Weaning from mechanical ventilation:

Transition to spontaneous breathing trials and extubation

Earlier liberation leads to better outcomes such as mortality, decrease in VAP, lung injury diaphragmatic
dysfunction, and shorter hospitalization stay

Perform the general algorithm for weaning and extubation

 Daily assessment of readiness, if successful SBT then assess airway anatomy for ability to
protect airway once airtube is removed, check cough strength, quantity of secretions, cuff
leak, and mentation
o If adequate then extubate
o If inadequate then do ventilator support and continue with daily assessments of
readiness
 What has the highest accuracy for detecting weaning outcome in mechanically ventilated
patients compared to other patients?
o Rapid shallow breathing index

SBTs

- Initiate the ventilator from full respiratory support mode to partial vent support modes such as
PS. CPAP, ventilation with T piece (no positive end-expiratory pressure)
- PSV and T tube have similar rate of intensive care unit mortality and weaning success
- 30 minute SBT vs 120 minute SBT have similar rates of extubation
- Criteria for successful SBT include breathing spontaneously with little or no vent support and
none of the following
o RR > 35 breaths/minute > 5 minute
o O2 saturation < 90%
o Heart rate > 140 bpm
o Sustained change in heart rate of 20 %
o SBP > 180 or < 90
o Increased anxiety
o Diaphoresis
- If they fail, find the cause and try again every 24 hours

Adjunctive therapies

- High nasal cannula oxygen therapy reduces intubation and postextubation with RF
- Noninvasive

Other considerations

- Daily interruption of sedatives may reduce duration of mechanical ventilation

- Protocolized weaning has been used for d/c of mechanical vent but unclear which aspect
 - Automated weaning and spontaneous breathing trial system may reduce weaning time
compared to nonautomated weaning strategies in critically ill adults

Assessing readiness for SBT

- Consider SBT if the following Criteria are met?

o Evidence orf reversal of underlying cause of respiratory failure
o Adequate oxygen
 Partial pressure of o2 to fraction of inspired os > 150 to 200 (PaO2/FiO2)
 PaO2 > 60 mm hg on FiO2 < .4
 PEEP < 5 cm water
 pH > 7.25
o hemodynamic stability
 Absence of active myocardial ischemia
 Absence of clinically significant hypotension
o Ability to initiate inspiration
o Other Criteria to consider?

Predicting Weaning Success:

- RSBI = RR/ Tidal Volume is most predictive < 105 breaths/min/L

Methods of SBTs:

- Assess the ability of the patient to breath while receiving little to no vent support
- SBTs when the patient are awake and not taking sedatives
- SBTs  PS / CPAP/ T-piece
- Should be > 30 minutes
- Monitor vitals
- 30 minute SBT vs 120 SBT have similar rates of extuabtion success/reintubation

Successful SBT criteria:

- The following are assessed

o Respiratory pattern
o Adequacy of gas exchange
o Hemodynamic stability
o Subjective comfort
- Criteria for successful SBT with no breathing spontaneously with little to no ventilator support
and none of the following
o RR > 35 for more than 5 minutes
o O2 saturation < 90 %
o Sustained change in heart rate of 20%
o Systolic blood pressure > 180 mm Hg or < 90 mm Hg
o Increased anxiety
o Diaphoresis