Discontinuation and weaning of the ventilated patient

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kjeidsness
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186295
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Discontinuation and weaning of the ventilated patient
Updated:
2012-11-30 16:31:56
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Resp 210
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Respiratory Critical Care
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  1. What % of pts. don't need to be weaned from the vent?
    80%
  2. What types of pts don't need to be weaned?
    • post-op surgical patient
    • recovery from anesthesia
    • treatment of uncomplicated overdose
  3. Factors to consider for weaning
    • 1. ventilation required during weaning
    • 2. O2 & PEEP needed for oxygenation
    • 3. Pts. needing artificial airway after venilator support
  4. Extubation to avoid the following risks
    • 1. Ventilation induced lung injury
    • 2. Nosocomial pneumonia-VAP
    • 3. Airway Trauma from ET tube
    • 4. Unnecessary sedation
  5. What measurements are used for respiratory assessment?
    • PIP
    • VC
    • MVV
    • TV
    • Minute Volume
  6. 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
  7. 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
  8. What is the success rate with 2-hour T-Piece trails?
    85% were weaned without reintubation
  9. Patients that could fail T-piece trials
    • Heart disease
    • Severe muscle wakness
    • Panicking with COPD
  10. How long does it take pts waking up from anesthesia to be withdrawn from vent?
    20-25% longer than 72 hours
  11. What muscles determine how quick someone can be weaned?
    • Diaphragm
    • Strenghtening & nutrition
  12. Strengthening respiratory muscles
    • Nourished without overfeeding
    • Undisturbed sleep with total vent support during night
  13. 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
  14. Volume targeted and pressure support
    • Support breath with pressure volume target 
    • ADVANTAGE! Maintaining volume to maintain FRC
  15. 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
  16. 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
  17. Potential complications
    • may not respond fast enough in apnea episode
    • some vents don't have high or low alarm for rate or volume
  18. 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 
  19. 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
  20. Pts. not tolerating the weaning process may show signs of?
    • Dyspnea
    • Pain
    • Anxiety
    • Sweating
    • Paleness or cyanosis
    • Fatigue
    • Drowsiness
    • Restlessness and or accessory muscle use
  21. 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
  22. Respiratory factors affecting successful weaning
    • central drive to breathe
    • gas exchange ability
    • mechanincal factors
  23. 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
  24. Extubation
    • if pt. able to mobilize secretions
    • trail spontaneous breathing without any vent support
  25. Postextubation difficulties
    • hoarseness
    • sore throat
    • cough
    • subglottic edema
    • increased WOB from secretions
    • airway obstruction- 70% He 30% O2
    • laryngospasm

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