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Introduction
Weaning a patient from mechanical ventilation is now supported by a
substantial body of good quality clinical trials. Weaning or liberation from
mechanical ventilation (MV) is the process where the level of ventilatory
assistance is reduced concomitant with resolution of the patients disease or
requirement for ventilatory assistance.
It is a distinct process from extubation of the trachea but naturally precedes
this.
Key Point: It is important to distinguish causes of extubation failure
from weaning failure.
Up to 40% of the time spent on a mechanical ventilator is during the
withdrawal process. Removal from MV needs to be prompt to avoid
nosocomial complications. To minimize the duration of MV it is necessary to:
Definition
Clinical problem
Simple weaning
Difficult weaning
Establish cause
of failure
Prolonged weaning
Global Rx needed
eg nutrition, sleep
Neurological
Cardiovascular
Respiratory System - Muscle/Load Interactions
Metabolic
Psychological
Key point : All weaning indices have low likelihood ratios (LR*)
indicating clinical applicability to individual patients is low
* Expression of the odds that a given test result will be present in a patient
with a given condition compared to a patient without the condition; LR >1
probability of success increases ;< 1probability of failure increases
Key point : RVR or f/Vt index is probably the best weaning indices.
Shallow, rapid ventilation is an index of failure. f/Vt : this records spontaneous
tidal volume as measured with a spirometer divided by respiratory rate. A
value <105 has been demonstrated to be helpful in prediction of extubation
outcome.
If so,
:
decrease sedation
establish pressure support ventilation (PSV)
decrease PSV in 2 cm H2O steps ( clinical judgment), as rapidly as
tolerated
the f/Vt ratio may be calculated ;if >100 predictive of failure of SBT
Extubate if PS 8-10 / PEEP 5, FIO2 < 40% and no
contraindications to extubation ( see below)
OR: undertake spontaneous breathing trial (SBT) as follows
Whilst assessing:
SUCCESSFUL SBT:
Consider removal of endotracheal tube (ETT) if:
Other:
SIMV ventilation has been shown to be the worst method of weaning from
MV.PS ventilation has been studied in two major trials. Esteban found PS
ventilation used in weaning to be inferior to once daily T piece trials. Brochard
found PS ventilation was superior to other approaches including IMV and T
piece trials.
Key points: PS ventilation can be used as a weaning strategy by gradual
reduction of the level of PS until a minimal level is attained. IMV can also
be used with a once daily trial spontaneous breathing.
Summary
The majority (2/3) of unselected patients with respiratory failure can be
extubated on their first attempt of spontaneous breathing without any
special weaning technique
Weaning strategies may influence the duration of mechanical
ventilation- once daily trial of spontaneous breathing expedites
weaning-constrained use of IMV and SBT may delay weaning
compared with pressure support Ventilation (PSV)
TRACHEOSTOMY
decreased sedation
decreased airway resistance
enhanced ability to eat, speak and communicate
discharge from ICU whilst retaining suction access and airway
protection
avoid morbidity and mortality of extubation failure
Note: this procedure is elective. Most are done percutaneously however some
require surgical input. There is no set time for when a tracheosotomy should
be performed. In some patients it will be clear one is needed early in others
not. As a general rule about 7-10 days is reasonable to assess the patient and
determine the course of action but shorter or longer times are acceptable.