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Weaning from the

ventilator
Doctor Chad
PulmCrit.com

Questions to answer before


attempted weaning
What is the cause of the respiratory
failure, and has it been reversed?
Is the patient capable of performing an
SBT?
How will the SBT be performed, and what
is considered passing?
How will the patient be managed after
failing an SBT?
What is the role of tracheostomy?

Requirements to meet before


SBT
Minimal vent settings: ie Oxygenation (PaO2 > 60 on
FiO2 50%, and positive end-expiratory pressure
[PEEP] 8).
Do not have copious secretions/can manage their own
secretions
pH 7.25 (metabolic acidosis increases respiratory rate
[RR] and places a load on the patient).
Hemodynamic stability (i.e., no active malignant
arrhythmias, cardiac ischemia, or critical
hypoperfusion).
Patient is initiating spontaneous breaths.
Presence of cough and gag reflexes (SBT/weaning
parameters can be obtained without this).

RSBI - Rapid shallow breathing


index
RSBI= RR/TV
Threshold value < 105 bpm is positive and
indicates a likelihood of weaning success.
RSBI sensitivity in multiple trials is about
7090% in predicting successful liberation.
However, false positives are the concern and
the positive predictive value is about 80%,
and specificity of 1164% (i.e., those who
pass but require reintubation or fail their
SBT).

Other measures of successful


weaning

PImax aka negative inspiratory force (NIF) aka


maximum inspiratory pressure (MIP)
o Measures pressure generated by patient from
functional residual capacity (FRC), and requires
patient effort.
o Poor indicator of success or failure of extubation.
Minute ventilation (VE): ie TVx RR. Values <10 L/min
thought to be an indicator of liberation success
o Values >1520 L/min helped identify those likely to
fail.
o Several large trials found this to be a poor predictor
of outcome.
TAKE AWAY: If in doubt, do a SBT!!

HOW IS AN SBT PERFORMED?


WHAT IS CONSIDERED PASSING?

SBT involves one of three methods:


CPAP 5 cmH2O; pressure support (PS) of 5 or 7 cmH2O
over PEEP; Removing the ventilator and using a T-piece.
Disadvantage of the T-piece method is the lack of
respiratory monitoring (ventilator waveforms, VT, alarms).
Monitoring is most important during the initial few
minutes, as this is when most patients fail.
If the patient does not fail (see below) within the
first few minutes, then a trial of 30120 minutes is
attempted.
If the patient passes an SBT, extubation is successful
8090% of the time (assuming that the endotracheal
tube [ETT] is no longer needed for other problems)
Cuff leak test

How do you define success in


SBT?

How do you define success in SBT?

SpO2 8590% or PaO2 5060


pH 7.32, increase in PaCO2 10
Hemodynamic stability
Not requiring significant vasopressors
Heart rate (HR) < 120140 bpm, change <
20%
SBP < 180200, but > 90, and no change >
20%
Breathing patternRR 3035 Not
increased by >50%

Subjective measures of success


No mental status changes (agitation,
anxiety, lethargy, or somnolence)
No visible discomfort
No diaphoresis
No signs of dramatically increased work
of breathing (accessory muscles,
abdominal paradox, respiratory
alternans)

Recent literature on weaning...

Multicenter, unblinded randomized controlled trial 304 patients to either a BNP or physician-driven
strategy of fluid management during weaning of mechanical ventilation weaning.
Patients included were hemodynamically stable on a PEEP of 8 or less and FiO2 50% or less,

Control group physicians were blinded to BNP assay results and other treatments were per usual care
with no explicit protocol.
When daily BNP was >/= 200 pg/ml, BNP-guided physicians followed a protocol that included restricting
fluid intake and administering furosemide to meet target urine output goal. BNP-guided strategy was
continued for at least 24 hours post-extubation.

Authors predefined three subgroups of interest: COPD, LV dysfunction and neither

Patients in the BNP-guided group received more diuretics and had a more negative fluid balance during
weaning.

BNP guided therapy resulted in faster time to extubation (statistically significant), faster removal of noninvasive ventilation (not quite statistically significant) and more ventilator-free days. This effect was
strongest in the group with left ventricular dysfunction

Mekontso-Dessap A et al. Natriuretic-peptide driven fluid management during ventilator weaning: a


randomized controlled trial. Am J Respir Crit Care Med2012;186(12):1256-63.

What approach should I take to


wean?

Two large randomized trials have evaluated the weaning


process .
Majority of patients considered for weaning are already
sufficiently recovered so as to be ready for extubation.
For the minority of patients who fail an SBT, alternate
modes were compared (T-piece vs. PS vs. SIMV).
In one trial, T-piece was found to be best, while in the
other, PS was superior. Both trials found SIMV to delay
weaning.
Weaning protocols (nurse or respiratory therapistdriven) lead to shorter duration of mechanical
ventilation.

T-piece

Cant get my patient of the vent.


What about TRACHEOSTOMY?
Possible benefits include:
Improved patient comfort
Effective airway suctioning
Decreased airway resistance
More secure airway
Ability for speech, eating
Mobility
More rapid weaning from ventilator
No data clearly support that tracheostomy reduces
risk of ventilator-associated pneumonia.

Tracman Trial

Duncan Young et al. Effect of Early vs Late Tracheostomy Placement on Survival in Patients
Receiving Mechanical Ventilation: The TracMan Randomized Trial.
To test whether early vs late tracheostomy would be associated with lower mortality in adult patients requiring
mechanical ventilation in critical care units.
An open multicentered randomized clinical trial conducted - 909 vented adult patients for less than 4 days
and identified by the treating physician as likely to require at least 7 more days of mechanical ventilation.
Randomized 1:1 to early tracheostomy (within 4 days) or late tracheostomy (after 10 days if still indicated).
Primary outcome measure was 30-day mortality and the analysis was by intention to treat.
92% of the early-group patients received a tracheostomy, while only 45% in the late group did.
Late group- surviving patients didnt need a tracheostomy by day 10 because they were successfully extubated.
No proven difference between groups in 30-day mortality (30.8% early vs. 31.5% late, primary outcome), nor
in any other outcome including 2-year mortality. Patients getting early tracheostomies required fewer days of
sedation, and there was a suggestion of a reduction of -1.7 ventilator days with early trach (mean 13.6 days vs
15.2 days, p=0.06). However, ICU stays were exactly equal at a median 13 days.

JAMA 2013;309(20):2121-2129.

TAKE AWAY
Start SBT trials early once patients meet criteria
(an RT driven protocol works best)
A reintubation rate of 10% is acceptable
Diurese if you can - a dry lung is a happy lung
NIFs & MIFs are poor predictors of successful
extubation. Consider only in patients with
neuromuscular diseases leading to respiratory
failure
Early trachs will reduce ventilator time and
sedation needs but ICU LOS is unchanged