1. WEANING The Discontinuation of Ventilatory Support By Adriana Adams and Cesar Mancillas

2. What is Weaning? Weaning is the gradual decrease in the transitional process from total ventilatory support to spontaneous breathing.

3. Reasons for Mechanical Ventilation RESPIRATORY FAILURE SECONDARY TO: Hemodynamically Unstable Airway Protection Neuromuscular Disorders Inadequate Ventilatory Capacity

4. Methods of Weaning SIMV/CPAP Mode PSV T-tube/ATC

5. DAILY SCREENING Resolved/Improved underlying problem Awake, oriented, Responsive Able to Cough Adequate gas exchange Off Sedations, vasopressor Adequate hemoglobin levels Hemodynamically Stable Airway Patency Ventilation Pump/Capacity adequacy

6. Airway Patency Parameters Maximal expiratory pressure Peak Expiratory Flow Cough Strength Secretion volume Suctioning frequency Cuff leak test Neurological Function(GCS):

7. Physiological Parameters Rate: <35bpm Maximal Inspiratory Pressure: < -20cmH2O RSBI: r/Vt= <100b/min Vital Capacity: <10-15mL/kg(<15L/min)

8. Adequate Oxygenation Parameters PaO2: >60mmHg(at FiO2 of 50%) PEEP: <5-8cmH2O PaO2/FiO2: >200mmHg PaO2/PAo2: >0.50 P(A-a)O2: <350mmHg (FiO2max1) %Qs/Qt: <20% pH: >7.25 PaCO2: Normal Level SaO2: >90% Hgb: 8-10g/dl

9. Ventilatory Pump Parameters Vt: >350ml(>4ml/kg) Cd: >25ml/cmH2O Cs: >35ml/cmH2O Ve: <10L/min Vd/Vt: <60%

10. SIMV PROTOCOL INITIAL SETTINGS RR: 8/min( <2-4bpm/hr at least BID) until pt is stable at 0-5bpm for 2hrs. PS: 25cmH2O(<2-4/hr) until pt is stable at 0- 5cmH2O/min for 2hrs, followed by extubation. *If no resp. disorders, use half hour intervals. *Changes are made as tolerated by patient.

11. T-PIECE Weaning Pt may be removed from ventilator or use CPAP T-Piece Trials: Progressive increase in length of time without ventilator support.(increments of 5-10min, then place back on ventilator for remainder of the hour. Until pt is off the vent for 30 min. on and off for 30 min, and so on. Use heated humidifier at desired FiO2(If 50%, consider extubation) If stable for 2hrs, consider extubation. Advantage CPAP use: available alarms, apnea back up settings, and able to monitor patients ventilatory capacity.

12. Recognizing Weaning Failure Tachypnea(>35bpm for >5min) Hypoxemia(<90% saturation) Tachycardia(>140bpm) Bradycardia(If <heart rate by 20%) Hypertension(>180mmHg) Hypotension(<90mmHg) Agitation, diaphoresis, anxiety, signs of >WOB

13. Ventilator Management Algorhythm >>

14. EXTUBATION VIDEO Do not try this at home kids!!!

15. The End!