Tufts-New England Medical Center Weaning Protocol. A Product of the T-NEMC Critical Care Committee October 2004. Tufts-New England Medical Center Weaning Protocol.
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A Product of the T-NEMC
Critical Care Committee
This is a general guideline and does not represent a professional standard of care governing providers' obligations to patients. Care is revised to meet individual patient's needs"
These guidelines do not prohibit or impede the planned rapid weaning and extubation of patients.
The studies listed above all demonstrate that any weaning protocol reduces days of mechanical ventilation when compared to patients not managed by a weaning protocol.The Kollef study from 1997 CCM actually compared three separate ICUs, each using a separate and different protocol to non-protocol weaning of patients. Each protocol resulted in similar days of mechanical ventilation when compared to each other and all three protocols resulted in fewer days of mechanical ventilation than did non-protocol weaning.All protocols studied utilized a nurse/therapist driven process that screened all patients daily and if criteria were met, a spontaneous breathing trial followed.
7 – Dangerous agitation
6 – Very agitated
5 – Agitated
4 – Calm & cooperative
3 – Sedated
2 – Very sedated
1 – Unarousable
Levels 3 – 4 are optimal levels for weaning
Over sedation stops the weaning process and should be avoided if possible.
The RSBI is a one minute trial of unassisted breathing.
It is the most accurate test to predict weaning success.
RSBI calculation: RSBI = RR / (MV/RR)
Measure RR and MV for 1 minute during unassisted breathing:(0 PEEP/5 cmH20 PSV).
At the end of 1 minute divide the MV by RR to calculate the average Vt.
Divide the RR by the VT to obtain the RSBI.
Spontaneous Breathing Trial (SBT)
A SBT is the continuation of unassisted breathing for 30 min. to 2 hours if the RSBI is < 105.
After successfully completing a SBT, current studies indicate extubation is generally successful in approximately 75% of patients.Protocol Definitions
The methodology chosen to assess the RSBI is based on several points.The use of zero PEEP is chosen for three reasons:1)to determine if the patient will tolerate a reduction in thoracic pressure without developing CHF.2)It demonstrates the adequacy of lung function in maintaining acceptable oxygenation.3)It allows the patient to demonstrate that there is minimal work imposed by trappingConsequently, all RSBI tests as well as Spontaneous Breathing Trials will be done at zero PEEP.The use of 5 cm H2O Pressure Support was chosen to allow the patient to demonstrate adequate ventilation without support. It is recognized that the artificial airway imposes some resistance but ET tubes with 7.5 mm ID’s and greater offer minimal imposed work. ET tubes with 6.0 and 7.0 mm ID’s may require 8 and 10 cm H2O PSV respectively to avoid excess imposed work.
Weaning Protocol Entry Criteria
When issues arise regarding excess sedation, high dose vasopressors or patients with ongoing cardiac process; consultation between the nurse, physician and respiratory therapist is necessary to determine if attempting weaning is appropriate.All patients must be screened each AM regardless and those meeting the criteria listed will have a RSBI measured. The results or the reason for deferring the RSBI must be charted daily in the medical record.
At some point during the SBT, the patient may display signs of agitation, anxiety and tachypnea. In an effort not to prematurely end the weaning trial, the patient must be closely assessed. If this is due to pain or discomfort the patient may require some analgesia or sedation but the SBT should be continued.On the other hand, if the clinical assessment reveals the patient is becoming fatigued (fast rate, low tidal volumes) or the onset of CHF or similar indications of intolerance, the patient should be retuned to the ventilator.The overall goal should be to assure the weaning attempt is continued for as long as possible without endangering the patient.
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