This document discusses strategies for liberating patients from mechanical ventilation. It outlines key factors that indicate readiness to wean, including improved respiratory function and organ system stability. Two common approaches to weaning are described: gradual weaning using methods like pressure support ventilation or spontaneous breathing trials followed by extubation if tolerated. Protocols using objective criteria can standardize and expedite the weaning process. Factors that may cause weaning failure include respiratory issues, cardiovascular problems, or infection. Readiness is assessed through measurements of ventilatory drive, muscle strength, and breathing patterns.
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
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
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
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
Inadequate respiratory drive
Inability to maintain adequate alveolar ventilation
Hypoxia
Decision to provide MV should be based on clinical examination and assessment of gas exchange by blood gas analysis. The principal goal of MV in the setting of respiratory failure is to support gas exchange while underlying diseased process is reversed.
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?
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
Similar to Weaning from mechanical ventilator (20)
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Objectives
Discuss physiologic variables that are used to
indicate readiness to wean from mechanical
ventilation
Contrast the approaches used to wean patients
from mechanical ventilation
Discuss the use of protocols to wean patients
from ventilatory support
Discuss the criteria used to indicate readiness for
extubation
Describe the most common reasons why
patients fail to wean from mechanical ventilation
3. WEANING versus LIBERATION
“Weaning”
graded removel of a therapeutic modality on which
the patient has become dependent (and hence
sudden withdrawal will not be tolerated). The term
gradual removal of a benevolent process.
In actual fact, “weaning” from many of the life support
interventions instituted in the intensive care is not
removal of a benevolent life sustaining process but
the removal of a necessary (in the short term) but
potentially damaging (when prolonged) intervention
as early as feasible.
In this context it is appropriate to name this process as
“liberation from mechanical ventilatory and other
life support measures.”
4. Introduction
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 gradual weaning over longer
time
1% of patients become chronically dependent
on MV
5. Readiness To Wean
Improvement of respiratory failure
Absence of major organ system failure
Appropriate level of oxygenation
Adequate ventilatory status
Intact airway protective mechanism (needed
for extubation)
7. Ventilation Status
Intact ventilatory drive: ability to control their
own level of ventilation
Respiratory rate < 30
Minute ventilation of < 12 L to maintain PaCO2
in normal range
VD/VT < 60%
Functional respiratory muscles
8. Intact Airway Protective
Mechanism
Appropriate level of consciousness
Cooperation
Intact cough reflex
Intact gag reflex
Functional respiratory muscles with ability to
support a strong and effective cough
9. Function of Other Organ
Systems
Optimized cardiovascular function
Arrhythmias
Fluid overload
Myocardial contractility
Body temperature
1◦
degree increases CO2 production and O2
consumption by 5%
Normal electrolytes
Potassium, magnesium, phosphate and calcium
Adequate nutritional status
Under- or over-feeding
Optimized renal, Acid-base, liver and GI
functions
10. Predictors of Weaning
Outcome
PredictorPredictor ValueValue
Evaluation of ventilatory drive:Evaluation of ventilatory drive:
P 0.1P 0.1 < 6 cm H2O< 6 cm H2O
Ventilatory muscle capability:Ventilatory muscle capability:
Vital capacityVital capacity
Maximum inspiratory pressureMaximum inspiratory pressure
> 10 mL/kg> 10 mL/kg
< -30 cm H< -30 cm H22OO
Ventilatory performanceVentilatory performance
Minute ventilationMinute ventilation
Maximum voluntary ventilationMaximum voluntary ventilation
Rapid shallow breathing indexRapid shallow breathing index
Respiratory rateRespiratory rate
< 10 L/min< 10 L/min
> 3 times V> 3 times VEE
< 105< 105
< 30 /min< 30 /min
11. Maximal Inspiratory
Pressure
Pmax: Excellent negative predictive value if less
than –20 (in one study 100% failure to wean at
this value)
An acceptable Pmax however has a poor positive
predictive value (40% failure to wean in this
study with a Pmax more than –20)
12. Frequency/Volume Ratio
Index of rapid and shallow breathing RR/Vt
Single study results:
RR/Vt>105 95% wean attempts unsuccessful
RR/Vt<105 80% successful
One of the most predictive bedside parameters.
13. Measurements Performed Either While Patient Was Receiving
Ventilatory Support or During a Brief
Period of Spontaneous Breathing That Have Been Shown to Have
Statistically Significant LRs To Predict the
Outcome of a Ventilator Discontinuation Effort in More Than
One Study*
14. Refertences
2 Tobin MJ, Alex CG. Discontinuation of mechanical ventilation. In: Tobin MJ, ed.
Principles and practice of mechanical ventilation. New York, NY: McGraw-Hill,
1994; 1177–1206
4 Cook D, Meade M, Guyatt G, et al. Evidence report on criteria for weaning from
mechanical ventilation. Rockville, MD: Agency for Health Care Policy and
Research, 199910 Lopata M, Onal E. Mass loading, sleep apnea, and the
pathogenesis of obesity hypoventilation. Am Rev Respir Dis 1982; 126:640–645
16 Hansen-Flaschen JH, Cowen J, Raps EC, et al. Neuromuscular blockade in the
intensive care unit: more than we bargained for. Am Rev Respir Dis 1993;
147:234–236
18 Bellemare F, Grassino A. Effect of pressure and timing of contraction on human
diaphragm fatigue. J Appl Physiol 1982; 53:1190–1195
20 Roussos C, Macklem PT. The respiratory muscles. N Engl J Med 1982; 307:786–797
24 Le Bourdelles G, Viires N, Boezkowski J, et al. Effects of mechanical ventilation on
diaphragmatic contractile properties in rats. Am J Respir Crit Care Med 1994;
149:1539–1544
17. Spontaneous Breathing
Trials
SBT to assess extubation readiness
T-piece or CPAP 5 cm H2O
30-120 minutes trials
If tolerated, patient can be extubated
SBT as a weaning method
Increasing length of SBT trials
Periods of rest between trials and at night
18. Frequency of Tolerating an SBT in Selected
Patients and Rate of Permanent Ventilator
Discontinuation
Following a Successful SBT*
*Values given as No. (%). Pts patients.
†30-min SBT.
‡120-min SBT.
19. Criteria Used in Several Large
Trials To Define Tolerance of an
SBT*
*HR heart rate; Spo2 hemoglobin oxygen saturation. See Table 4 for
abbreviations not used in the text.
20. Pressure Support
Gradual decrease in the level of PSV on
regular basis (hours or days) to minimum
level of 5-8 cm H2O
PSV that prevents activation of accessory
muscles
Once the patient is capable of maintaining
the target ventilatory pattern and gas
exchange at this level, MV is discontinued
21. SIMV
Gradual decrease in mandatory breaths
It may be applied with PSV
Has the worst weaning outcomes in clinical
trials
Its use is not recommended
23. Protocols
Developed by multidisciplinary team
Implemented by respiratory therapists and
nurses to make clinical decisions
Results in shorter weaning times and shorter
length of mechanical ventilation than
physician-directed weaning
24. Daily SBT
<100
Mechanical Ventilation
RR > 35/min
Spo2 < 90%
HR > 140/min
Sustained 20% increase in HR
SBP > 180 mm Hg, DBP > 90 mm Hg
Anxiety
Diaphoresis
30-120 min
PaO2/FiO2 ≥ 200 mm Hg
PEEP ≤ 5 cm H2O
Intact airway reflexes
No need for continuous infusions of vasopressors or inotrops
RSBI
Extubation
No
> 100
Rest 24 hrs
Yes
Stable Support Strategy
Assisted/PSV
24 hours
Low level CPAP (5 cm H2O),
Low levels of pressure support (5 to 7 cm H2O)
“T-piece” breathing
25. Failure to Wean
Respiratory:
Increased resistance
Decreased compliance
Increased WOB and exhaustion
Auto-PEEP
Cardiovascular:
Backward failure: left ventricular dysfunction
Forward heart failure
Metablic/Electrolytes:
Poor nutritional status
Overfeeding
Decreased magnesium and phosphate levels
Metabolic and respiratory alkalosis
Infection/fever
Major organ failure
Stridor
26. Weaning to Exhaustion
RR > 35/min
Spo2 < 90%
HR > 140/min
Sustained 20% increase in HR
SBP > 180 mm Hg, DBP > 90 mm Hg
Anxiety
Diaphoresis
27. Work-of-Breathing
Pressure= Volume/compliance+ flow X resistance
High airway resistance
Low compliance
Aerosolized bronchodilators, bronchial
hygiene and normalized fluid balance assist in
normalizing compliance, resistance and
work-of-breathing
28. Auto-PEEP
Increases the pressure gradient needed to
inspire
Use of CPAP is needed to balance alveolar
pressure with the ventilator circuit pressure
Start at 5 cm H2O, adjust to decrease patient
stress
Inspiratory changes in esophageal pressure
can be used to titrate CPAP
32. Left Heart Failure
Increased metabolic demands that are
associated with the transition from mechanical
ventilation to spontaneous breathing
Increases in venous return as that is associated
with the negative pressure ventilation and the
contracting diaphragm which results into an
increase in PCWP and pulmonary edema
Appropriate management of cardiovascular
status is necessary before weaning will be
successful
33. Post Extubation Stridor
The Cuff leak test:
The expired tidal volume is measured with the cuff inflated on Assist Control
mode with a tidal volume of 10-12ml/kg..
The cuff is then deflated , four to six consecutive breaths are used
to compute the average value for the expiratory tidal volume.
The difference in the tidal volumes with the cuff inflated and
deflated is the leak.
A value of 130ml (12% of inspiratory tidal volume) gave a
sensitivity of 85% and a specificity of 95% to identify patients
with an increased risk of post extubation stridor.
Cough / Leak test: In spontaneously breathing patients
the tracheal cuff is deflated and monitored for the first 30 seconds for cough.
Only cough associated with respiratory gurgling (heard without a stethoscope
and related to secretions) is taken into account.
The tube is then obstructed with a finger while the patient
continues to breath. The ability to breathe around the tube is
assessed by the auscultation of a respiratory flow.
34. Critical Care is A Promise
يتقنه أن عمل عمل اذا العبد يحب ال ان
35. If you are admitted and ventilated in our
ICU we will:
Assess your readiness for extubation on a daily basis
Optimize oxygenation, ventilation, the function of all
organ systems, electrolytes, nutrition before weaning
is attempted
Use spontaneous breathing trials (SBT) in the
assessment
Use RSBI <100 and Maximum inspiratory pressure of
<-30 to predict weaning failure
Discontinue ventilatory support if you tolerate SBT
for 30-120 minutes
Use of liberation and weaning protocol to facilitate
process and decreases the ventilator length of stay
36. Discontinuation of Mechanical
Ventilation
To discontinue mechanical ventilation requires:
Patient preparation
Assessment of readiness
For independent breathing
For extubation
A brief trial of minimally assisted breathing
An assessment of probable upper airway patency after extubation
Either abrupt or gradual withdrawal of positive pressure,
depending on the patient’s readiness
39. The frequency to tidal volume ratio (or rapid shallow breathing index, RSBI) is a
simple and useful integrative indicator of the balance between power supply and
power demand. A rapid shallow breathing index < 100 generally indicates adequate
power reserve. In this instance, the RSBI indicated that spontaneous breathing
without pressure support was not tolerable, likely due in part to the development of
gas trapping.
Even when the mechanical requirements of the respiratory system can be met by
adequate ventilation reserve, congestive heart failure, arrhythmia or ischemia
may cause failure of spontaneous breathing.
42. Three Methods for Gradually
Withdrawing Ventilator Support
Although the majority of patients do not require gradual withdrawal of ventilation,
those that do tend to do better with graded pressure supported weaning than
with abrupt transitions from Assist/Control to CPAP or with SIMV used with only
minimal pressure support.
43. Extubation Criteria
Ability to protect upper airway
Effective cough
Alertness
Improving clinical condition
Adequate lumen of trachea and larynx
“Leak test” during airway pressurization with the
cuff deflated