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WEANING FROM MV

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Tujuan Pembelajaran Menjelaskan parameter kesiapan proses

penyapihan

Menjelaskan beberapa teknik penyapihan dan

faktor-faktor yang menyebabkan kegagalan

penyapihan

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Weaning ??? Is the process of withdrawing MV support

and transfering the work of breathing from

ventilator to the patient.

Taking the patient off the ventilator

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Purposes of weaning To safely remove the patient from MV

support in a timely manner

Removal of artificial airway if possible

Train respiratory muscles

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WEANING SUCCESS WEANING SUCCESS IS DEFINED AS

EFFECTIVE SPONTANEOUS BRETHING

WITHOUT MECHANICAL ASISTANCE FOR 24

HUORS OR MORE

( Fiestro et al, 1988; Morganroth, 1984)

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TIMING AND CRITERIA FOR

BEGINNING OF WEANING

WHEN TO START ?

HOW TO PROCEED ?

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WHEN TO START ? The full recovery approach : only when a patient

has returned to almost normal physiological function

may the physician approach weaning

The less iatrogenic approach : MV must be

withdrawn as early as possible ; any data suggesting

successful restoration of spontaneous breathing may

be enough to start weaning

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HOW TO PROCEED ? The less iatrogenic approach : spontaneous

ventilation has to be resumed progressively to

avoid stress to the patient. The iatrogenic approach : if spontaneous

ventilation can be resumed quickly and delay

in withdrawn MV may induced furthercomplication

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Criteria to be met before weaning trials

are initiated1. Resolution of the cause for requiring MV

2. Hemodynamic stability

3. Adequate oxygenation4. Adequate neurologic status

5. Ability to protec airway and manage

respiratory secretion6. Acceptable hemoglobin level

7. Absence of fever

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WEANING FAILUREIS HARDER TO DEFINE THAN WEANING

SUCCESS

Weaning failure has occurred when the patient is

returned to MV after any length of waningtrial

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Wich patient may be hard to wean ???

Patient with chronic lung disease, especiallychronic type 2, eg : Emphysema

Patient with neuromuscular disease ( GuillainBarre syndrome )

Patient who have been paralyzed for morethan 24 hours

Patient who are not ready ( underlyingdesease is not in remission )

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Adverse factor in weaning # 1

Patient not ready due to :

* Have not optimized lung function

* Nutritional status is not correct

* Acid-base balance problems

* Extra vascular lung water ( CHF )

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Adverse factor in weaning # 2

Reduced respiratory muscle strength due to :

Hyphosphatemi

Hypomagnesemia

Hypoxia

Hypercarbia

Acidosis

SepsisPolyneuropathy

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Adverse factor in weaning # 3

Increased load applied to the respiratory

muscle pump ( diaphragm athropy )

Ressistance of the artificial airway andventilator circuit

Malnutrition

Poor left venticular function Residual sedative and anesthetic drugs

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Other factor to consider in weaning

Hypothyroidism

Patient with either renal or liver impairment and

residual drug activity ( sedative, narcotic or

neuromuscular blocking agents)

Hypermetabolism

Metabolic disorder

Malnutrition

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SUMMARY Weaning from MV is not always easy because there are no

absolute criteria that can guarantee successful weaning everytime

The more weaning criteria that are met by a patient, the morelikely the weaning process will be successful

The patient progress should also be monitored on acontinuing basis

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SUMMARY

Multiple credible studies have demonstrated :

- protocol based trategies wean patients more

rapidly than SIMV or PSV based approach