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WEANING PROTOCOL IN MECHANICAL

VENTILATION PATIENT

DRBISWAJIT BHUYAN
INTRODUCTION

• Weaning –process of withdrawing mechanical ventilatory


support & transfering work of breathing from ventilator to
patient
• 75% -can be liberted from ventilator when physiologic reason
for ventilatory support is reversed
• Small % of patient-never be physiologically ready for
discontinuation & become chronically ventilator dependent
• Weaning success: absence of ventilatory support 48 hrs
following extubation. While spontaneous breaths are
unassisted , supplemental O2 , bronchodilators, pressure
support or CPAP may be used to support & maintain
spontaneous ventilation

• Weaning in progress: intermediate category. Here pt. is


extubated but continue to receive ventilatory support by NIV.
Use of NIV allows early weaning attempts & minimizes
complications of prolonged mechanical ventilation
• Weaning failure: either the failure of spontaneous breathing
trial (SBT) or the need for reintubation within 48 hrs following
extubation . Failure of SBT—tachypnea , tachycardia,
hypertension, hypotension, hypoxemia , acidosis or
arrhythmias. Physical signs– agitation, distress, diminished
mental status , diaphoresis & increased work of breathing

• Weaning - more challenging in patients with an earlier failed


attempt
• Excessive secretions , hypercapnia , prolonged mechanical
ventilation(> 72 hrs) & upper airway disorders affect weaning
outcome
• One retrospective review— 79% of 2486 pt.s passed initial
SBT , weaning success rate—68.8% . 13% who passed initial
SBT required reintubation
-Boles et al. , 2007

• Duration needed to wean also vary greatly


• Medical patients often have coexisting problems, so take
more time to complete weaning process than surgical pt.s
Before a patient is considerd a candidate for discontinuation
of ventilatory support , a basic level of physiologic readiness
must be established:
• Improvement of respiratory failure
• Pao2> 60 mm hg with Fio2 < 0.4 & PEEP < 5 cm H2O
• Intact Ventilatory Drive
• Cardiovascular stability
• Electrolytes normal
• Normal body temperature
• Adequate nutritional status
• Absence of major organ system failure
• Stable vital signs following a 1-2 hr SBT
• pH & paCO2 within acceptable limits
Weaning criteria

Clinical criteria
• Resolution of acute phase of disease
• Adequate cough
• Absence of excessive secretions
• Cardiovascular & hemodynamic stability
Ventilatory criteria

• Can tolerate Spontaneous breathing trial of 20 to 30 min

• PaCO2- partial pressure of Co2 in arterial blood a reliable


indicator of ventilatory status. Weaning attempted only when
PaCO2 is < 50 mm with compensated pH. In COPD pt. ,
acceptable PaCO2 slightly higher & pH lower

• Vital capacity & spontaneous tidal volume – minimal vital


capacity & spontaneous tidal volume consistent with
successful weaning 10 ml/kg & 5 ml/kg
• If pt. is receiving full ventilatory support, it is advisable to
allow pt. to breathe spontaneously for 3 min prior to
measuring vital capacity & spontaneous tidal volume. An
equilibration period is needed to obtain spontaneous effort

• Vital capacity measurement- Poor effort or inability to follow


commands result in lower than actual value
• Spontaneous frequency: should be < 35/min .frequency >
35/min associated with rapid shallow brathing. Moderate to
significant increase in spont. frequency after discontinuation
of ventilation –sign of impending weaning failure

• f/VT: reflects degree of rapid shallow breathing. An f/VT of <


100 breaths/min/L correlates with weaning success
• Minute ventilation: a high minute ventilation requirement
>10 L to normalize the PaCO2 implies that work of
spontaneous breathing is excessive. Excessive minute
ventilation may result from increased CO2 production,
increase in alveolar deadspace or metabolic acidosis
• Increased CO2-extensive burn injuries, elevated body
temperature, overfeeding, especially with excessive
carbohydrates
• Alveolar deadspace increased if alveolar ventilation exceeds
perfusion(overventilated-emphysema, underperfused-
pulmonary embolism, decreased cardiac output)
OXYGENATION CRITERIA

• Weaning success will be more likely if pt. is adequetly


oxygenated while receiving partial or no ventilatory support
• PaO2 & SaO2: PaO2 without PEEP >60 mm hg at FiO2 upto .4
& with PEEP >100 mm hg at FIO2 upto .4
• SaO2 should be more than 90%

• PaO2 /FiO2: simplified method of estimating degree of


intrapulmonary shunt. Pao2/Fio2>150 mm hg acceptable
physiologic shunt & compatible to successful weaning
• QS/QT: physiologic shunt to total perfusion ratio used to
estimate how much pulmonary perfusion is wasted.shunt
perfusion cannot take part in gas exchange. Shunt of 10% to
20% --mild shunt. 20% -30% --significant shunt

• Since physiologic shunt is usually intrapulmonary in origin ,


weaning failure becomes likely when spontaneous ventilation
cannot keep up with pulmonary perfusion
• P(A-a) O2 : alveolar-arterial o2 tension gradient is used to
estimate degree of hypoxemia & degree of physiologic shunt.
A large gradient reflects more severe hypoxemia or shunt.

• On 100% o2, every 50 mm hg difference in gradient approx.


2% physiologic shunt. In mechanical ventilation , P(A-a)O2 of
less than 350 mm hg while on 100% oxygen suggestive of
weaning success. Any large gradient should be corrected prior
to weaning trial
PULMONARY RESERVE

• It is assessed by measuring vital capacity & maximum


inspiratory pressure. VC & MIP are effort dependent

• Vital capacity: includes 3 lung volumes. Inspiratory reserve


volume , tidal volume & expiratory reserve volume. It
measures maximum amount of lung volume that pt. can
exhale following maximal inspiration. For successfully weaning
, pt. should have a VC of greater than 10 ml/kg.
• Maximum inspiratory pressure: it is the amount of negative
pressure that pt. can generate in 20 sec when inspiring against
an occluded messuring device. In some pt.s , a waiting period
without assisted ventilation may be needed to induce mild
hypoxia & hypercapnia for best inspiratory efforts.

• MIP is a measure of ventilatory muscle strength & weaning


will likely successful if pt. can generate an MIP of at least -30
mm hg
PULMONARY MEASUREMENTS

• Static compliance,airway resistance & deadspace to tidal


volume ratio are not dependent on pt.s efforts
• Static compliance: measured by dividing tidal volume by
difference in plateau pressure & PEEP. Lower the compliance ,
greater the work of breathing. Minimal compliance for
weaning success is 30 ml/cm H2O
• Airway resistance: normal range for airway resistance is .6-2.4
cm H2O/L/sec. higher for ventilated pt.s because of
associated pathological conditions & tubing resistance. Effect
of resitance through tube is minimised by ensuring Tube Is
Not kinked or suction catheter is not protruding into tube

• Deadspace/tidal volume ratio: calculated as partial pressure


of arterial CO2 minus mean partial pressure of CO2 in
exhaled air divided by arterial CO2 tension. Should be <60%
for weaning success
RAPID SHALLOW BREATHING INDEX

• Spontaneous breathing pattern that is rapid(high frequency)


& shallow (low tidal volume). Induces inefficient , deadspace
ventilation
• Defined as f(no. of breaths/min ) divided by VT in liters
• When greater than 100 breaths/min/L , correlates with
weaning failure
• To measure f/VT index, pt. is taken off ventilator & allowed to
breathe spontaneously for 3 min or until a stable breathing
pattern is established
WEANING PROCEDURE

• Spontaneous breathing trial is major diagnostic test to


determine if pt.s can be successfully extubated & weaned.
Low level pressure support , CPAP, automatic tube
compensation (ATC) may be used along with SBT to augment
pt.s breathing efforts.
• SIMV –should be avoided as stand alone weaning modality
SPONTANEOUS BREATHING TRIAL

• Placed on a spontaneous breathing mode via ventilator or T-


tube (brigg’s adaptor) for upto 30 min
• Criteria for passing SBT-normal respiratory pattern(absence
of rapid shallow breathing), adequate gas exchange,
hemodynamic stability
• No difference in terms of successful SBT among pt.s
undergoing stand-alone SBT,SBT with low level pressure
support, SBT with CPAP or automatic tube compensation
• FAILURE OF SBT: pt.s who fail SBT do so within first 20-30
minutes of trial.
• Exhibit agitation, & anxiety, diminished mental status,
diaphoresis, cyanosis, increased work of breathing
PRESSURE SUPPORT VENTILATION

• It helps to reduce airflow resistance imposed on pt. by


endotracheal tube & ventilator circuit.
• Done by starting pressure support level at 5 to 15 cm H2O &
adjusting gradually (upto 40 cm H2O) until a desired
spontaneous VT (10 to 15 ml/kg) is obtained
• Some titrate pressure support until a desired spontaneous
frequency is reached, typically 25/min or less
• If tolerated well , pressure support is gradually decreased by
3 to 6 cm H2O increments until a level close to 5cm H2O
reached. extubation is considerd if blood gases & vital signs
remain satisfactory
AUTOMATIC TUBE COMPENSATION

• Is a mode in EVITA 4 ventilator that reduces airflow resistance


imposed by artificial airway. Allows pt. to have a breathing
pattern as if breathing spontaneously without an artificial
airway
OTHER MODES OF PARTIAL VENTILATORY
SUPPORT
• Using SIMV to shift work of breathing from ventilator to pt. is
accomplished by progressively reducing mandatory SIMV
frequency (usually 1 to 3 breaths/min at each step). Arterial
blood gaese may be measured after 30 min or more at that
setting. If pH remains near normal , SIMV frequency reduced
further in steps until a frequency of 2 to 4/min reached.

• Other modes –volume support & volume-assured pressure


support . VS-pressure support is adjusted automatically to
achieve target tidal volume. VAPS—guarantees a preset tidal
volume by incorporating inspiratory PSV with conventional
volume assisted cycles. VAPS assures stable tidal volume.
• Mandatory minute ventilation form of SIMV –minute
ventilation is guaranteed. ventilator adjusts frequency
automatically to achieve target minute ventilation.
• Airway pressure release ventilation (APRV) is another mode
Weaning protocol
SIGNS OF WEANING FAILURE

• Early signs –tachypnea, use of accessory muscles, paradoxical


abdominal movements
• Pt. may hyperventilate d/to hypoxia, pain, anxiety or
inappropiate ventilator settings
• Indicators-
• Blood gaes- increasing PaCO2(>50) , decreasing pH(<7.30),
decreasing PaO2(<60), decreasing SpO2(<90%)
• Vital signs- changing blood pressure, increasing heart rate.
Abnormal ECG
• Respiratory parameters- decreasing VT(<250ml), increasing f,
increasing f/VT, decreasing MIP, decreasing static
compliance(<30ml/cm H2O)
EXTUBATION

• Successful extubation requires patient s are able to protect


their airway, mobilize secretions, & donot have a level of
airway obstruction requiring an artificial airway
FAILURE TO WEAN

• Weaning to exhaustion: whether fatigue actually develops


during weaning is controversial, but exhaution observed in
some pt.s results in delay in weaning progression. Rest is
always a key component to any lenghty weaning program

• Work of breathing: excessive workload may be primary


reason why a pt. fails a weaning trial. High airway resistance &
low compliance contribute to increased effort necessary to
breathe
• Auto-PEEP: increases the pressure gradient needed to inspire,
whether triggering the ventilator or spontaneously breathing.
Use of CPAP is important in them to balance alveolar pressure
with ventilator circuit pressure. Generally 5 to 10 cm H2O
CPAP is needed
• Nutritional status/electrolyte balance: imbalance of
electrolytes causes muscular weakness. Especially decreased
K+, Mg, phosphate, Ca impair ventilatory muscle function
• Infection/fever: increased O2 consumption & CO2
production increased drive
• Left heart failure: these patients may rapidly develop
pulmonary edema during weaning. Some pt.s develop
myocardial ischemia during weaning
• Teachnical limitations: with older generation ventilators ,
imposed work-of-breathing during CPAP trials may be
excessive or work imposed by a small endotracheal tube may
prevent weaning.
Chronic ventilator dependency

• In spite of doing everything correctly , some pt. s will not be


able to wean from ventilatory support. Their level of chronic
pulmonary or neuromuscular neurologic disease may make it
impossible for them to wean. Some can be transitioned to
NIPPV while others will require continued invasive ventilation
TERMINAL WEANING

• Defined as withdrawal of mechanical ventilation that results


in the death of a patient
• Terminal weaning may be justified if medical intervention is
futile or hopeless
• Another reason for terminal weaning is to stop pain &
suffering
Thank you…..