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Weaning Modes and Protocol. Causes of Ventilator Dependence Assessment for Discontinuation Trial Spontaneous Breathing Trial (SBT) Extubation Criteria Failure of SBT Weaning Modes Weaning Protocols Role of Tracheostomy Long-term Facilities. Stages of Mechanical Ventilation. 2.

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Weaning modes and protocol

Weaning Modesand Protocol


  • Causes of Ventilator Dependence

  • Assessment for Discontinuation Trial

  • Spontaneous Breathing Trial (SBT)

    • Extubation Criteria

  • Failure of SBT

  • Weaning Modes

  • Weaning Protocols

  • Role of Tracheostomy

  • Long-term Facilities



Causes of ventilator dependence
Causes of Ventilator Dependence

Who is the “ventilator dependent’?

  • Mechanical ventilation > 24 h

    or

  • Failure to respond during discontinuation attemps



Assessment for discontinuation trial
Assessment for Discontinuation Trial

Criteria for discontinuation trial:

  • Evidence for some reversal of the underlying cause for respiratory failure

  • Adequate oxygenation and pH

  • Hemodynamic stability; and

  • The capability to initiate an inspiratory effort


Assessment for Discontinuation Trial

Extubation failure

  • 8-fold higher odds ratio for nosocomial pneumonia

  • 6-fold to 12-fold increased mortality risk

  • Reported reintubation rates range from 4 to 23% for different ICU populations


Assessment for Discontinuation Trial

Criteria Used in Weaning/Discontinuation in different studies


Assessment for Discontinuation Trial

Measurements used To Predict the Outcome of a Ventilator Discontinuation Effort in More Than One Study


Spontaneous Breathing Trial

  • Formal discontinuation assessments should be performed during spontaneous breathing

  • An initial brief period of spontaneous breathing can be used to assess the capability of continuing onto a formal SBT.


Spontaneous Breathing Trial

  • How to assess patient tolerance?

    • the respiratory pattern

    • the adequacy of gas exchange

    • hemodynamic stability, and

    • subjective comfort.


Criteria used in several large trials to define tolerance of an sbt

Spontaneous Breathing Trial

Criteria Used in Several Large Trials To Define Tolerance of an SBT*

*HR heart rate; Spo2 hemoglobin oxygen saturation.


Spontaneous Breathing Trial

  • The tolerance of SBTs lasting 30 to 120 min should prompt consideration for permanent ventilator discontinuation


Frequency of Tolerating an SBT in Selected Patients and Rate of Permanent Ventilator DiscontinuationFollowing a Successful SBT*

Spontaneous Breathing Trial

*Values given as No. (%). Pts patients.

†30-min SBT.

‡120-min SBT.


Do not wean to exhaustion

Do Not Wean To Exhaustion of Permanent Ventilator Discontinuation


Weaning to exhaustion
Weaning to Exhaustion of Permanent Ventilator Discontinuation

  • RR > 35/min

  • Spo2 < 90%

  • HR > 140/min

  • Sustained 20% increase in HR

  • SBP > 180 mm Hg, DBP > 90 mm Hg

  • Anxiety

  • Diaphoresis


Rest 24 hrs of Permanent Ventilator Discontinuation

PaO2/FiO2 ≥ 200 mm Hg

PEEP ≤ 5 cm H2O

Intact airway reflexes

No need for continuous infusions of vasopressors or inotrops

> 100

RSBI

<100

Stable Support Strategy

Assisted/PSV

Daily SBT

24 hours

30-120 min

RR > 35/min

Spo2 < 90%

HR > 140/min

Sustained 20% increase in HR

SBP > 180 mm Hg, DBP > 90 mm Hg

Anxiety

Diaphoresis

Extubation

No

Yes

Mechanical Ventilation

Low level CPAP (5 cm H2O),

Low levels of pressure support (5 to 7 cm H2O)

“T-piece” breathing


Extubation Criteria of Permanent Ventilator Discontinuation

  • Ability to protect upper airway

    • Effective cough

    • Alertness

  • Improving clinical condition

  • Adequate lumen of trachea and larynx

    • “Leak test” to identify patients who are at risk for post-extubation stridor


Post extubation stridor
Post Extubation of Permanent Ventilator DiscontinuationStridor

Extubation Criteria

  • The Cuff leak test during MV:

    • Set a tidal Volume 10-12 ml/kg

    • Measure the expired tidal volume

    • Deflated the cuff

    • Remeasure expired tidal volume (average of 4-6 breaths)

    • The difference in the tidal volumes with the cuff inflated and deflated is the leak

  • A value of 130ml  85% sensitivity

    95% specificity


Post extubation stridor1
Post Extubation of Permanent Ventilator DiscontinuationStridor

Extubation Criteria

  • Cough / Leak test in spontaneous breathing

    • Tracheal cuff is deflated and monitored for the first 30 seconds for cough.

    • Only cough associated with respiratory gurgling (heard without a stethoscope and related to secretions) is taken into account.

    • The tube is then obstructed with a finger while the patient continues to breath.

    • The ability to breathe around the tube is assessed by the auscultation of a respiratory flow.


Extubation Criteria of Permanent Ventilator Discontinuation

  • The risk of postextubation upper airway obstruction increases with

    • the duration of mechanical ventilation

    • female gender

    • trauma, and

    • Repeated or traumatic intubation


Failure of sbt
Failure of SBT of Permanent Ventilator Discontinuation

  • Correct reversible causes for failure

    • adequacy of pain control

    • the appropriateness of sedation

    • fluid status

    • bronchodilator needs

    • the control of myocardial ischemia, and

    • the presence of other disease processes

  • Subsequent SBTs should be performed every 24 h


Failure of SBT of Permanent Ventilator Discontinuation

  • :

  • :

  • :


Failure of SBT of Permanent Ventilator Discontinuation

  • Left Heart Failure:

    • Increased metabolic demands

    • Increases in venous return and pulmonary edema

  • Appropriate management of cardiovascular status is necessary before weaning will be successful


Failure of SBT of Permanent Ventilator Discontinuation

Factors affecting ventilator demands


Failure of SBT of Permanent Ventilator Discontinuation

Therapeutic measures to enhance weaning progress


Weaning modes
Weaning Modes of Permanent Ventilator Discontinuation

  • Patients receiving mechanical ventilation for respiratory failure who fail an SBT should receive a stable, nonfatiguing, comfortable form of ventilatory support


Weaning modes1
Weaning Modes of Permanent Ventilator Discontinuation

Modes of Partial Ventilator Support

*SIMV synchronized intermittent mandatory ventilation; PSV pressure support ventilation; VS volume support; VAPS(PA) volume assured pressure support (pressure augmentation); MMV mandatory minute ventilation; APRV airway pressure release ventilation.


Weaning modes2
Weaning Modes of Permanent Ventilator Discontinuation

PSV: Pressure Support

  • Gradual decrease in the level of PSV on regular basis (hours or days) to minimum level of 5-8 cm H2O

  • PSV that prevents activation of accessory muscles

  • Once the patient is capable of maintaining the target ventilatory pattern and gas exchange at this level, MV is discontinued


Weaning modes3
Weaning Modes of Permanent Ventilator Discontinuation

SIMV: synchronized intermittent mandatory ventilation

  • Gradual decrease in mandatory breaths

  • It may be applied with PSV

  • Has the worst weaning outcomes in clinical trials

  • Its use is not recommended


Weaning modes4
Weaning Modes of Permanent Ventilator Discontinuation

New Modes

  • VS, Volume support

  • Automode

  • MMV, mandatory minute ventilation

  • ATC, automatic tube compensation

  • ASV, adaptive support ventilation


Weaning protocols
Weaning Protocols of Permanent Ventilator Discontinuation

  • With the assisted modes, to achieve patient comfort and minimize imposed loads, we should consider:

    • sensitive/responsive ventilator-triggering systems

    • applied PEEP in the presence of a triggering threshold load from auto-PEEP

    • flow patterns matched to patient demand, and

    • appropriate ventilator cycling to avoid air trapping are all important to


Weaning protocols1
Weaning Protocols of Permanent Ventilator Discontinuation

  • Weaning protocols

    • Developed by multidisciplinary team

    • Implemented by respiratory therapists and nurses to make clinical decisions

    • Results in shorter weaning times and shorter length of mechanical ventilation than physician-directed weaning

  • Sedation protocols should be developed and implemented


Role of tracheotomy
Role of Tracheotomy of Permanent Ventilator Discontinuation

  • Candidates for early tracheotomy:

    • High levels of sedation

    • Marginal respiratory mechanics

    • Psychological benefit

    • Mobility may assist physical therapy efforts.


Role of tracheotomy1
Role of Tracheotomy of Permanent Ventilator Discontinuation

  • The benefits of tracheotomy include:

    • improved patient comfort

    • more effective airway suctioning

    • decreased airway resistance

    • enhanced patient mobility

    • increased opportunities for articulated speech

    • ability to eat orally, and

    • more secure airway


Role of tracheotomy2
Role of Tracheotomy of Permanent Ventilator Discontinuation

  • Concerns:

    • Risk associated with the procedure

    • Long term airway injury

    • Costs


Long term facilities
Long-term Facilities of Permanent Ventilator Discontinuation

  • Unless there is evidence for clearly irreversible disease (e.g., high spinal cord injury or advanced amyotrophic lateral sclerosis), a patient requiring prolonged mechanical ventilatory (PMV) support for respiratory failure should not be considered permanently ventilator-dependent until 3 months of weaning attempts have failed.


Long term facilities1
Long-term Facilities of Permanent Ventilator Discontinuation

  • Critical-care practitioners should familiarize themselves with specialized facilities in managing patients who require prolonged mechanical ventilation

  • Patients who failed ventilator discontinuation attempts in the ICU should be transferred to those facilities


Long term facilities2
Long-term Facilities of Permanent Ventilator Discontinuation

  • Weaning strategies in the PMV patient should be slow-paced and should include gradually lengthening SBTs

  • Psychological support and careful avoidance of unnecessary muscle overload is important for these types of patients


Thank You of Permanent Ventilator Discontinuation


Introduction
Introduction of Permanent Ventilator Discontinuation

  • 75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process

  • 10-15% of patients require a use of a weaning protocol over a 24-72 hours

  • 5-10% require a gradual weaning over longer time

  • 1% of patients become chronically dependent on MV


Readiness to wean
Readiness To Wean of Permanent Ventilator Discontinuation

  • Improvement of respiratory failure

  • Absence of major organ system failure

  • Appropriate level of oxygenation

  • Adequate ventilatory status

  • Intact airway protective mechanism (needed for extubation)


Oxygenation status
Oxygenation Status of Permanent Ventilator Discontinuation

  • PaO2≥ 60 mm Hg

  • FiO2 ≤ 0.40

  • PEEP ≤ 5 cm H2O


Ventilation status
Ventilation Status of Permanent Ventilator Discontinuation

  • Intact ventilatory drive: ability to control their own level of ventilation

  • Respiratory rate < 30

  • Minute ventilation of < 12 L to maintain PaCO2 in normal range

  • Functional respiratory muscles


Intact airway protective mechanism
Intact Airway Protective Mechanism of Permanent Ventilator Discontinuation

  • Appropriate level of consciousness

  • Cooperation

  • Intact cough reflex

  • Intact gag reflex

  • Functional respiratory muscles with ability to support a strong and effective cough


Function of other organ systems
Function of Other Organ Systems of Permanent Ventilator Discontinuation

  • Optimized cardiovascular function

    • Arrhythmias

    • Fluid overload

    • Myocardial contractility

  • Body temperature

    • 1◦ degree increases CO2 production and O2 consumption by 5%

  • Normal electrolytes

    • Potassium, magnesium, phosphate and calcium

  • Adequate nutritional status

    • Under- or over-feeding

  • Optimized renal, Acid-base, liver and GI functions


Predictors of weaning outcome
Predictors of Weaning Outcome of Permanent Ventilator Discontinuation


Maximal inspiratory pressure
Maximal Inspiratory Pressure of Permanent Ventilator Discontinuation

  • Pmax: Excellent negative predictive value if less than –20 (in one study 100% failure to wean at this value)

    An acceptable Pmax however has a poor positive predictive value (40% failure to wean in this study with a Pmax more than –20)


Frequency volume ratio
Frequency/Volume Ratio of Permanent Ventilator Discontinuation

  • Index of rapid and shallow breathing RR/Vt

  • Single study results:

    • RR/Vt>105 95% wean attempts unsuccessful

    • RR/Vt<105 80% successful

  • One of the most predictive bedside parameters.


Measurements Performed Either While Patient Was Receiving Ventilatory Support or During a BriefPeriod of Spontaneous Breathing That Have Been Shown to Have Statistically Significant LRs To Predict theOutcome of a Ventilator Discontinuation Effort in More Than One Study*


Weaning to exhaustion1
Weaning to Exhaustion Ventilatory Support or During a Brief

  • RR > 35/min

  • Spo2 < 90%

  • HR > 140/min

  • Sustained 20% increase in HR

  • SBP > 180 mm Hg, DBP > 90 mm Hg

  • Anxiety

  • Diaphoresis


Work of breathing
Work-of-Breathing Ventilatory Support or During a Brief

  • Pressure= Volume/compliance+ flow X resistance

  • High airway resistance

  • Low compliance

  • Aerosolized bronchodilators, bronchial hygiene and normalized fluid balance assist in normalizing compliance, resistance and work-of-breathing


Auto peep
Auto-PEEP Ventilatory Support or During a Brief

  • Increases the pressure gradient needed to inspire

  • Use of CPAP is needed to balance alveolar pressure with the ventilator circuit pressure

  • Start at 5 cm H2O, adjust to decrease patient stress

  • Inspiratory changes in esophageal pressure can be used to titrate CPAP


Gradient Ventilatory Support or During a Brief

0

-5

-5


Gradient Ventilatory Support or During a Brief

0

Auto PEEP +10

-5

-15


Gradient Ventilatory Support or During a Brief

PEEP

10

Auto PEEP +10

5

-5


Preparation factors affecting ventilatory demand
Preparation: Factors Affecting Ventilatory Demand Ventilatory Support or During a Brief


Integrative indices predicting success
Integrative Indices Predicting Success Ventilatory Support or During a Brief



Three methods for gradually withdrawing ventilator support
Three Methods for Gradually Withdrawing Ventilator Support Ventilatory Support or During a Brief

Although the majority of patients do not require gradual withdrawal of ventilation, those that do tend to do better with graded pressure supported weaning than with abrupt transitions from Assist/Control to CPAP or with SIMV used with only minimal pressure support.


Thank You Ventilatory Support or During a Brief


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