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Weaning From Mechanical Ventilation
Weaning From Mechanical Ventilation
Liberation
Weaning
If the patient was breathing effectively before the event and no lung or respiratory control process was damaged, they should breathe after correction of the inciting event.
Why Liberate?
Complications of intubation
Larynx, vocal cords, trachea, nose, sinus
Respiratory complications
Nosocomial pneumonia, atelectasis, barotrauma, hypotension, ventilator-associated lung injury
Non-respiratory complications
Gastric, cardiac, renal, nutrition
Over-distension of alveoli
VALI Increase dead space (Zone 1)
Decrease LV Afterload
Positive pleural pressure augments LV contraction, lowering impedance to emptying Equivalent to decrease in aortic root pressure
Conclusion: MV and NIP criteria predictive of successful liberation; MVV helpful in tough calls
Weaning
Weaning Methods
RCT- 546 patients with ARF/ALI
Mostly medical
NEJM 1995;332:345-50
Weaning Methods
3 minute spontaneous breathing trial: T-piece
Measure NIP, Vt, f
Weaning Methods
NEJM 1995;332:345-50
Weaning
How long spontaneous breathing trial?
73-76% remained liberated for >48 hrs No difference between 30 and 120 min SBT
AM J RESPIR CRIT CARE MED 1999;159:512518.
Weaning
Tracheostomy Patients
RCT 500 patients in specialty hospital; patients referred for weaning; >30 days MV Almost 200 removed from MV after 5 day SBP Randomized to PS wean (3x/day) vs trach collar (up to 12hrs/day) 50% of patients liberated SBP had shorter median time to liberation (15 vs 19 days) No difference in mortality (60-66%)
Weaning
Who can do it?
Weaning
Who can do it?
117 Respiratory Therapists, 1067 patients, >9000 patient-days Daily Screen ready to wean physician order
MV < 15 L/min, FiO2 < 0.60, PEEP < 10
Structured education and periodic reinforcement of protocols to RTs and Physicians necessary for success
Respiratory muscles
Tension-time index: AJRCCM 180:982-8, 2009
Liberation
Identifying Patients
AJRCCM 2012; 186:12561263
70% of patients had at least one elevated BNP BNP group received more diuretics (70% vs 85%)
Airway Resistance
Mucus, secretions Bronchospasm
Lung/Respiratory Compliance
Volume overload Abdominal distension
Extubation
Unassisted ventilation vs. Extubation
Airway protection, clearance of secretions, cough Mental status, frequent suctioning
Post-extubation stridor
Pulmonary edema Nebulized epinephrine, systemic steroids, HeliOx
Non-invasive ventilation
Incentive spirometry
Summary
Liberation is often just a question of doing it
Minority of patients require weaning Correct underlying cause, reduce mechanical ventilatory support, optimize electrolytes and acidbase
Often patients are liberated more quickly with less involvement from physicians
Summary
My Approach
Assess for respiratory, metabolic, and neurologic stability
Minute ventilation Delirium, Sedation, Sleep/wake cycle
Airway/larynx consideration Extubate to humidified air/O2 mixture Follow clinically for at least 4 hours, longer if prolonged respiratory failure
Terima Kasih