The document discusses weaning patients off mechanical ventilation. It defines weaning as the transition from full ventilator support to spontaneous breathing. Patients can have simple, difficult, or prolonged weaning depending on how many spontaneous breathing trials they require. Daily screening checks if patients meet criteria for an initial spontaneous breathing trial. Successful trials are then followed by extubation. Patients who fail trials should have their causes investigated and corrected before retrying weaning.
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Weaning and Discontinuing Ventilatory Supporthanaa
1) The epidemiology of weaning
2) Evidence-based weaning guidelines
3) The pathophysiology of weaning failure
4) Is there a role for different ventilator modes in weaning?
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Weaning and Discontinuing Ventilatory Supporthanaa
1) The epidemiology of weaning
2) Evidence-based weaning guidelines
3) The pathophysiology of weaning failure
4) Is there a role for different ventilator modes in weaning?
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
Predictors of weaning from mechanical ventilator outcomeMuhammad Asim Rana
This is a very useful presentation for respiratory therapists and ICU and Emergency physicians. Intended to teach how to assess you patient's readiness for weaning from mechanical ventilator and successful separation from machine.
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
Weaning from mechanical ventilation , also called ventilator liberation, refers to the process of the patient assuming more and more of the work of breathing and finally demonstrating that ventilator support is no longer required.
Simply it means the process of withdrawing mechanical ventilatory support and transferring the work of breathing from the ventilator to the patient . Weaning can be accomplished with an endotrachel tube ( ETT) or a tracheostomy tube in place.
In the case of the ETT, the final step in the process is the removal of the tube( extubation). With a tracheostomy, the final step may be the ability to breath spontaneously for a designated period of time with the tube in place.
Weaning success is defined as absence of ventilatory support 48 hours following the extubation.
While the spontaneous breaths are unassisted by mechanical ventilation, supplemental oxygen, bronchodilators, low level pressure support ventilation or continuous positive airway pressure (CPAP) may be used to support and maintain adequate spontaneous ventilation and oxygenation.
Purpose
The purpose is to assess the probability that mechanical ventilation can be successfully discontinued.as
75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process.
10-15% of patients require a use of a weaning protocol over a 24-72 hours.
5-10% require a prolonged weaning plan.
1% of patients become dependent on chronic mechanical ventilation.
Indication
Improvement of the cause of respiratory failure.
Absence of major system dysfunction.
Appropriate level of oxygenation.
Adequate ventilatory status.
Intact airway protective mechanism.
Contraindication
Altered sensorium either drowsiness or restlessness.
Spo2 ˂90%
Rising PaCO2 with drop in PH
Tachypnoea ˃35/ min
Tachycardia ˃120 /min
Drop in systolic blood pressure
Sweating
Cold clammy skin
Signs of diaphragmatic weakness
Paradoxical abdominal wall movement
Assessment of readiness for weaning
Hemodynamic stability
Minimum inotropic support
Adequate cardiac output
Afebrile
Hematocrite greater than 25%
Respiratory stability
Improved chest x-ray
Arterial oxygen tension (PaO2) greater than 60mm Hg with fraction of inspired oxygen ( FiO2) less than 0.5
PaO2/FiO2 greater than 300 mm Hg
Positive end expiratory pressure (PEEP) less than 0-5 cm H2O
Vital capacity (VC) 10-15ml/kg
Spontaneous tidal volume (VT) 5ml/Kg
Respiratory rate less than 30 breaths/mim
Minute ventilation 5-10 L/min
Negative inspiratory pressure greater than -20cm H2O
Rapid shallow breathing index (RSBI) less than 105
metabolic factors stable
Electrolytes within normal range.
ABGs( Arterial blood gases) normalized
Other
Adequate management of pain and anxiety.
Patient is well rested
Weaning criteria
Weaning criteria are used to evaluate the readiness of a patient for a weaning trial and the likelihood of weaning success.
Clinical criteria
Ventilatory criteria
Oxygenation criteria
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
Predictors of weaning from mechanical ventilator outcomeMuhammad Asim Rana
This is a very useful presentation for respiratory therapists and ICU and Emergency physicians. Intended to teach how to assess you patient's readiness for weaning from mechanical ventilator and successful separation from machine.
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
Weaning from mechanical ventilation , also called ventilator liberation, refers to the process of the patient assuming more and more of the work of breathing and finally demonstrating that ventilator support is no longer required.
Simply it means the process of withdrawing mechanical ventilatory support and transferring the work of breathing from the ventilator to the patient . Weaning can be accomplished with an endotrachel tube ( ETT) or a tracheostomy tube in place.
In the case of the ETT, the final step in the process is the removal of the tube( extubation). With a tracheostomy, the final step may be the ability to breath spontaneously for a designated period of time with the tube in place.
Weaning success is defined as absence of ventilatory support 48 hours following the extubation.
While the spontaneous breaths are unassisted by mechanical ventilation, supplemental oxygen, bronchodilators, low level pressure support ventilation or continuous positive airway pressure (CPAP) may be used to support and maintain adequate spontaneous ventilation and oxygenation.
Purpose
The purpose is to assess the probability that mechanical ventilation can be successfully discontinued.as
75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process.
10-15% of patients require a use of a weaning protocol over a 24-72 hours.
5-10% require a prolonged weaning plan.
1% of patients become dependent on chronic mechanical ventilation.
Indication
Improvement of the cause of respiratory failure.
Absence of major system dysfunction.
Appropriate level of oxygenation.
Adequate ventilatory status.
Intact airway protective mechanism.
Contraindication
Altered sensorium either drowsiness or restlessness.
Spo2 ˂90%
Rising PaCO2 with drop in PH
Tachypnoea ˃35/ min
Tachycardia ˃120 /min
Drop in systolic blood pressure
Sweating
Cold clammy skin
Signs of diaphragmatic weakness
Paradoxical abdominal wall movement
Assessment of readiness for weaning
Hemodynamic stability
Minimum inotropic support
Adequate cardiac output
Afebrile
Hematocrite greater than 25%
Respiratory stability
Improved chest x-ray
Arterial oxygen tension (PaO2) greater than 60mm Hg with fraction of inspired oxygen ( FiO2) less than 0.5
PaO2/FiO2 greater than 300 mm Hg
Positive end expiratory pressure (PEEP) less than 0-5 cm H2O
Vital capacity (VC) 10-15ml/kg
Spontaneous tidal volume (VT) 5ml/Kg
Respiratory rate less than 30 breaths/mim
Minute ventilation 5-10 L/min
Negative inspiratory pressure greater than -20cm H2O
Rapid shallow breathing index (RSBI) less than 105
metabolic factors stable
Electrolytes within normal range.
ABGs( Arterial blood gases) normalized
Other
Adequate management of pain and anxiety.
Patient is well rested
Weaning criteria
Weaning criteria are used to evaluate the readiness of a patient for a weaning trial and the likelihood of weaning success.
Clinical criteria
Ventilatory criteria
Oxygenation criteria
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. OBJECTIVES
Rationale for weaning
Predictors of Weaning success or failure
Methods of weaning
Weaning failure
3. WEANING
The transition process from total ventilatory support to
spontaneous breathing trial.
This period may take many forms ranging from abrupt
withdrawal to gradual withdrawal from
ventilatory support.
4. CATEGORIES
• First SBT trial successful, extubation successful.
SIMPLE
WEANING
• Fails first SBT, requires upto 3 SBTs before successful
(7 days or less from 1st SBT to successful SBT)
DIFFICULT
WEANING
• Fails atleast 3 SBTs or requires > 7 days from 1st
SBT to successful SBT
PROLONGED
WEANING
5. WHEN SHOULD WEANING
COMMENCE ?
• Evaluation of weanability should commence with decision to
intubate, ventilate.
• Patient should be tested for reduced support when it is safe.
• Physicians must relay on clinical judgement.
• Consider when the reason for IPPV is stabilized and the patient is
improving and haemodynamically stable
• Daily screening may reduce the duration of MV and ICU cost
6. DOUBLE EDGED SWORD !!
!! Unnecessary delays in this discontinuation process
increase the complication rate from mechanical
ventilation (e.g., pneumonia, airway trauma) as well
as the cost
!! Premature discontinuation carries its own set of
problems, including difficulty in re-establishing
artificial airways and compromised gas exchange.
7. DAILY SCREENING
• Resolution/improvement of patient’s underlying
problem
• Patient able to initiate an inspiratory effort.
• Normal state of consciousness
• Absence of fever, temperature < 38C
• Correction of metabolic and electrolyte disorders
• Adequate hemoglobin concentration, > 8-10 g/dl
8.
9. PHYSIOLOGICAL PARAMETERS
Ventilatory
performance and
muscle strength
VC > 15mL/kg
VE < 10 to 15 l/min
VT > 4 to 6 ml/kg
f < 35 breaths per min
f/VT < 60 to105
breaths/min/L
PImax < -20 to -30 cm
H2O
Measure of drive to
breath
P0.1 > -6cm H20
Measure and
estimation of WOB
WOB < 8J/L
Cdyn > 25mL/cm H2O
VD/VT < 0.6
CROP index > 13
mL/breaths/min
11. Patients receiving MV for respiratory failure should
undergo a formal assessment of discontinuation potential
if the criteria are satisfied.
Reversal of cause, adequate oxygenation, haemodynamic
stability, capability to initiate respiratory effort. The
decision must be individualized.
12. Search for all the causes that may contribute to
ventilator dependence in all patients with longer than
24hrs of MV support, particularly who has fail
attempts. Reversing all possible causes should be an
integral part of discontinuation process.
13. PREDICTORS OF THE OUTCOME OF
WEANING
Patient parameters
Awake, alert and cooperative
Haemodynamically stable
RR < 30/min
No effect of sedation/neuromuscular blockade
Minimal secretions
Nutritional status good
Burton GG Respir Care 1997, Caruso P 1999 Chest
Girault C. 1994 Monaldi Arch Chest Dis,TobinMJ. 1990 Eur Respir J,Yang KL.1991 N Engl J Med
14. Ventilator parameters
Spontaneous TV > 5 - 8 ml/kg ,
VC > 10 - 15 ml/kg ,
PEEP requirement < 5 mm of H2O
Static compliance > 30 ml/cm of H2O
MV < 10 L
VD/VT < 60 %
MIP < -30 cm H2O
NIF Burton GG Respir Care 1997, Caruso P 1999 Chest
Girault C. 1994 Monaldi Arch Chest Dis,TobinMJ. 1990 Eur Respir J,Yang
KL.1991 N Engl J Med
15. Oxygenation criteria
PaCO2 < 50 mm of Hg with Normal pH
PaO2 > 60 at FiO2 0.4 or less
SaO2 > 90 % at FiO2 0.4 or less
PaO2/FiO2 > 200
Qs/QT < 20 %
P(A-a)O2 < 350 mm of Hg at FiO2 of 1.0
Burton GG Respir Care 1997, Caruso P 1999 Chest
Girault C. 1994 Monaldi Arch Chest Dis,TobinMJ. 1990 Eur Respir J,Yang
KL.1991 N Engl J Med
16. The removal of the artificial airway from a patient
who has successfully been discontinued from
ventilatory support should be based on assessment of
airway patency and the ability of the patient to
protect the airway.
17. PARAMETERS THAT ASSESS
AIRWAY PATENCY AND
PROTECTION
1. Maximal expiratory
pressure
2. Peak expiratory flow rate
3. Cough strength
4. Secretion volume
5. Suctioning frequency
6. Cuff leak test
7. Neurological function
(GCS)
19. GRADUAL V/S SUDDEN
WEANING ???
No data available
Most trials have used sudden
weaning using Spontaneous
breathing trial with T-piece,
PSV or CPAP
However if a patient fails
recurrent weaning attempts
gradual weaning strategy is
advocated
Respir Care 2002; 47: 69-
90
20. SPONTANEOUS BREATHING
TRIAL
• Communicate with patient, weaning is about to begin, allow patient
to express fear whenever possible
• Obtain baseline value and monitoring clinical parameters; vital
signs, distress, gas exchange, arrhythmia
• Ensure a calm atmosphere, avoid sedation
• Fit T-tube with adequate flow, observe for 2 hrs.
21. Esteban et al compared a 30 min to a 120min T-piece trial
No reported difference in the
rate of re-intubation between
groups.
Patients who were randomized
to the shorter T-piece trial
benefited from statistically
significant reductions in ICU
and hospital lengths of stay (2
days and 5 days shorter,
respectively)
22. The criteria to assess patient tolerance during SBTs
are respiratory pattern, gas exchange, hemodynamics
stability and patient comfort. The tolerance of SBTs
lasting 30 to 120 minutes should prompt for permanent
ventilator discontinuation.
23. PRESSURE SUPPORT
PROTOCOL
Esteban et al compared 2-h trials of unassisted
breathing
using PS of 7 cm H2O v/s a T-piece
A smaller proportion of patients in the PS group
(14%)
failed to tolerate the weaning and to achieve
extubation
at the end of the 2-h trial than in the T-pieceReintubation rates were similar
24. A superior weaning technique among the three
most popular modes, T-piece, pressure support
ventilation, or synchronized intermittent mandatory
ventilation cannot be identified
SIMV may lead to a longer duration of the
weaning process than either T-piece or PSV
The most effective mode of ventilation for
weaning still needs to be determined and
more work is required in this area.
25. FAILED TO WEAN
Patients receiving MV who fail an SBT should have the cause
determined. Once causes are corrected, and if the patient still
meets the criteria , subsequent SBTs should be performed
every 24 hours.
29. Associated with intrinsic lung disease
Associated with prolonged critical illness
Incidence approximately 20%
Increased risk in patient with longer duration of mechanical
ventilation
Increased risk of complications, mortality
30. Patients receiving MV for respiratory failure who fail
an SBT should receive a stable, non fatiguing,
comfortable form of ventilatory support.
Rest 24 hours
Correct the
causes
Retry weaning
Retry with
gradual
modes
Tracheostomy
long term
ventilation
32. Tracheostomy should be considered after period of
stabilization on the ventilator when it becomes apparent that
the patient will require prolonged MV. Tracheostomy should be
performed when the patient appears likely to gain one or more
benefits from the procedure
33. • Improved patient comfort
• More effective airway suctioning
• Decreased airway resistance
• Enhanced patient mobility
• Increased opportunities for articulated speech
• Ability to eat orally, a more secure airway
• Accelerated weaning from mechanical ventilation
• Ability to transfer ventilator-dependent patients from ICU
34. Unless there is evidence for clearly irreversible disease, a
patient requiring prolonged MV should not be considered
permanently ventilator-dependent until 3 months of weaning
attempts have failed.
35. SUMMARY
• The ventilator discontinuation process is a critical component of ICU care.
• Daily wean screen and subsequent SBT should be done in all patients
recovering from respiratory failure.
• Early extubation with backup ventilation of NIPPV is usefull especially in COPD
• Role of newer modes unclear – require more studies.
•Managing the patients who fails the SBT - determine the reasons for failure.
36. REFERENCE
1. Neil R. Maclntyre, Mechanical Ventilation: 2nd edition; Chapter 18,
Discontinuing Mechanical Ventilation; pg.no. 317-322.
2. Lynelle N. B. Pierce, Management of the mechanically ventilated Patient: 2nd
edition; Chapter 11, Weaning from Mechanical Ventilation; pg.no. 378-398.
3. Susan P. Pilbeam, Mechanical Ventilation: 5th edition; Part 7: Discontinuation
from Ventilation and Long term Ventilation; pg.no. 402 – 452