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
![Tutorial on Electrophysiology of the Heart ] Sam Dudley, Brown University](https://imgv2-1-f.scribdassets.com/img/document/428646523/149x198/d5548a51ee/1570135827?v=1)
