2. Table of contents
How to survive your first night on call
Mechanical ventilation 4
AC versus SIMV 5
Volume versus pressure 6
Parameters 7
Initial values 8
Assessing ventilation 9
Assessing oxygenation 10
PIP and plateau pressure monitoring 11
Mechanical ventilation of patients with obstructive airway disease
Airway disease versus alveolar disease 13
PIP monitoring 14
Flow monitoring 15
PEEP monitoring 16
Mechanical ventilation of patients with restrictive airway disease
Introduction to ARDS 18
Low tidal volume strategy 19
High respiratory rate strategy 20
Optimal PEEP strategy 21
Goals of lung protective modes 22
Pressure control 23
Bilevel mode 24
APRV mode 25
Assessing for extubation
Screening before weaning 27
Weaning using the SIMV strategy 28
Weaning using the SBT method 29
Weaning parameters 30
Tracheostomy 31
Weaning after prolonged mechanical ventilation 32
Managing patients with special considerations
Upper airway swelling 34
Neuromuscular weakness 35
Appendix
Reference list 37
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All
Full respiratory support
OR
What is mechanical
ventilation?
Mechanical ventilation
Ventilate
Oxygenate
CO2
CO2
CO2
CO2 CO2
CO2
CO2
CO2
Ventilation Oxygenation
O2
Itās not
that simple
Mode
Some
Partial respiratory support
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AC versus SIMV
AC mode
SIMV mode
Reduce the work
of breathing
Respiratory rate (RR) = 15 breaths/min
Tidal volume (VT
) = 500 mL
Tidal
volume
(mL)
Tidal
volume
(mL)
i
n
s
p
i
r
a
t
o
r
y
i
n
s
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
Time (sec)
Time (sec)
500
500
1
1
3
3
5
5
2
2
4
4
6
6
Ideal for muscle recovery
Ventilator does work
Patient responsible for breath
Hypoventilation
AC SIMV
Which initial mode
of ventilation
should I use?
Reference:
Esteban A, Ferguson ND, Meade MO, et al. Evolution of
mechanical ventilation in response to clinical research.
Am J Respir Crit Care Med. 2008. 177: 170ā177.
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RR = 14 breaths/min
VT
= 600 mL
Minute ventilation
= 0.6 L x 14 breaths/min
= 8.4 L/min
We can calculate minute ventilation
to ensure enough CO2
is exhaled.
RR = 14 breaths/min
VT
= ?
Minute ventilation
= VT
x 14 breaths/min
= ?
We canāt calculate minute
ventilation without VT
!
Volume versus pressure
Why volume ventilation
and not pressure
ventilation?
Pressure
Note
Some people will still beneļ¬t from pressure,
but more will beneļ¬t from volume ventilation.
Volume
Minute ventilation
VT
x RR
Key:
amount of
CO2
exhaled
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1. Tidal volume (VT
) 2. Respiratory rate (RR)
3. PEEP 4. FiO2
5. Flow
Which settings are
available for my
patient?
Parameters
Parameters
1. Tidal volume (VT
)
2. Respiratory rate (RR)
3. PEEP
4. FiO2
5. Flow
L or mL
breaths/min
cmH2
O
%
L/min
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What are the initial
values for each
parameter?
Initial values
Parameters
1. VT
2. RR
3. PEEP
4. FiO2
5. Flow
Initial values
6ā8 mL/kg
10ā20 breaths/min
0ā5 cmH2
O
100%
40ā60 L/min
1. Tidal volume (VT
)
2. Respiratory rate (RR)
5. Flow
3. PEEP
4. FiO2
Use ideal body weight based on gender
and height, not actual weight.
6ā8 mL/kg
10ā20 breaths/min
40ā60 L/min
0ā5 cmH2
O
100%
65 kg
6ā8 mL/kg
10ā20 breaths/min
0ā5 cmH2
O
100%
40ā60 L/min
x = 390 mL ā 400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
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Minute ventilation
= 400 mL x 15 breaths/min
= 6 L/min
How do I assess for
adequate ventilation?
Assessing ventilation
65 kg
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
VT
RR
PEEP
FiO2
Flow
Initial settings
Initial settings Ventilation = Removal of CO2
Is this adequate
removal of CO2
?
Check PaCO2
on ABG
ABG results (PaCO2
)
35ā45 mmHg
<35 mmHg
>45 mmHg
Interpretation
Acceptable range
Hyperventilating
Hypoventilating
Recommendation
Maintain settings
Decrease minute ventilation (VT
or RR)
Increase minute ventilation (Vt
or RR)
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How do I assess for
adequate oxygenation?
Assessing oxygenation
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
Initial settings
ABG results (PaO2
)
80ā100 mmHg
<80 mmHg
>100 mmHg
Interpretation
Acceptable range
Hypoxemia
Hyperoxemia
Recommendation
Maintain settings
Increase FiO2
? Increase PEEP
Reduce FiO2
Is this adequate
intake of O2
?
Check PaO2
on ABG
65 kg
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
Initial settings
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PIP = Peak inspiratory pressure
Plateau pressure
How do I monitor and
measure pressure
inside the lungs?
PIP and plateau pressure monitoring
PIP
Plateau
pressure
1 sec
< 30 cmH2
O
Inspiratory pause
Monitor regularly
Monitor regularly
< 35 cmH2
O
PIP is the highest level of pressure applied
to the lungs during inhalation.
Resistance anywhere along the path from
the ventilator to the lungs can cause an
increase in PIP.
PIP should be kept below 35 cmH2
O.
Plateau pressure is the pressure in the lungs
during peak inspiratory hold.
Plateau pressure should be kept below
30 cmH2
O.
Correct by
1. Checking for causes of resistance
2. Reducing VT
3. Changing mode.
PIP
Plateau pressure
< 35 cmH2
O
< 30 cmH2
O
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Alveolar disease
A problem with oxygenation.
Airway disease
A problem with ventilation.
Airway disease
Ventilation issue
āObstructive diseaseā
Airway disease versus alveolar disease
Which general lung
disease category does
the patient fall under?
airways
alveoli
alveoli
Blood
Oxygen
āObstructiveā āRestrictiveā ARDS
Air trapping
O2
Normal
airways
Normal
alveoli
Collapsed
alveoli
Inflamed
airways
Airways
blocked
by mucus
Asthmatic
bronchial
tube
CO2
Signs
Increased PaCO2
Enlarged lungs on chest x-ray
Signs
Decreased PaO2
Lung size appears smaller on chest x-ray
CO2
PaCO2
Alveolar disease
Oxygenation issue
āRestrictive diseaseā
O2
PaO2
Chest x-ray
Chest x-ray
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How can I identify
and manage patients
with obstructive
airway disease?
PIP monitoring
Identify obstructive airway disease
Treat obstructive airway disease
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Permissive hypercapnia may be necessary.
Monitoring and maintaining PIP at an acceptable level can help manage patients with obstructive airway disease.
PIP can indicate airway compromise or air trapping*
.
AND
Amount of PIP represents the severity of air trapping.
*
You should conļ¬rm with a chest x-ray.
CO2
Chest x-ray
Decrease VT
Reducing volume in, reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on a case-by-case basis.
< 35 cmH2
O
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Flow-time waveformānormal Flow-time waveformāair trapping
Flow monitoring
How can I identify
and treat patients
with obstructive
airway disease?
Time
(sec)
Flow
(L/min)
inspiration
expiration
Time
(sec)
Flow
(L/min)
inspiration
expiration
Examining the flow-time waveform on the ventilator can help manage patients with obstructive airway disease.
Identify obstructive airway disease
Treat obstructive airway disease
As long as the expiratory limb reaches zero, the lung
is fully deflated and the patient is not air trapping.
A shift in the waveform, such that the expiratory limb
does not return to zero, indicates air trapping.
Decrease VT
Reducing volume, in reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on case-by-case basis.
< 35 cmH2
O
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Permissive hypercapnia may be necessary.
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
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PEEP monitoring
What other tools do I
have to identify and
treat air trapping?
600 mL
15 breaths/min
5 cmH2
O
40%
60 L/min
VT
RR
PEEP
FiO2
Flow
Expiratory hold
Expiratory pause
Date/Time
RR
12
breats/min
VT
600
mL
FiO2
30
%
PEEP
5
cmH2
O
PEEP (total)
Reference:
M J Tobin; R F Lodato. PEEP, auto-PEEP, and waterfalls.
Chest. 1989;96(3):449-451. doi:10.1378/chest.96.3.449
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Increase PEEP
Permissive hypercapnia may be necessary.
Increase set PEEP
To keep work of breathing to a minimum you want
intrinsic PEEP = extrinsic PEEP. In patients with
obstructive airway disease, air trapping causes the
intrinsic PEEP > extrinsic PEEP. By performing an
expiratory hold and determining the total PEEP and
calculating the intrinsic PEEP, you can increase the set
PEEP by this amount to reduce the work of breathing.
Determining the amount of intrinsic PEEP (inadvertent PEEP or auto PEEP)āthe difference between the set PEEP
and the total PEEPācan help manage patients with obstructive airway disease.
Depressing the expiratory hold or expiratory pause
button on the ventilator keeps the lungs at maximal
exhalation for about 1 second and allows you to
measure the total PEEP.
You can then calculate the intrinsic PEEP:
Total PEEP - set PEEP = intrinsic PEEP
Intrinsic PEEP > 0 air trapping
Identify obstructive airway disease
Treat obstructive airway disease
Decrease VT
Reducing volume in, reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on case-by-case basis.
< 35 cmH2
O
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
(Tobin 1989)
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What happens in the
lungs in acute respiratory
syndrome (ARDS)?
Introduction to ARDS
alveoli
Alveolar collapse
Refractory hypoxemia
Severity of ARDS = Oxygenation status
P/F ratio =
PaO2
FiO2
Recruitment
Fluids ļ¬ll airsac
Normal
Supplemental
oxygen does
not help!
ARDS
Decreased volume in
Increased recoil
Shallow and rapid
breathing
ARDS Severity
Mild
Moderate
Severe
*
on PEEP 5+; **
observed in cohort
PaO2
/ FiO2
*
200-300
100-200
< 100
Mortality **
27%
32%
45%
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What strategies can I
use to treat patients
with ARDS?
Low tidal volume strategy
You can use volume control mode with a low tidal volume strategy to manage patients with ARDS.
Add more VT
?
Increasing volume in does not help because the extra
volume just enters the normal alveoli and overextends
them, further increasing the plateau pressure above
the acceptable 30 cmH2
O. This can damage the lung.
Instead, it is better to reduce the VT
to keep plateau
pressure down and reduce the risk of barotrauma.
6ā8 mL/kg 4ā6m L/kg
VT
by 1 mL/kg
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
Note
Reducing VT
may cause an increase in PaCO2
and
a decrease in pH.
According to the ARDSnet protocol,
compared to barotrauma, respiratory
acidosis is the lesser of the evils.
1. Reduce VT
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Air trapping in restrictive lung disease is bad, but air
trapping may help your ARDS patient!!!
Air trapping can act like PEEP and help recruit and
stabilize the collapsed alveoli.
What strategies can I
use to treat patients
with ARDS?
High respiratory rate strategy
High respiratory rate
Low tidal volume
Plateau pressure ā¤ 30 cmH2
O
pH as low as 7.30
Alveolar
recruitment
PaCO2
pH
35
7.35
45
7.45
<7.30
Treating ARDS patients with a high RR strategy is
like walking a ļ¬ne line... and you may need to adjust,
and readjust, RR as necessary to balance PaCO2
and
plateau pressure.
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
You can use volume control mode with a high respiratory rate (RR) strategy to manage patients with ARDS.
Increase RR PaCO2
Air trapping
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PEEP
PEEP
What strategies can I
use to treat patients
with ARDS?
Optimal PEEP strategy
PaO2
Static compliance
ABG
PEEP that produces the highest PaO2
=
Optimal PEEP
PEEP that produces the highest static compliance =
Optimal PEEP
*
Use inspiratory hold.
Static compliance =
Tidal
volume
Plateau
pressure
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
You can use volume control mode with an optimal PEEP strategy to manage patients with ARDS.
Alveolar
recruitment
Lots of needle sticks (ABG)
Highest PaO2
= best oxygenation
(not necessarily best lung compliance)
Easier to ensure no negative
hemodynamic effects of a high PEEP.
Still a debated topic... and so you
might want to switch modes!
Volume control ???
In this strategy, you adjust PEEP up and down to ļ¬nd the PEEP at which
the lung is the most compliant. To determine when the lung is most
compliant you can monitor PaO2
or calculate the static compliance.
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Goals of lung protective modes
What is lung
protection?
Switch
mode + PEEP Inhalation
āSweet spotā
Pressure
Volume
VT
Lung protective modes:
Pressure control
Bilevel
APRV
When treating patients with ARDS it is common to switch from AC volume control to a mode that is more
lung protective.
We are trying to protect the lungs from two things:
1. alveolar collapse
2. overdistension barotrauma!
1. alveolar collapse 2. overdistension
When using AC volume control you need to constantly
adjust and readjust tidal volume and PEEP to keep the
lungs in the sweet spot.
Other lung protective modes have been developed that
are less frustrating and make it easier to keep the lung
in the sweet spot.
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CON
Asynchrony
Set i-time may not match the patientās desired
i-time, causing patient to be out-of-sync with
venilator anxiety!
1. Adjust and readjust i-time
2. Sedate patient
3. Switch to another mode
Pressure control
Which lung protective
modes can I use to treat
patients with ARDS?
Bilevel?
APRV?
PRO
VT
= Lung compliance
In pressure control mode, the VT
changes with
lung compliance so you can easily monitor
improvement in lung function.
1
10
20
Pressure
(PIP)
(cmH2
O)
Time (sec)
i-time
0.8-1.2 sec
20 cmH2
O
PEEP > 5 cmH2
O
30 cmH2
O
30
3
2 4 5 6
Pressure control mode is a lung protective mode that can be used to treat patients with ARDS.
Pressure
control
Pressure control
Bilevel mode
APRV mode
Initial settings
PIP 20ā30 cmH2
O
i-time 0.8ā1.2 sec
PEEP >5 cmH2
O
Monitor PaCO2
(ABG)
Adjust RR as necessary
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Bilevel mode
Which lung protective
modes can I use to treat
patients with ARDS?
Pressure
(cmH2
O)
Time (sec)
T high
spontaneous breaths
P high
T low
P low
30 cmH2
O
Pressure
(cmH2
O)
Time (sec)
i-time
PIP
e-time
PEEP
30 cmH2
O
triggered breath
Bilevel
Pressure
control
Pressure control
Bilevel mode
APRV mode
Bilevel mode is a lung protective mode that can be used to treat patients with ARDS.
Bilevel
1. Max/min pressure support
(P high/P low).
2. Set RR. But, breaths are
spontaneous and can be
taken any time.
3. Set T high (T low*
).
Pressure support
1. Max/min total pressure
(PIP/PEEP).
2. Set RR. Breaths are controlled
(or triggered at set times).
PRO
Protect lung from
exceeding high
pressure.
Lessen anxiety
because patient
can breathe freely.
Initial settings
P high 20ā30 cmH2
O
T high 0.8ā1.2 sec
RR 20-30 breaths/min
PEEP (P low) >10 cmH2
O
Pressure support 0ā10 cmH2
O
*
This method closely resembles
the pressure control method.
NOTE
Physicians may choose to closely
resemble the APRV initial settings.
*
T low is automatically set based on T high and RR.
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APRV mode
Which lung protective
modes can I use to treat
patients with ARDS?
APRV
Bilevel
+ Pressure
support
APRV mode is a lung protective mode that can be used to treat patients with ARDS.
Time (sec)
P high
P low
T high
T low
RR
Pressure
(cmH2
O)
Time (sec)
P high
PEEP
T high
T low
RR = 30
Pressure
(cmH2
O)
APRV
1. Set P high/P low. (No pressure support.)
2. Set T high (traditionally set longer).
3. Set T low (traditionally set shorter to prevent lung deflation).
Bilevel
1. Set P high/P low (PEEP).
2. Set T high (T low*
).
3. Set RR.
Pressure control
Bilevel mode
APRV mode
Initial settings
P high 20ā30 cmH2
O
T high 4ā6 sec
P low 0ā5 cmH2
O
T low 0.2ā0.8 sec
*
T low is automatically determined
based on T high and RR.
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3. Hemodynamic status
No active myocardial infarction
No (or low) vasopressor infusion
4. Sedation status
No neuromuscular
blocking agents
2. Ventilation status
< 35 breaths / minute
1. Oxygenation status
SpO2
ā„ 90% on FiO2
ā¤ 40%
PEEP ā¤ 5 cmH2
O
What should I screen
before weaning my
patient?
Screening before weaning
O2
CO2
O2
CO2
Before weaning you need to screen your patient to make sure they meet the following criteria.
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Tidal
volume
(mL)
i
n
s
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
Time
(sec)
500
1 3 5
2 4 6 7
Spontaneous
breaths
Pressure support < 20 cmH2
O
What strategies can
I use to wean my
intubated patients?
Weaning using the SIMV strategy
You can use the SIMV strategy to wean your patient off the ventilator.
1. Check patient meets screening criteria.
2. Switch patient from AC SIMV
(with same settings).
3. Reduce RRāgradually.
Reducing the RR allows for more opportunity for
spontaneous breathing.
SIMV strategy
SBT
(CPAP or T-piece)
Reduce RR to as
low as possible.
Reference:
Hess Dean, RRT, PhD, FCCP. Ventilator modes
used in weaning. Chest 2001. 120: 474S-476S.
PRO
Patient assessment
You are often more successful with
something you are familiar with.
CON
Poor outcomes
4. Observe patientās spontaneous ability.
5. Add pressure support as needed.
Added pressure support can assist low volume
spontaneous breaths; but be careful not to add
more than 20 cmH2
O support this probably
means patient isnāt ready.
(Hess 2011)
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What strategies can
I use to wean my
intubated patients?
Weaning using the SBT method
CPAP T-piece
CPAP
5 cmH2
O
Pressure support
6-8 cmH2
O
CPAP
0 cmH2
O
Pressure support
0 cmH2
O
SIMV
SBT
SIMV strategy
SBT
(CPAP or T-piece)
You can use the SBT method to wean your patient off the ventilator.
1. Check patient meets screening criteria.
2. Switch patient from AC T-piece.
3. Remove all pressure support (but leave connected
to ventilator).
Keeping patient connected to ventilator
allows you to monitor spontaneous breaths and VT
.
4. Cycle between no support and support, with
increasing duration of no support.
No support for 2 hours.
1. Check patient meets screening criteria.
2. Switch patient from AC CPAP
3. CPAP of 5cmH2
O helps distend alveoli.
4. Add pressure support of 6ā8 cmH2
O.
Sink or swim method
Even though the SBT method can be considered a
sink or swim method, it appears to be better than
SIMV because the patient breaths spontaneously
with little support.
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1. Respiratory 2. Cardiovascular
3. Neurologic 4. Psychologic
Which weaning
parameters do I
monitor to help
guide my decision
to extubate?
Weaning parameters
RSBI = RR/VT
RSBI < 105
RSBI < 80
Stable with
minimum
pressors
FiO2
< 40%
PEEP < 5-8
No seizures
p/f > 150
Follow
instructions
WOB O2
No dyspnea
Awake
RR < 35
breaths/min
Alert Anxiety
Stress
Fear
Before extubating, you need to monitor your patient and make sure they meet the following weaning parameters.
And... you should always evaluate to ensure there has been
a reversal of the primary cause for mechanical ventilation.
Key
Reversal of the primary cause
for mechanical ventilation.
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How do I know
if a patient requires
a tracheostomy?
Tracheostomy
Ventilatory
capability
Ventilatory
demand
Multiple failed weaning attempts
Secrection clearance
Neuromuscular impairment
After prolonged mechanical ventilation, some patients will require a tracheostomy.
The length of time mechanical ventilation is needed
is often dependent on the severity of the disease.
And, once a patient has been on ventilation for two
weeks, a tracheostomy is commonly considered.
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TIPS protocol
How do I wean my
patients with a
tracheostomy?
Weaning after prolonged
mechanical ventilation
You can still
wean after
tracheostomy
Go slow!
Barlow hospital
TIPS protocol
Step 1: AC to SIMV of 10/min and PS of 20
Step 2: SIMV of 8/min and PS of 20
Step 3: SIMV of 6/min and PS of 20
Step 4: SIMV of 4/min and PS of 20
Step 5: SIMV of 4/min and PS of 18
Step 6: SIMV of 4/min and PS of 16
Step 7: SIMV of 4/min and PS of 14
Step 8: SIMV of 4/min and PS of 12
Step 9: SIMV of 4/min and PS of 10
Step 10: 1 hour
Step 11: 2 hours
Step 12: 4 hours
Step 13: 6 hours
Step 14: 8 hours
Step 15: 10 hours
Step 16: 12 hours
Step 17: 16 hours
Step 18: 20 hours
Step 19: 24 hours
4 breaths/min (SIMV)
Pressure support (PS)
to 10 cmH2
O
CPAP and PS to 0
Patient can be extubated
Up to 3 steps per day at 4-
hour intervals.
Up to 2 steps per day.
If patient is breathing comfortably
at the 9th step, a slow-paced,
spontaneous breathing trial can
be started.
After completion of daily steps,
put back on step 9 for rest of day.
If patient is breathing comfortably
after 19th step, they can be
removed from ventilator.
SBT: Reduce to CPAP of 0
and PS of 0 and monitor for:
Reduce the pressure support (PS):
Reduce to SIMV:
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How do I know if my
patientās upper airway
swelling is reduced
enough to extubate?
Upper airway swelling
Leak No leak
Deflate cuff
How do we know
when the swelling
has decreased
enough in order to
extubate the patient?
Leak No leak
Deflate cuff and listen for a leak.
Swelling
reduced
OK to
extubate
Swelling
still present
Check
daily
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How do I know if my
patientās neuromuscular
weakness has improved
enough to extubate?
Neuromuscular weakness
better than
-20 cmH2
O
worse than
-20 cmH2
O
check
daily
Remember a lower
pressure (more
negative) is better!
NIF
Negative inspiratory force
NIF/MIP
OK to
extubate
Check
daily
OR MIP
Maximum inspiratory pressure
The amount of force that is generated
by the patient in an inspiration.
37. 37
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