ICU book reading

Chap 27 Discontinuing
mechanical ventilation
Outline
Readiness criteria
Rapid-shallow breathing index
Maximum inspiratory pressure
The spontaneous breathing trial
Breathing through the ventilator
Breathing through the T-piece
Protocol
An approach to Rapid breathing
Failure of spontaneous breathing
Low cardiac output
Overfeeding
Respiratory muscle weakness
Tracheal decannulation
Protect airway
Laryngeal edema
Postextubation period
Who can be considerate for
weaning trial
Respiratory criteria:
PaO2 60mmhg on FiO2 40-50% and PEEP5-
8cmH2O.
PaCO2 normal or baseline (except for permissive
hypercapnia
Patient is able to initiate an inspiratory effort
Cardiovascular criteria
No evidence of myocardial ischemia
Heart rate 140 beats/minute.
Blood pressure normal without vasopressors or with
minimum vasopressor support (e.q., dopamine <
5ug/kg/min)
Who can be considerated for
weaning trial
Adequate mental status
Patient is arousable or Glosgow coma score13.
Absence of correctible comorbid condition
Patient is afebrile
There are no significant electrolyte abnormalities
Measurements Used to Identify Patients
Who Will Tolerate a
Spontaneous Breathing Trial (SBT)
The predictive value
The Spontaneous
Breathing Trial

Breathing Through the Ventilator
Breathing Through the T-Piece
Breathing Through the Ventilator
The advantage:
Monitor the tidal volume and respiratory rate
during spontaneous breathing to detect the rapid
and shallow breathing
Disadvantage: increased work of breathing
the negative pressure that must be generated to
open an actuator valve in the ventilator and
receive the inhaled oxygen mixture
the resistance created by the ventilator tubing
between the patient and the ventilator
Pressure-Support Ventilation
add enough inspiratory pressure to reduce
the work of breathing through the
endotracheal tube and ventilator circuit
without augmenting the spontaneous tidal
volume
A positive pressure of 57 cm H2O is
routinely used for this purpose.
inspiratory pressure support is not
necessary during spontaneous breathing
trials
Breathing through endotracheal tubes and
ventilator circuits is not associated with an
increased work of breathing, at least in
comparison to the early time period following
extubation
Breathing Through the T-Piece
Breathing Through the T-Piece
Advantage:
it creates a suction effect that carries the exhaled gas out
of the apparatus and prevents rebreathing of exhaled gas.
it prevents the patient from inhaling room air from the
exhalation side of the apparatus.
The disadvantage
inability to monitor the patient's spontaneous tidal volume
and respiratory rate
less work of breathing when compared to spontaneous
breathing while connected to the ventilator
Protocol
Allow 30 to 120 minutes for the initial trial
Increase the FiO2 by 10% for the period of
spontaneous breathing
Judgement:
Combination of patient appearance (comfortable
versus labored breathing), breathing pattern (i.e.,
the presence or absence of rapid, shallow breathing)
and gas exchange (e.g., ability to maintain SaO2
=90% and end-tidal PCO2 normal or constant
throughout the trial).
Protocol
Our practice for patients who have been
ventilator-dependent for one week or longer
is to permit at least 8 hours (and sometimes
up to 24 hours) of spontaneous breathing
before deciding to remove the ventilator from
the room.
An Approach to Rapid
Breathing
Anxiety versus ventilatory failure
Abdominal Paradox
Rapid breath
Tidal volume
Decreased
No Decreased
Aterial PaCO2
Decreased No Decreased
Resume
ventilator support
Sedation Resume
ventilator support
Low Cardiac Output
positive-pressure ventilation to negative-
pressure spontaneous breathing
=> increase in left-ventricular afterload
=> decrease in cardiac output
=> promoting pulmonary congestion (which
reduces lung compliance)
=> impairing diaphragm function (Diaphram
depend heavily on Cardiac output)

Low Cardiac Output
O2 EXTRACTION: (SaO2 - SvO2)
Arterial-End Tidal PCO2 Gradient:
(PaCO2 PetCO2)
increase in the (PaCO2 PetCO2) difference
=> A decrease in cardiac output
=> increase in dead-space ventilation from
lung disease
Myocardial Ischemia
Continuous Positive Airway
Pressure
CPAP can help by eliminating the increased
afterload caused by negative intrathoracic
pressures
CPAP has been used effectively in patients
with acute cardiogenic pulmonary edema,
Overfeeding
An increase in the daily
intake of calories is
associated with an
increase in metabolic
CO2 production
Respiratory Muscle Weakness
the diaphragm becomes weak during
mechanical ventilation
the diaphragm is not a voluntary muscle
that will stop contracting during mechanical
ventilation.
The diaphragm is controlled by the
respiratory neurons in the lower brainstem,
and these cells fire automatically throughout
life.
Critical Illness Polyneuropathy
and Myopathy
These conditions often accompany cases of
severe systemic sepsis with multiorgan
failure, and they can prolong the need for
mechanical ventilation
The diagnosis is usually made by exclusion
(although nerve conduction studies and
electromyography can secure the diagnosis).
There is no treatment for these disorders,
and recovery takes weeks to months.
Electrolyte Depletion
Depletion of magnesium and phosphorous
can impair respiratory muscle strength
Tracheal Decannulation
Protecting the Airway
the gag and cough reflexes,
the volume of respiratory secretions.
Laryngeal Edema
reported in as many as 40% of cases of
prolonged translaryngeal intubation

Protecting the Airway
The ability to protect the airway =
the gag and cough reflexes,
the volume of respiratory secretions.

Cough strength
can be assessed by placing a file card or piece of
paper 1-2 cm from the end of the tracheal tube
and asking the patient to cough. If wetness
appears on the card, the cough strength is
considered adequate
The Cuff-Leak Test
The test is performed while the patient is
receiving volume-cycled ventilation, and it
involves measuring the volume of gas
exhaled through the endotracheal tube before
and after deflating the cuff
a decrease in exhaled volume after cuff
deflation is used as evidence against the
presence of a significant obstruction at
the level of the larynx.
The Cuff-Leak Test
Different studies have used volumes of 110-
140 mL, and a 25% change in volume as the
threshold.
volume leak during positive-pressure lung
inflation, related to lung compliance and
airways resistance
the diameter of the endotracheal tube relative
to the diameter of the trachea.
Fenestrated Tracheostomy
Tubes
Laryngeal injury maybe
related to prior
endotracheal tube or
ischemic injury.
Steroids for Anything That
Swells?
Controversial
it seems unlikely that one dose of steroids (or
one day of therapy) will reverse the
cumulative effects of days of trauma to the
larynx
The Postextubation Period
The Work of Breathing
Endotracheal tube is smaller in diameter.
But work of breathing is less
endotracheal tubes should never be removed based on
the assumption that it will be easier for the patient to
breathe.
Posrtextubation Stridor
Postextubation stridor is not always an indication for
immediate reintubation
aerosolized epinephrine (2.5 mL of 1% epinephrine)
Breathing a helium-oxygen (heliox) gas mixture
A Final Word
recognizing when a patient is ready to try
spontaneous breathing
A trial of spontaneous breathing
If the patient does well, then consider
extubation,