 130 bpm and within ± 20% of

pre-trial HR• Systolic Blood Pressure (SBP) between 90-170 mmHg and

within ± 20% of pre-trial SBP• Exhaled TV ≥ 5 cc/ kg IBW ( ≈ 300 – 400 ml )• SpO2 ≥ 92 %• Patient showing no diaphoresis, paradoxical respiration,

retractions, nasal flaring, agitation, or complaining of SOB, or use of accessory muscles

• Serial assessments of tolerance are made 5,15,30,60,and 120 minutes after the INITIAL setting and following any subsequent ventilator changes.

STEP 5: Tolerating weaning trial – success! Notify physician and teamArterial blood gas, if orderedPhysician informed about the

successful weaningRT - set up for extubationPhysician will be present for

extubationThe patient is monitored following

extubation:◦ In addition to vital signs including

Sp02 ,always check for stridor, breath sounds, secretions

Not tolerating weaning today…If not tolerating weaning go to

pre-trial settingsDocument on Weaning Flow

record – in what way the patient did not tolerate weaning, duration of weaning, level of support used

This will improve our communication and plan for the next weaning trial so that we can move forward with weaning the patient

DocumentationThe daily outcome will be written in

the weaning flow record which will be kept in the Respiratory Care book. The RN and RT document the progress

The medical, nursing and respiratory staff will view the flow record in making further decisions about weaning

Vital signs, ventilator settings, extubation are charted in the ICU flow record as usual

Weaning Flow Sheet Documentation

Chronic Vent WeaningThis protocol applies to patients

with tracheostomies who are undergoing weaning in the Critical Care Units, MPCU, stepdown vent units RH 10B, SL 10E

The early assessment is the same

Screening by nurse or respiratory therapist for readiness◦ Document in nursing/respiratory

notes or ICU flow record

Only one order to wean is needed and will apply until the order is discontinued

Weaning will be started by 9 am daily

Methods of Chronic Vent WeaningSome patients who have been on a

ventilator for a prolonged period or have a tracheostomy may need a more progressive program for weaning

The two general methods are:◦Pressure support PS– gradually

decrease the PS amount and prolong the time

◦Trach collar – use trach mask for progressively longer periods of time

◦Other methods such as volume support may also be used

Chronic Weaning

DocumentationThe duration of weaning is

documented on the flow record. This will be kept in the respiratory folder. The RN or RT may document the progress

The medical, nursing and respiratory staff will view the flow record for further decisions about weaning

Tracheostomy: IndicationsProlonged ventilator requirement and

inability to wean due to ◦ Generalized weakness, such as critical illness

polyneuropathy◦ Multiple comorbid conditions that require

prolonged ventilation◦ Chronic critical illness

Inability to clear secretions Severe neurologic dysfunction Airway obstruction

◦ Tumor, upper airway injury, edema◦ Severe obstructive sleep apnea with

complications, not amenable to usual treatments

Patients not expected to wean- Addressing goals of careSome patients are not expected

to be weaned from a ventilator so tracheostomy would be considered for indefinite ventilator-dependence

In these patients, this decision point for tracheostomy would be an appropriate time to readdress life support/end-of-life decisions

Benefits of tracheostomyAbility to mobilize patients with

prolonged need for ventilator with a more secure airway

Potential for patient to require less sedatives and communicate

Allows transfer to a chronic ventilator facility

Planning for TracheostomyClinician assesses the potential for liberation from ventilator based on the patient’s illness, prognosis, and patient preference

Tracheostomies can be performed early (within 7 days) or later (at 2-3 weeks)

If the patient is unlikely to be weaned due to neurological/chronic pulmonary process, a decision on tracheostomy can often be made within few days of intubation

Patients with reversible disease who are unable to wean in 10-14 days are usually considered for tracheostomy at that time

Tracheostomy is not performed in unstable or dying patients

Timing of TracheostomiesBased on individual patient

situationBenefits of early tracheostomy

include: improved comfort and decreased sedation, improved mobility

In some patients, early tracheostomy may facillitate weaning, so may decrease duration of mechanical ventilation

Patients with tracheostomiesAssess for speech and swallowing

– may be candidate for speech valve

MOBILITY – out of bed, sit, stand, walk

Decannulation – removal of tracheostomyPatients are completely off ventilator for

sufficient number of days to assure that the primary process is resolved

Able to cough secretionsTolerate speech valveTolerate capping of the tracheostomyClinically assure there is no upper

airway obstructionPatient requires close monitoring in the

first 24 hrsIf patient develops distress – consider

secretions, airway obstruction

Respiratory distress in patients with endotracheal tubes and tracheostomies

Secretions and mucous pluggingDislodgement of tracheostomy/ ETTPneumothoraxVentilator dyssynchrony due to vent

settingsBecause of underlying diseases, may be

at risk for pulmonary embolism, heart failure, volume overload

Granulation tissue formation in the trachea can lead to high peak pressures

**These causes must be considered before treatment with sedatives**

Look at the overall plan of careMobility in patients with

endotracheal tube or tracheostomy

SpeechNutritionGoals of care discussion with

patient and family

MobilityEarly mobility can

◦ Decrease intensive care unit and hospital length of stay in survivors

◦ Reduce the functional decline from the illness

◦ Decrease risk of pressure ulcers and improve wound care

Multidisciplinary team – collaboration to provide safe mobilization of patients in the intensive care unit, progressive care and stepdown units.

Weaning and mobilityIn addition to the effects on

duration of ventilation, mortality and ICU complications, weaning and mobility can potentially:

Improve patient spiritImprove communicationReduce delirium Reduce depression

DocumentationOrders will be placed by MD using

the pre-printed paper order:◦Weaning orders

Physician places order for weaning in Prism

ICU Flowsheet will reflect the readiness screen and the weaning

RN/RT will document in weaning flow record

Extubation – Physician documents in progress note

So let’s W.E.A.N.! at SLRH

Work together – RN, RT, NP, PA, MD/DO

Early identification – Early in the day, early in the course

Assessment by RN and RT in daily screen and protocol

Notify physician to start protocol and how patient tolerates weaning

Thank you for completing this program!We believe that a comprehensive

and multidisciplinary approach will improve care and outcomes of our patients who require mechanical ventilation.

For questions, please contact:Manju Pillai MDRaymonde Jean MDMark Collazo RRTJanet Shapiro MD