The document discusses weaning patients from mechanical ventilation. It begins by defining weaning as the process of withdrawing ventilator support and transferring breathing work to the patient. It states that patients must recover from their acute illness and be able to breathe spontaneously before weaning. Weaning is gradually started by evaluating clinical status and giving spontaneous breathing trials to assess readiness for extubation. Different ventilator modes used for weaning, like pressure support ventilation, are described. Weaning criteria involving clinical, ventilatory, oxygenation, and pulmonary measurements are provided to determine weaning success. The weaning procedure, including spontaneous breathing trials and parameters like the rapid shallow breathing index to predict weaning outcome, are outlined. Causes of we
i have prepared this ppt. from various Books as a refrences as well as uses of web pages and explain and modify in simplify language which are easily understand by medical or para medical personnel..thank you..
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
Short review of the practical elements to consider in the interruption of the mechanical ventilation in a hospitalized patient in the Critical Care Unit.
i have prepared this ppt. from various Books as a refrences as well as uses of web pages and explain and modify in simplify language which are easily understand by medical or para medical personnel..thank you..
Mechanical ventilation ppt including airway, ventilator, tubings and connections, nursing management, trouble shooting common problems and issues, suctioning etc.
Short review of the practical elements to consider in the interruption of the mechanical ventilation in a hospitalized patient in the Critical Care Unit.
Weaning from postoperative mechanical ventilationJohn Zaleski
Weaning from postoperative mechanical ventilation is a common activity in surgical intensive care units. This presentation provides an example of key activities and measures used during the process for clinical decision making.
Basic concepts of organic chemistry such as structural formulas, different kinds of representation, types of isomerism, examples, alkanes, alkenes, alkynes etc.
The presentation deals with the principles of mechanical ventilation, its only for the educations purpose!
Any kind of replication, modifications and republication is strictly prohibited.
All Rights reserved to the Author. 2016
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
This slide include information regarding ventilators, modes of ventilators , its parts, weaning process, nursing care of patient in mechanical ventilation.
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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2. • Weaning is the process of withdrawing
mechanical ventilatory support and
transferring the work of breathing from
the ventilator to the patient.
3. • Before weaning, the patient should have recovered from
the acute phase of the disease leading to mechanical
ventilation and be able to assume adequate spontaneous
breathing.
• Weaning is gradually started after evaluating the patient’s
clinical condition, pulmonary and cardiovascular status.
• Depending upon these parameters patient may be given
spontaneous breathing trials on air and extubated.
• If SBT unsuccessful patient is taken back on partial
ventilatory support or pressure support and gradually the
settings reduced and SBT repeated.
4. VENTILATORY MODES USED FOR WEANING
• Conventional Modes used –
Pressure support ventilation
Continuous positive airway pressure
Synchronised Intermittent Mandatory Ventilation
• Advanced Modes used –
Volume support
Volume-assured pressure support
Mandatory minute ventilation
Airway pressure-release ventilation
Automatic tube compensation
5. 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
Pulmonary reserve and measurements
6. Clinical criteria
• Resolution of acute phase of disease
• Adequate cough
• Absence of excessive secretions
• Cardiovascular and hemodynamic stability
10. Weaning Procedure
• Weaning can be done using : –
Spontaneous breathing trials
Pressure support Ventilation
Synchronised Mandatory Intermittent
Ventilation (SIMV)– Not Recommended alone
11. Weaning Procedure
• Spontaneous breathing trial (SBT): An evaluation of a
patient’s readiness for weaning from mechanical
ventilation and extubation.
• SBT is the major diagnostic test to determine if patients
can be successfully extubated and weaned from
mechanical ventilation.
• Spontaneous breathing may be augmented with low-
level (≤ 8 cm H2O) of pressure support, CPAP, or
automatic tube compensation (ATC).
• SBT may last up to 30 minutes.
14. Rapid shallow breathing index (RSBI):
RSBI is used to evaluate the spontaneous breathing pattern
Rapid shallow breathing index (RSBI): The RSBI (f/VT index) is calculated by dividing the
spontaneous breathing frequency (breaths/min) by the average spontaneous VT (L).
Absence of rapid shallow breathing, as defined by an f/VT ratio of less than 100
breaths/ min/L, is an accurate predictor of weaning success.
15. • When the RSBI or f/VT index is greater than
100 breaths/min/L, it correlates with weaning
failure.
• On the other hand, absence of rapid shallow
breathing (f/VT ratio ,100 breaths/min/L), is
an accurate predictor of weaning success.
17. Weaning using SIMV
Based on the results of the sixth International Consensus Conference on Intensive Care
Medicine, synchronized intermittent mandatory ventilation (SIMV) should be avoided as a
stand-alone weaning modality (Boles et al., 2007). However, SIMV remains an effective tool
in providing partial ventilatory support during continuous mechanical ventilation.
18. Termination criteria: Spontaneous frequency >35/min for 5 min; SpO2 <90%;Heart rate >140/min or 120%
of baseline; Systolic pressure >180 mmHg or <90 mm Hg; Signs of anxiety or use of accessory muscles.
19. • Weaning success is defined as absence of ventilatory
support 48 hours following the extubation.
• Weaning in progress is an intermediate category
(between weaning success and weaning failure) for
patients who are extubated but continue to receive
ventilatory support by noninvasive ventilation (NIV).
• Weaning failure- Failure of spontaneous breathing
trial (SBT) or the need for reintubation within 48
hours following extubation.
20. Weaning Failure
Early signs of weaning failure include: tachypnea, use of accessory muscles and
paradoxical abdominal movements, dyspnea, chest pain, chest-abdomen asynchrony
and diaphoresis.
21.
22. Causes of Weaning Failure
• Weaning failure is generally related to
(1) increase of airflow resistance
(2) decrease of compliance
(3) respiratory muscle fatigue.
23. Increase of Airflow Resistance
• Normal subjects using an endotracheal (ET) tube have an
increase of 54% to 240% in the work of breathing,
depending on the size of the ET tube and ventilator flow
rate.
• An 8-mm ET tube has a cross-sectional area of 50 mm2,
which is slightly smaller than adult glottis (66 mm2), the
narrowest part of the airway .
• To minimize this ET tubes of larger size should be used
when it is appropriate to the patient’s size & the ET tube
may be cut to about an inch from the patient’s lips.
24. • Other strategies for decreasing airway resistance
Periodic monitoring of the ET tube for kinking or
obstructions by secretions, or other devices attached
to the ET tube such as a continuous suction catheter,
heat and moisture exchanger, or end-tidal CO2
monitor probe.
Endotracheal suctioning to remove retained
secretions and use of bronchodilators to relieve
bronchospasm
26. Respiratory Muscle Fatigue
Causes are :
o Low lung or thoracic compliance , increased airway resistance
o Muscle disuse may lead to respiratory muscle dysfunction and
diaphragmatic atrophy.
o Mechanical ventilation-induced oxidative stress ventilator
induced proteolysis and contractile dysfunction.
o Inadequate oxygen delivery (low O2 content or cardiac output),
o Insufficient nutrition
o Electrolyte imbalance, especially hypokalemia, hypophosphatemia,
hypocalcemia, and hypomagnesemia.
• Retraining of atrophied muscles may be accomplished by short
T-tube trials that improve respiratory muscle strength. Pressure
support ventilation may also be tried as it increases diaphragmatic
endurance .
27. Terminal Weaning
• Terminal weaning is defined as withdrawal of mechanical ventilation that
results in the death of a patient who is terminally ill or brain dead.
• Different from “EUTHANASIA” or mercy killing as disease is allowed to take its
natural course to death.
• Ethical and moral concerns and legal issues arise before ending mechanical
ventilatory support.
• Only done after detailed discussion with family members and taking their
consent and patient’s consent (conscious patients)when medical intervention
is futile or hopeless in treating the illness.
• In India, terminal weaning only legalised in brain dead or patient in persistent
vegetative state . (On 7 March 2011 Supreme court of India made this decision
as part of verdict in case of Aruna Shanbaug as rarest of rare cases).
• As still there is no clear legislation , such a move requires the permission of
High Court.