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Chapter 47 Discontinuing Ventilatory Support
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Objectives List factors associated with ventilator dependence. Explain how to evaluate a patient before attempting ventilator discontinuation or weaning. List acceptable values for specific weaning indices used to predict a patient’s readiness for discontinuation of ventilatory support. Describe factors that should be optimized before an attempt is made at ventilator discontinuation or weaning.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Objectives (cont.) Describe techniques used in ventilator weaning, including daily spontaneous breathing trials, synchronized intermittent mandatory ventilation, pressure support ventilation, and other newer methods. Contrast the advantages and disadvantages associated with various weaning methods and techniques. Describe how to assess a patient for extubation. Explain why some patients cannot be successfully weaned from ventilatory support.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Introduction Ventilatory support sustains life but is not curative. It has many complications and hazards. It should be withdrawn expeditiously. Balance desire for early extubation with its exposure to the risks of reintubation.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Methods of Discontinuing Ventilation Three main methods Spontaneous breathing trials (SBT) SIMV PSV Novel modes with no data to support MMV = mandatory minute volume, VSV = volume support ventilation, ATC = automatic tube compensation, PAV = proportional assist ventilation **Systematic review: 1 SBT per day has shown best results
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Discontinuing Ventilatory Support Success is tied to Ventilatory work load versus capacity Oxygenation status Cardiovascular status Psychological factors
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Most Important Criteria 1. Reversal of disease state that necessitated ventilatory support 2. Oxygenation status adequate on <0.5 F IO 2 3. Medically and hemodynamically stable 4. Patient can breathe spontaneously If the above are all true, then perform a formal evaluation for extubation.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 8 66 Measurements: 8 Most Consistently Predictive Spontaneous rate 6 to 30 beats/min Spontaneous V T >5 ml/kg f/V T (RSBI) – most predictive<105 Minute ventilation<10 L/min MIP< 20 to 30 mm Hg P 0.1 <6 cm H 2 O P 0.1 /MIP<0.3 CROP (C Dyn, f, O 2, PI max )>13 * No single index has high predictive power, so it is important to consider the total picture.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Preparing the Patient Patient should be rested and stable. Maximize bronchodilator and antiinflammatory medications as well as bronchial hygiene. Communicate well with patient so as to relieve/minimize anxiety. Optimize nutrition, acid/base status, fluid balance, and oxygenation. Minimize sedation.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Rapid Ventilator Discontinuance Patients that are likely to wean rapidly Presenting problem corrected in 72 hours Good weaning parameters Good results in SBT of 30 to 120 minutes If the above criteria are met, most patients can be removed from ventilatory support. If the patient can protect his or her airway, then extubate at this time.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Progressive Weaning of Ventilatory Support Patients likely to need longer weaning period Ventilated longer then 72 hours Marginal: oxygen, ventilatory, cardiovascular, or medical status Most common methods of weaning: SBT alternating with rest periods on A/C, SIMV, or significant levels of PSV A/C, SIMV, or significant levels of PSV
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Progressive Weaning: SBT T-tube trial 5 to 30 minutes SBT 1 to 4 hours of rest on A/C, SIMV, or high PSV Gradually, SBT times increase while rest periods diminish. Patients are rested at night. Alternate method is 1 SBT/day and then rest. This can also be done on the ventilator in CPAP mode with PSV or ATC.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Initial Screening SBT Perform 2–3 minute SBT. If 2 out of 3 of the criteria below are met, start a formal wean V T >5 ml/kg RR <30–35 beats/min MIP < 20 cm H 2 O Alternate: adequate cough, no vasopressors P/F ratio>200 PEEP 5 f/V T <105
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 14 SBT Termination Termination occurs if any of these criteria met Agitation, anxiety, diaphoresis, altered mental state Respiratory rate > 30 or 35 beats/min Sp O 2 <90% 20% change in HR or HR > 120 to 140 beats/min Systolic BP > 180 mm Hg or 180 mm Hg or < 90 mm Hg
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Weaning With SIMV Faster weans claimed but contrary to evidence Ease of use is primary reason for use Evidence that at 50% of full ventilatory support, patient WOB approximates that on CPAP In addition, demand flow SIMV imposes considerable WOB. Modern ventilators minimize this effect.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Support set below required level; patient makes up the difference. Once precipitating event corrects, support is rapidly reduced. Support is typically reduced in increments of 2 breaths per minute until spontaneous ventilation is achieved. Weaning With SIMV (cont.)
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 17 PSV Weaning Level is set to PSVmax 8 to 10 ml/kg. On resolution of precipitating event PSV reduced increments 2 to 4 cm H 2 O, usually 1 to 2 times per day Rested at nights 2 strategies for discontinuance of PSV: Patient tolerates PSV of 5 – 8 cm H 2 O with no distress Patient tolerates PSV of 5 – 8 cm H 2 O with no distress Patient tolerates CPAP with no PSV without distress Patient tolerates CPAP with no PSV without distress
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Monitoring During Weaning Pa CO 2 best index of adequacy of ventilation but only tied to clinical data Pa CO 2 40 mm Hg with f/V T of 250 shows impending ventilatory failure. Pa CO 2 40 mm Hg with f/V T of 40 shows ability to breathe spontaneously. Sp O 2 monitor continuously Cardiovascular status
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Extubation Weaning and extubation separate decisions Extubation requires Ability to protect airway Gag Gag Effective cough Effective cough Airway patency Minimal edema Minimal edema Positive “cuff-leak” > 12% volume loss Positive “cuff-leak” > 12% volume loss Adequate pulmonary hygiene
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Postextubation Stridor Occurs in 2% to 16% of ICU patients Can result in complete airway obstruction Management includes Cool aerosol mist with oxygen via mask Nebulized racemic epinephrine (0.5 ml 2.25%) Nebulized 1 mg in 4 ml NS dexamethasone HeliOx 60%/40%
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Failure of Extubation Up to 25% of patients require MV again. Half of patients with distress following MV discontinuance develop marked hypercapnia. Myocardial ischemia is associated with failed weaning attempts. Failed weans may be undiagnosed NMD or psychological dependence. Most common reason: inadequate ventilatory capability which cannot meet ventilatory demand
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Chronically Ventilator-Dependent Patients Prolonged MV occurs in 3% to 7% of ventilated patients, while <1% become dependent. Definition: ventilator dependency remains following 3 months of weaning attempts. Special long-term acute care facilities specialize in weaning these patients. Once dependency established, goal is to restore highest level of independence.
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Terminal Weaning Refers to weaning in the face of catastrophic and irreversible illness Weaning occurs despite the likely result of patient death Decision is made by patient and/or family in consultation with physician. Must meet ethical and legal guidelines May be due to advanced directives, current patient decision, or very poor prognosis
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