Presentation on theme: "The SLRH Ventilator Weaning Protocol Workgroup"— Presentation transcript:
1 The SLRH Ventilator Weaning Protocol Workgroup Mechanical Ventilation Weaning Protocol Education for Nurses, Respiratory Therapists and PhysiciansThe SLRH Ventilator Weaning Protocol Workgroup
2 Objectives of this program Provide education about ventilator weaning in the Critical Care Units and Medical Progressive Care and Step down UnitsProvide rationale and benefits for using a ventilator weaning protocolReview the assessment tool for ventilator weaning in critically ill patientsReview SLRH vent weaning protocol:Revised acute vent weaning protocolNew chronic vent weaning protocolExplain tracheostomy decisions and careDemonstrate how weaning is integrated into the total care of the patient
3 A Weaning Protocol:Promotes a standardized assessment of each patient’s readiness to wean as part of the daily assessment by the nurse and respiratory therapistEmpowers the nurse and respiratory therapist to initiate the process of early weaning from the ventilator by identifying patients who are readyFacilitates collaboration between the RN/RT and physician or nurse practitionerThe Physician can order the weaning protocol based on the assessment by the RN/RT and MD/DO
4 Benefits of a Weaning Protocol Studies have shown that weaning protocols lead to a DECREASE IN:Duration of mechanical ventilationICU and hospital length of stayNumber of tracheostomies performedComplications associated with mechanical ventilationVentilator-associated pneumonia and lung injuryVenous thromboembolic diseaseGastrointestinal hemorrhage
5 Improving weaning from mechanical ventilation Early morning daily awakening and daily spontaneous breathing trial decrease duration of mechanical ventilationBoth nurse-driven and respiratory therapist- driven weaning protocols lead to earlier weaning and extubation, compared to physician-driven protocolsWesley,E et al; N Engl J Med 1996; 335:Kollef,Marin et al;Crit Care Med 1997; 25:
6 Why do we need a weaning protocol in our critical care units? Weaning Protocols are the Standard of Care in Intensive Care UnitsWe can REDUCE:Duration of mechanical ventilationICU and hospital length of stayICU and hospital mortalitySedationICU complications such as ventilator-associated pneumonia (VAP), ventilator-associated lung injury venous thromboembolism and GI hemorrhageNeuromuscular dysfunction, delirium, and cognitive dysfunctionWeakness due to delay in mobilization
7 We need to standardize our goals and management of mechanically ventilated patients in order to provide the best care for our patients.
8 W.E.A.N.! at SLRH Work together – RN, RT, NP, PA, MD/DO Early identification – Early in the day, early in the courseAssessment by RN and RT in daily screen and protocolNotify physician to start protocol and how patient tolerates weaning
9 Weaning: working together - clinicians and patients The ICU and stepdown nurse and the respiratory therapist for the patient have the important role of timely assessment of weaning readinessThe Physician needs to make the overall decision about whether the patient should undergo the weaning protocolThere are different ways of weaning and this process is individualized. So different modes of weaning may be chosen based on the patient’s disease and course.
10 Weaning protocols in different units Our protocols will take into account the resources of the different units – critical care and stepdown units - so that the presence and support of nursing and respiratory care are optimal.
11 In addition to the early morning protocol, weaning assessment can be done at any time during the day.
12 Acute and Chronic Weaning What is the difference? Acute generally refers to patients with an endotracheal tube who have been on the ventilator for less than 2-3 weeksChronic generally refers to patients who have been on the ventilator for longer periods and who have a tracheostomyPatients with a tracheostomy may require a more prolonged processHowever, even some patients with a tracheostomy may be weaned in a short period of time
13 The weaning protocols The protocols are found on Forms on Demand We will go through the steps of the protocols for acute and chronic weaning
14 Step 1: Assessment for Weaning Readiness Initial assessment is the “screening” based on patient factors, ventilator factors and sometimes ABG. This is the daily screening to be done by the RN and RT to see if the patient is ready for a weaning trial.This screening does not involve any ventilator changes.Screening facilitates early morning weaning trial and extubation and does not have to wait for physician roundsThis assessment ties in with the sedation policy: using the sedation protocol to achieve a RASS of 0 or a daily interruption of sedation is appropriate for weaning patients
15 Early assessment for weaning The screening is done in the ICU daily by the night shift (between 5:30 and 7 am) so that, if the patient passes, weaning can be started earlyDocument readiness on ICU flowsheetIf a barrier is found, such as the patient is too sedated, this is the opportunity to reduce/stop sedatives to achieve the RASS goal and scoreThe screening can be repeated at any point if the condition changes
16 STEP 1: Assessment for weaning readiness The patient meets the following criteria: PATIENT FACTORS□ Hemodynamically stabilizing:□ Vital signs acceptable ( BP ≥ 90 systolic, HR ≈ 55 to 135 bpm)□ Tapering/low doses of vasopressors□ Sp02 > 92%□ Can follow simple commands□ Adequate cough on command□ Initiate good inspiratory effort□ Patient is not expected to follow commandsVENTILATOR PARAMETERS□ FiO2 < 50%□ PEEP ≤ 5 cm H20ABG PARAMETERS□ PaO2 ≥ 75 mmHg□ pH > 7.25
17 STEP 2: Criteria met, Notify Physician for initiation of protocol RN and RT communicate the weaning readiness with the MD/DO ( fellow/housestaff/attending)Physician decides whether weaning should be initiated. Some situations in which the patient meets criteria but weaning will not be done include – procedure or test that will require ventilation, concerning lab test or change in stability.Physician decides on the vent weaning mode, completes orders and places order in Prism to initiate weaning protocolFeedings heldSedation goal RASS of 0 achieved or hold sedationExplain to the patient
18 Physician Order for Weaning The MD/NP needs to place the order for weaning only onceThis order will remain active for daily weaning unless cancelled due to change in patient condition
19 Please note…There are some patients who have a neurologic injury or baseline dysfunction – who are not expected to follow commands, but who still may be able to wean from the ventilator.The clinicians may decide to proceed with a trial of weaning in patients who do not pass all readiness criteria.
20 Start weaning protocol early Between 5:30 and 7 am in the ICUsBy 9 am for chronically-ventilated patients in the stepdown units
21 STEP 3: Method of weaning chosen by physician SPONTANEOUS BREATHINGTRIAL METHOD (SBT)□ PS=____□ CPAP = ___□ FI02 ___%□ T-piece□ Duration ___minutes□ ABG needed ( )Y( ) NGOAL : ____ minSIMV METHOD□ Set IMV___ PS___□ FiO2___%□ Decrease IMV rate by __ q __ h□ Decrease PS by ___ q ___ h□ ABG needed ( ) Y ( ) NGOAL: IMV ≤ 4 AND PS ≤ 8 for ___minPRESSURE SUPPORT VENTILATION METHOD (PSV)□ Set PS___□ FiO2___ %□ Decrease PS by ___q ___h□ ABG ( ) Y ( ) NGOAL : PS ≤ 5 for ____ minSICU METHOD□ CPAP = 5, PS=0□ FI02 21%□ Tolerates 20 min□ Then ABG:GOAL:Pa02 >50mmHgPaC02 <50 mmHgRR < 35/min
22 Acute weaning – Spontaneous Breathing Trial “SBT” The most common method is the SBT: CPAP mode, pressure support 5-8 cm H20. Duration minutes.Other methods include:SIMV with gradual reduction in respiratory ratePressure support with gradual reduction in amount of pressure supportFor SICU patients, CPAP trial for 20 minPhysician Order: must complete method, settings, and duration
23 STEP 4: Assessing patient tolerance of weaning Respiratory Rate <35 breaths per minuteHeart rate between 50 and 130 bpm and within ± 20% of pre-trial HRSystolic Blood Pressure (SBP) between mmHg and within ± 20% of pre-trial SBPExhaled TV ≥ 5 cc/ kg IBW ( ≈ 300 – 400 ml )SpO2 ≥ 92 %Patient showing no diaphoresis, paradoxical respiration, retractions, nasal flaring, agitation, or complaining of SOB, or use of accessory musclesSerial assessments of tolerance are made 5,15,30,60,and 120 minutes after the INITIAL setting and following any subsequent ventilator changes.
24 STEP 5: Tolerating weaning trial – success! Notify physician and team Arterial blood gas, if orderedPhysician informed about the successful weaningRT - set up for extubationPhysician will be present for extubationThe patient is monitored following extubation:In addition to vital signs including Sp02 ,always check for stridor, breath sounds, secretions
25 Not tolerating weaning today… If not tolerating weaning go to pre-trial settingsDocument on Weaning Flow record – in what way the patient did not tolerate weaning, duration of weaning, level of support usedThis will improve our communication and plan for the next weaning trial so that we can move forward with weaning the patient
26 DocumentationThe daily outcome will be written in the weaning flow record which will be kept in the Respiratory Care book. The RN and RT document the progressThe medical, nursing and respiratory staff will view the flow record in making further decisions about weaningVital signs, ventilator settings, extubation are charted in the ICU flow record as usual
28 Chronic Vent WeaningThis protocol applies to patients with tracheostomies who are undergoing weaning in the Critical Care Units, MPCU, stepdown vent units RH 10B, SL 10EThe early assessment is the sameScreening by nurse or respiratory therapist for readinessDocument in nursing/respiratory notes or ICU flow record
29 Only one order to wean is needed and will apply until the order is discontinued Weaning will be started by 9 am daily
30 Methods of Chronic Vent Weaning Some patients who have been on a ventilator for a prolonged period or have a tracheostomy may need a more progressive program for weaningThe two general methods are:Pressure support PS– gradually decrease the PS amount and prolong the timeTrach collar – use trach mask for progressively longer periods of timeOther methods such as volume support may also be used
34 DocumentationThe duration of weaning is documented on the flow record. This will be kept in the respiratory folder. The RN or RT may document the progressThe medical, nursing and respiratory staff will view the flow record for further decisions about weaning
35 Tracheostomy: Indications Prolonged ventilator requirement and inability to wean due toGeneralized weakness, such as critical illness polyneuropathyMultiple comorbid conditions that require prolonged ventilationChronic critical illnessInability to clear secretionsSevere neurologic dysfunctionAirway obstructionTumor, upper airway injury, edemaSevere obstructive sleep apnea with complications, not amenable to usual treatments
36 Patients not expected to wean - Addressing goals of care Some patients are not expected to be weaned from a ventilator so tracheostomy would be considered for indefinite ventilator-dependenceIn these patients, this decision point for tracheostomy would be an appropriate time to readdress life support/end-of-life decisions
37 Benefits of tracheostomy Ability to mobilize patients with prolonged need for ventilator with a more secure airwayPotential for patient to require less sedatives and communicateAllows transfer to a chronic ventilator facility
38 Planning for Tracheostomy Clinician assesses the potential for liberation from ventilator based on the patient’s illness, prognosis, and patient preferenceTracheostomies can be performed early (within 7 days) or later (at 2-3 weeks)If the patient is unlikely to be weaned due to neurological/chronic pulmonary process, a decision on tracheostomy can often be made within few days of intubationPatients with reversible disease who are unable to wean in days are usually considered for tracheostomy at that timeTracheostomy is not performed in unstable or dying patients
39 Timing of Tracheostomies Based on individual patient situationBenefits of early tracheostomy include: improved comfort and decreased sedation, improved mobilityIn some patients, early tracheostomy may facillitate weaning, so may decrease duration of mechanical ventilation
40 Patients with tracheostomies Assess for speech and swallowing – may be candidate for speech valveMOBILITY – out of bed, sit, stand, walk
41 Decannulation – removal of tracheostomy Patients are completely off ventilator for sufficient number of days to assure that the primary process is resolvedAble to cough secretionsTolerate speech valveTolerate capping of the tracheostomyClinically assure there is no upper airway obstructionPatient requires close monitoring in the first 24 hrsIf patient develops distress – consider secretions, airway obstruction
42 Respiratory distress in patients with endotracheal tubes and tracheostomies Secretions and mucous pluggingDislodgement of tracheostomy/ ETTPneumothoraxVentilator dyssynchrony due to vent settingsBecause of underlying diseases, may be at risk for pulmonary embolism, heart failure, volume overloadGranulation tissue formation in the trachea can lead to high peak pressures**These causes must be considered before treatment with sedatives**
43 Look at the overall plan of care Mobility in patients with endotracheal tube or tracheostomySpeechNutritionGoals of care discussion with patient and family
44 Mobility Early mobility can Decrease intensive care unit and hospital length of stay in survivorsReduce the functional decline from the illnessDecrease risk of pressure ulcers and improve wound careMultidisciplinary team – collaboration to provide safe mobilization of patients in the intensive care unit, progressive care and stepdown units.
45 Weaning and mobilityIn addition to the effects on duration of ventilation, mortality and ICU complications, weaning and mobility can potentially:Improve patient spiritImprove communicationReduce deliriumReduce depression
46 DocumentationOrders will be placed by MD using the pre- printed paper order:Weaning ordersPhysician places order for weaning in PrismICU Flowsheet will reflect the readiness screen and the weaningRN/RT will document in weaning flow recordExtubation – Physician documents in progress note
47 So let’s W.E.A.N.! at SLRH Work together – RN, RT, NP, PA, MD/DO Early identification – Early in the day, early in the courseAssessment by RN and RT in daily screen and protocolNotify physician to start protocol and how patient tolerates weaning
48 Thank you for completing this program! We believe that a comprehensive and multidisciplinary approach will improve care and outcomes of our patients who require mechanical ventilation.For questions, please contact:Manju Pillai MDRaymonde Jean MDMark Collazo RRTJanet Shapiro MD