Discontinuation and weaning of the ventilated patient
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What % of pts. don't need to be weaned from the vent?
What types of pts don't need to be weaned?
- post-op surgical patient
- recovery from anesthesia
- treatment of uncomplicated overdose
Factors to consider for weaning
- 1. ventilation required during weaning
- 2. O2 & PEEP needed for oxygenation
- 3. Pts. needing artificial airway after venilator support
Extubation to avoid the following risks
- 1. Ventilation induced lung injury
- 2. Nosocomial pneumonia-VAP
- 3. Airway Trauma from ET tube
- 4. Unnecessary sedation
What measurements are used for respiratory assessment?
Methods of titrating ventilator support during weaning
- 1. SIMV: reduce mandatory vent breaths. PS & PEEP
- 2. PS Ventilation: Pt controls rate, timing and depth of each breath. Pt triggered, pressure limited to achieve volume and flow cycled.
- 3. T-piece weaning: time schedule, without vent support
What will be seen if there is inappropriate PSV settings?
- 1. cardiopulmonary stress
- 2. tachycardia
- 3. tachypnea
- 4. paradoxical breathing
- 5. excessive work with respiratory muscles
- 6. hypertension
- 7. diaphoresis
What is the success rate with 2-hour T-Piece trails?
85% were weaned without reintubation
Patients that could fail T-piece trials
- Heart disease
- Severe muscle wakness
- Panicking with COPD
How long does it take pts waking up from anesthesia to be withdrawn from vent?
20-25% longer than 72 hours
What muscles determine how quick someone can be weaned?
- Strenghtening & nutrition
Strengthening respiratory muscles
- Nourished without overfeeding
- Undisturbed sleep with total vent support during night
Automatic Tube Compensation
- Delivers the adequate amount needed to reduce work of breathing from tube. It is not a set amount.
- support breath with out under or over compensation for each breath
- Provides variable PS and variable flow
- mode & tube size on screen
Volume targeted and pressure support
- Support breath with pressure volume target
- ADVANTAGE! Maintaining volume to maintain FRC
Mandatory minute ventilation
- if pts spontaneous ventilation decreases, system automatically increases level of mechanical ventilation
- if pt starts to breathe on their own level of mechanical ventilation decreases
Advantages of MMV
- 1. greater control over PaCO2
- 2. acute hypoventilation or apnea occurring in pts will not result in hypercarbia
- 3. less concern of acute hypoventilation following sedatives, narcotics or tranquilizers
- 4. smooth transition from mech. support to spontaneous vent. in pts recovering from DOD or anesthesia
- may not respond fast enough in apnea episode
- some vents don't have high or low alarm for rate or volume
Weaning priorities and factors for reducing weaning time
- 1. PEEP/CPAP of 3-5 to maintain FRC
- 2. PSV to reduce breathing workload to overcome system resistance
- 3. Large breath at lease once every 1 or 2 mins
Guidelines to help in weaning process
- 1. select appropriate time of day from standing point of pt. physiology, pt. psychology and personnel availability
- 2. test pts. spont. breathing daily
- 3. rest pt. at night or when dyspnea
- 4. withdraw support as quickly as tolerated
Pts. not tolerating the weaning process may show signs of?
- Paleness or cyanosis
- Restlessness and or accessory muscle use
Identify problems during weaning process
- 1. rise in f above 25-30 want 8-10
- 2. Vt below 250-300ml
- 3. significant change in blood pressure
- 4. rise in heart rate of more than 20 bpm or above 110 bpm
- 5. frequent premature ventricular contractions
- 6. any clin. signs swhoing deterioration of pts. condition
Respiratory factors affecting successful weaning
- central drive to breathe
- gas exchange ability
- mechanincal factors
Non respiratory factors affecting weaning
- 1. cardiac factors in weaning: acute CHF, loss of pressure and redistrunution of blood flow
- 2. acid-base factors : CO2 retainer and difficult to wean
- 3. metabolic status
- 4. drugs: pts. with sedatives, opioids, tranqs & hypnotic= depressed resp. center.
- 5. nutrition: overfeeding= over productions of CO2
- 6. psychological status
- if pt. able to mobilize secretions
- trail spontaneous breathing without any vent support
- sore throat
- subglottic edema
- increased WOB from secretions
- airway obstruction- 70% He 30% O2
What would you like to do?
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