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Weaning & Discontinuation of Mechanical Ventilation
- 1. Weaning & Discontinuing Mechanical Ventilation
- 2. WEANING PROTOCOLS ARE RECOMMENDED DAILY ASSESS PATIENT READINESS TO BREATHE INDEPENDENTLY USE PREDICTORS OF SUCCESS OR FAILURE ENSURE EXTUBATION SUCCESS
- 4. Spontaneous Breathing Trial Perform only once per day once patient is deemed ready Perform SBT with patient breathing through the ETT one of three ways Without any ventilator support through a T-piece With low level of pressure support 5-8 cmH2O With low level continuous positive airway pressure [CPAP] SBT for 30 mins should be adequate, but can extend to 120 mins in some circumstances
- 5. Rapid Shallow Breathing Index: A Weaning Indicator • RSBI = frequency / tidal volume (in liters) • RSBI > 100 suggests a patient will fail liberation from the mechanical ventilator (95% negative predictive value) • RSBI <100 suggest a patient will successfully liberate from the mechanical ventilator (80% positive predictive value)
- 6. Ensure Extubation Success Airway Protection • Cough • Secretions • GCS >8 Post-Extubation Stridor • Prolonged or Traumatic ETT • >80 years old • Large ETT (female > male) • GCS < 8
- 7. Extubation Procedure • Head up • Suction • Oxygen ready Pre-extubation • Oxygen delivered • Titrate oxygen flow to SpO2 • Auscultate • Monitor closely Post-extubation
Editor's Notes
- Patients who are intubated on mechanical ventilators should be continuously monitored and reassessed for their ventilatory support needs. As the patients’ etiology for respiratory failure resolves and the patients’ condition improves, they will require less mechanical support for oxygenation and ventilation.
- Although MV can be life-saving, prolonged intubation and MV can lead to increased infections, weakness, cost, and complications. Therefore, as the patient improves, their need for ETT & MV should be continuously reassessed for weaning and/or discontinuation. Weaning protocols are recommended as studies show that their use decreases the length of ETT & MV by 25% and decreases length of ICU stay and VAP. However, not all institutions or ICUs are the same necessitating protocols be tailored to the patient population being served. Patients should undergo daily readiness testing to assess readiness for weaning, discontinuation of MV, and the ability to breath independently Indicators of successful liberation from MV and extubation such as the rapid shallow breathing index and cuff leak test should be considered in each patient as appropriate. The process of extubation should be done in such a way to ensure successful extubation and independent patient breathing.
- Daily readiness assessments include more than breathing and respiratory parameters. Hemodynamic stability and intact neuro-cognitive functioning are also required for successful extubation, airway protection and independent breathing. This example of clinical assessment of readiness for a SBT includes ensuring the cause of RF has resolved or improved, oxygenation is adequate, acid/base status is in an acceptable range, the patient is hemodynamically stable, and the patient is able to initiate breaths independently. Additional considerations include adequate hemoglobin levels, normothermia, and mental status.
- Once a patient is deemed ready for a SBT, the provider must decide how to perform the SBT. SBTs should only be conducted once per day. Conducting them more frequently can lead to further respiratory weakness and has not been shown to improve successful extubation rates. Although historically SBTs have been conducted using CPAP, PSV, and T-piece, the ATS and ACCP released an updated guideline in 2017 stating: “For acutely hospitalized patients ventilated more than 24 h, we suggest that the initial SBT be conducted with inspiratory pressure augmentation (5-8 cm H2O) rather than without (T-piece or CPAP) “ This group of experts also stressed the importance of pairing ventilator weaning protocols with sedation weaning protocols which has been shown to decrease days on MV and in ICU.
- Patients who need continued ventilatory support tend to breath rapidly and more shallow Patients who no longer need ventilatory support tend to breath more slowly and deeply The RSBI is a sensitive and specific predictor of weaning success. RSBI is calculated by dividing the respiratory rate by the tidal volume in liters. Using the cut of 100breaths/minute/liter, the RSBI has a 95% negative predictive value of patients failing extubation if the RSBI is greater than 100. Patients with an RSBI calculated below 100 had ann 80% likelihood of successful weaning (positive predictive value).
- Providers must ensure patients can protect their own airways from aspiration by assessing the strength of the patient’s cough, their ability to manage secretions, and ensure their GCS is >8 Some patients are at higher risk for post-extubation stridor. Providers must rule out these Risks for Post-extubation stridor which include = Prolonged intubation (variably defined as ≥36 hours to ≥6 days); Age greater than 80 years; A large endotracheal tube (>8 mm in men, >7 mm in women) An elevated Acute Physiology and Chronic Health Evaluation (APACHE) II score; A GCS score <8 ;Traumatic intubation ;Female gender ;A history of asthma or Aspiration
- Even when patients pass their SBT, the procedure of extubating patients should set the patients up for success and prevent complications. Pre-extubation procedure includes preparing for re-intubation in the event the patient fails. Patient should be positioned head up. Pre-extubation suctioning of mouth and ETT is necessary to clear secretions. Providers should ready post-extubation oxygen delivery devices such as O2 mask or nasal cannula. TO extubate providers should Remove ETT securing devices, deflate pilot balloon and remove ETT. Post-extubation Place patient on oxygen mask, Set oxygen to meet goal SpO2, Auscultate at neck for stridor, Auscultate lungs to assess bilateral air movement, Observe patient closely for stability