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Weaning and Discontinuation of Ventilatory Support

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Presentation on theme: "Weaning and Discontinuation of Ventilatory Support"— Presentation transcript:

1 Weaning and Discontinuation of Ventilatory Support

2 Educational Objectives
Differentiate between weaning, discontinuation, and extubation List the causes of ventilator dependence List the patient parameters evaluated and the values required prior to initiating weaning

3 Educational Objectives
Describe the various techniques of weaning, with the advantages and disadvantages of each Describe the overall factors associated with successful weaning List the steps of extubation

4 Definitions Weaning Discontinuation
The process of gradually reducing ventilatory support and its replacement with spontaneous ventilation in an incremental manner Discontinuation The permanent removal of the ventilator

5 Definitions Extubation Ventilatory Demand
Removal of the artificial airway Ventilatory Demand The level of ventilation required to meet the patient’s need for elimination of carbon dioxide

6 Definitions Ventilatory capacity
The level of the patient’s drive (CNS) to breathe and the ability of the respiratory muscles to maintain this drive (strength and endurance)

7 Causes of Ventilator Dependence
Ventilatory demand in excess of ventilatory capacity Non-respiratory factors Psychological factors Nutritional needs

8 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Increased CNS drive Hypoxia Acidosis Pain Fear/anxiety Stimulation of J receptors

9 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Increased metabolic rate Increased carbon dioxide production Fever Shivering Trauma Infection/sepsis

10 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Decrease in lung compliance Atelectasis Pneumonia Fibrosis Pulmonary edema ARDS

11 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Decreased thoracic compliance Obesity Ascites Abdominal distention Pregnancy

12 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Increased airway resistance Bronchospasm Mucosal edema Secretions

13 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Artificial airways Endotracheal tube Tracheostomy tube

14 Ventilatory Demand in Excess of Ventilatory Capacity
Factors increasing ventilatory demand Mechanical factors Ventilator circuits Demand flow systems Inappropriate ventilator settings Flow Sensitivity

15 Ventilatory Demand in Excess of Ventilatory Capacity
Factors affecting ventilatory capacity Decreased PaCO2 Metabolic alkalosis Pain Electrolyte imbalance

16 Ventilatory Demand in Excess of Ventilatory Capacity
Factors affecting ventilatory capacity Respiratory depressants Narcotics Sedatives

17 Ventilatory Demand in Excess of Ventilatory Capacity
Factors affecting ventilatory capacity Fatigue Overall fatigue Malnutrition Atrophy of respiratory muscles

18 Ventilatory Demand in Excess of Ventilatory Capacity
Factors affecting ventilatory capacity Decrease in metabolic rate Carbon dioxide retention Neurologic or neuromuscular disease

19 Non-Respiratory Factors
Cardiovascular factors Myocardial ischemia Heart failure Hemodynamic instability Arrhythmias

20 Non-Respiratory Factors
Neurological factors Decreased central drive Decreased peripheral nerve transmission

21 Psychological Factors
Confusion/altered mental status Fear and anxiety Stress Depression Support from staff and family

22 Nutritional Needs Preferably, patient is not on hyperalimentation
No excessive carbohydrates Increased carbohydrate intake increases respiratory quotient > 0.8 Results from increase in carbon dioxide production

23 Factors Affecting Readiness For Weaning
Reversal or stabilization of underlying disease causing initiation of support Stable vital signs Afebrile Pulse, blood pressure within normal limits

24 Factors Affecting Readiness For Weaning
Adequate cardiovascular reserves Absence of acute myocardial ischemia Minimal requirement for vasopressors to maintain blood pressure No significant arrhythmias

25 Factors Affecting Readiness For Weaning
Adequate blood gas results PaO2 ≥ 60 mmHg with FIO2 < 0.5 and PEEP ≤ 5 cmH2O pH > 7.25 PaCO2 at patient’s normal level (may be greater than 45 mmHg for COPD patients)

26 Factors Affecting Readiness For Weaning
Adequate ventilatory status Spontaneous respiratory rate < 30 breaths/min Spontaneous tidal volume > 5 mL/kg Vital capacity > 10 – 15 mL/kg

27 Factors Affecting Readiness For Weaning
Adequate respiratory muscle strength Maximum inspiratory force MIF < −30 cmH2O

28 Factors Affecting Readiness For Weaning
Adequate ventilatory reserve Maximum voluntary ventilation MVV > 20 L/min or two times minute ventilation

29 Factors Affecting Readiness For Weaning
Adequate ventilatory reserve Rapid Shallow Breathing Index (RSBI) Respiratory rate divided by tidal volume in liters (f/VT) Calculated during one minute of unsupported, spontaneous breathing Pressure support reduces predictive value

30 Factors Affecting Readiness For Weaning
Adequate ventilatory reserve Rapid Shallow Breathing Index (RSBI) Most predictive for patients on ventilatory support less than eight days f/VT < 105 predictor of weaning success; < 80 associated with 95% success

31 Approaches to Weaning Spontaneous breathing trials (SBT)
Synchronized intermittent mandatory ventilation Pressure support ventilation Extubation

32 Spontaneous Breathing Trials (SBT)
Method Prepare the patient psychologically Set FIO2 either at the ventilator setting or 10% above setting Patient placed on T piece or left on ventilator with no backup rate and CPAP set at zero

33 Spontaneous Breathing Trials (SBT)
Method Start with five minutes off the ventilator (or less, if not tolerated by patient); may increase initial time up to 120 minutes if tolerated well

34 Spontaneous Breathing Trials (SBT)
Method Response is monitored; trial discontinued if changes observed f > 35 breaths/min SPO2 < 90% Heart rate > 140 beats/min or increase by 20%

35 Spontaneous Breathing Trials (SBT)
Method Response is monitored; trial discontinued if changes observed BP ≥ 20% change; systolic >180 mmHg and diastolic > 90 mmHg Diaphoresis Increased anxiety

36 Spontaneous Breathing Trials (SBT)
Method If first trial unsuccessful and patient has auto-PEEP secondary to airway obstruction, may add 5 cmH2O If patient has nasal ET tube or small ET tube, to 7 cmH2O pressure support may be added If patient fails SBT, patient replaced on ventilatory Support to rest for one to four hours

37 Spontaneous Breathing Trials (SBT)
Method Increase duration of spontaneous breathing trials Some patients may tolerate the procedure so well that they do not have to resume ventilator use at all

38 Spontaneous Breathing Trials (SBT)
When weaning is difficult, process can last weeks or months Generally, ventilatory support is resumed overnight

39 Synchronized Intermittent Mandatory Ventilation
Method Initially, respiratory rate and tidal volume set to provide full ventilatory support Initiation of weaning by SIMV May wait until patient’s condition has improved considerably May begin as soon as patient’s condition allows

40 Synchronized Intermittent Mandatory Ventilation
Method Rate decreased in increments of two with assessment of patient following each adjustment May be reduced more rapidly as patient condition improves Once rate is equal to 4 breaths/min and can be tolerated at least two to four hours, the patient may be extubated

41 Synchronized Intermittent Mandatory Ventilation
Decreases respiratory muscle atrophy and discoordination Minimizes chance of barotrauma through rapid reduction of mean airway pressure

42 Pressure Support Ventilation
Mode of ventilatory support that assists the patient’s spontaneous inspiratory effort with a level of positive airway pressure

43 Pressure Support Ventilation
Mode works best for short-term weaning (< 72 hours); if used for long-term weaning, increase support to near maximum at night to allow patient to rest

44 Pressure Support Ventilation
Technique Begin with pressure support level at which respiratory rate and tidal volume are close to full support Gradually reduce support as tolerated by patient

45 Pressure Support Ventilation
Technique Continue to reduce support until a minimum level of between 5 and 10 cmH2O can be tolerated When patient can maintain this level for a minimum of two and four hours, the patient is considered weaned

46 Extubation Decision to wean and decision to extubate are separate decisions

47 Extubation Guidelines for extubation
No immediate need for mechanical ventilation Achievement of adequate oxygenation and ventilation during spontaneous breathing

48 Extubation Guidelines for extubation
Minimal risk of upper airway obstruction Minimal upper airway edema; perform cuff leak test Suction upper airway above cuff Deflate cuff

49 Extubation Guidelines for extubation
Minimal risk of upper airway obstruction Minimal upper airway edema; perform cuff leak test Briefly occlude endotracheal tube If patient is unable to breathe around the occluded endotracheal tube with the cuff deflated, laryngeal edema may be present

50 Extubation Guidelines for extubation
Minimal risk of upper airway obstruction No evidence of mass obstructing airway Minimal risk of aspiration Adequate protection of airway Adequate clearance of pulmonary secretions

51 Failure to Wean Approximately 25% of patients removed from ventilatory support experience enough respiratory distress to require reinstitution of support

52 Causes of Weaning Failure
Oxygenation problems Decreased ventilation/perfusion ratio Asthma Emphysema Chronic bronchitis Bronchospasm

53 Causes of Weaning Failure
Oxygenation problems Increase in shunt Atelectasis Pneumonia ARDS Pulmonary edema

54 Causes of Weaning Failure
Oxygenation problems Low oxygen content of mixed venous blood

55 Causes of Weaning Failure
Ventilation problems Central hypoventilation Neurological injury Drugs Impaired neuromuscular function

56 Causes of Weaning Failure
Ventilation problems Increased dead space Embolism ARDS Emphysema

57 Causes of Weaning Failure
Ventilation problems Increased carbon dioxide production Increased carbon dioxide production from increased muscle activity Carbohydrate overfeeding Fever

58 Causes of Weaning Failure
Cardiovascular problems Left ventricular failure Hemodynamic instability

59 Terminal Weaning Discontinuation of ventilatory support in the presence of catastrophic or irreversible illness

60 Terminal Weaning Decision to terminally wean made by family in conjunction with physician and according to established ethical and legal guidelines Patient’s prior known desire to not continue life support Predictions of a low chance of survival

61 Terminal Weaning Decision to terminally wean made by family in conjunction with physician and according to established ethical and legal guidelines Likelihood of significant future cognitive impairment Inability to maintain blood pressure without continuous need for medication

62 Terminal Weaning Patient is discontinued from ventilator after all procedures to ensure as much comfort as possible for the patient have been performed

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