Weaning From Mechanical Ventilation Draft 2014 Feb 7 Feedback NPD

Our Lady of Lourdes
Hospital Drogheda
Weaning from Mechanical Ventilation
Intensive Care Unit
Our Lady of Lourdes Hospital Drogheda
Document Cli/Nurs/ICU001 Document Caroline O Donnell

reference developed by Research and
number development team
Revision 0 Document Dr Dinesh Kuriakose

number approved by Consultant Anaesthetist
OLOL Drogheda
Approval 13/08/2018 Responsibility Unit/Ward Managers
date for
implementation
Next 13/08/2020 Responsibility Unit/Ward Managers
Revision for review and
date audit
OQR029 HSE Procedure for developing Policies, Procedures, Protocols and Guidelines.
Document reference no. OQR029 Revision no.3 Revised March 2012
Page 1 of 36
Table of contents
1.0 Policy Statement......................................................4

2.0 Purpose..................................................................4
3.0 Scope.....................................................................4
4.0 Legislation...............................................................4
5.0 Glossary of terms and definitions…………………………………. .5
6.0 Roles and Responsibilities......................................…..7
7.0 Guideline.................................................................8
8.0 Difficult Weaning....................................................13
9.0 Prolonged Weaning………………………………………………………. 14
10. References …………..………………………………………………………. 19
Appendix I Ventilator Associated Pneumonia (VAP)......................21
Appendix II Weaning Guideline Algorithm....................................24
Appendix III Weaning readiness assessment/weaning guideline......26
Appendix IV Conditions associated with failure to wean.................28
Appendix V Members of Research and Development group….………..31
Appendix VI Peer review of Guidance..........................................32
Page 2 of 36
Acknowledgements: Thanks to all who have been involved in
developing and reviewing the guideline.
Members of the Research and Development Team

Fionnuala Monaghan (CNM1)
John Gilmore (Staff Nurse)
Blaithin Halloran (Staff Nurse)
Gary Duffy (Clinical Facilitator)
Dr Rosemary Moriarty (Anaesthetic Consultant)
Dr Dinesh Kurikose (Anaesthetic Consultant)
Page 3 of 36
Policy Statement
1.1 The Health Care Professionals within the Critical Care Environment
(Intensive Care and High Dependancy Unit) are committed to ensuring best
practice for weaning patients promptly and safely from mechanical
ventilation.
2.0 Purpose
2.1 The purpose of this guideline is to provide a standardised methodology for

recognizing patients who are ready to wean from mechanical ventilation,
weaning them appropriately and have a plan for patients who are slow to
wean.
2.2 This document has also been developed to:

 Promote best practice
 Standardise practice and service delivery
 Ensure employees and line managers are clear on their roles and
responsibilities
 Facilitate effective staff induction
 Act as educational tools
 Act as a basis for audit and evaluation
3.0 Scope
This guideline relates to all health personnel who are involved in weaning
patients from mechanical ventilation- Anaesthetists, Nurses, Physiotherapists and
Speech and Language therapist (SALT).
4.0 Legislation
Sari guidelines (2011) has emphasised the importance of reducing ventilator-

associated pneumonia (VAP). The use of a weaning guideline is effective in
reducing the duration of mechanical ventilation and the incidence of VAP (Sari,
2011). Evidence based guidelines which incorporate daily assessments of
readiness to wean should be in place.
Page 4 of 36
5.0 Glossary of Terms and Definitions
5.1 Clinical Audit

Organized review of current clinical procedures compared with pre-determined
standards. Action is then taken to rectify any identified deficiencies in current
practices. The review is repeated to see if the standards are being met (WHO
2009).
5.2 Consultation
The exchange of views and establishment of dialogue between either or both
a) One and more employees or the employees’ representative(s) and
b) The employer (Employees (Provision of Information and Consultation) Act
2006).
5.3 Evaluation
Evaluation is defined as assessment/appraisal of the degree of success in
meeting the goals and expected results (outcomes) of the organisation, service,
programme, population or patients/clients (Quality and Risk Taxonomy
Governance Group report 2008).
5.4 Evidence Based Practice

Consensus approaches for handling recurring health management problems
aimed at reducing practice variability and improving health outcomes (WHO
2009).
5.5 Healthcare Audit

Healthcare audit is audit of current practice against standards in any aspect of
healthcare and includes both clinical and non-clinical audit (Clinical Audit Criteria
and Guidance Working Group 2008).
5.6 Monitor
Any parameter that is regularly and consistently used to evaluate the quality of
care (WHO 2009).
5.7 Guideline
A guideline is defined as a principle or criterion that guides or directs action
(Concise Oxford Dictionary 1995). Guideline development emphasizes using clear
evidence from the existing literature, rather than expert opinion alone, as the
basis for advisor materials (WHO 2009).
5.8 Scope
Page 5 of 36
This includes both the target users and target population (only refer to a target
population if the PPPG is referring to specific groups for example all service users
aged 16 years and over) of the policy, procedure, protocol or guideline. It
identifies to whom the policy, procedure, protocol or guideline applies.
5.9 Weaning from Mechanical Ventilation

Weaning is defined as the entire process of liberating a patient from mechanical
support and from the endotracheal tube (Boles et al, 2007).
6.0 Ventilaor Associated Pneumonia (VAP)

Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or
longer after mechanical ventilation is given by means of an endotracheal tube or
tracheostomy. Ventilator-associated pneumonia (VAP) results from the invasion
of the lower respiratory tract and lung parenchyma by microorganisms.
Intubation compromises the integrity of the oropharynx and trachea and allows
oral and gastric secretions to enter the lower airways.
Page 6 of 36
6.0 Roles and Responsibilities
6.1 Roles
 Nurse Managers and the research and development group to ensure
that nursing staff are aware of this guideline
 Nurse Managers to facilitate training for employees where necessary.
 Nurse Managers to ensure that employees comply with this guideline
through monitoring audit and review.
 Anesthetic lead to ensure that the anesthetic team is aware of this
guideline and facilitate training.
6.2 Responsibility
 Each health professional/HSE employee is accountable for their
practice. This means being answerable for decisions he/she makes
and being prepared to make explicit the rationale for those decisions
and justify them in the context of legislation, case law, professional
standards and guidelines, evidence based practice, professional and
ethical conduct.
 It should be recognised that the protocol represents a statement
reflecting an expected standard of care and could be introduced in
law as evidence of the standard of care expected. There may be
occasions when it is acceptable to deviate from the guideline but
clinical judgement in such a decision must be clearly documented.
 The public may request access to the guideline and public bodies
may be called on to publish such documents under Freedom of
Information Act (1997) and appropriate legislation.
Page 7 of 36
7.0 Guideline
7.1 Background
Mechanical Ventilation (MV) is a life-supporting modality and is deemed to be the

defining event marking many ICU admissions. Multiple complications and risks
associated with intubation and MV increase over time. As MV is associated with
risks such as increased susceptibility to airway trauma, ventilator associated
pneumonia (VAP), ventilator induced lung injury, gastrointestinal bleeding,
venous thrombus and increased sedation usage, it follows that weaning should
occur as soon as possible.
Weaning from mechanical ventilation is an integral part in the care of critically ill
intubated patients. It incorporates the entire process of liberating the patient
from mechanical support and from the endotracheal tube. Unstructured
overzealous attempts to wean can lead to respiratory muscle fatigue or
cardiovascular instability thus delaying weaning. Premature extubation leading to
reintubation carries additional risks of inability to re-establish the airway,
pneumonia, and increase mortality. Because mechanical ventilation incurs
significant morbidity, mortality and costs, and because both premature weaning
and delayed weaning can cause harm, weaning that is both expeditious and safe
is highly desirable.
VAP is by far the most serious complication of MV and has directed the
development of this protocol. It is often due to the increase number of MV days
and the intubation procedure itself. Oral flora is introduced into the trachea and
lower respiratory tract via the endotracheal tube. A systematic review found that
VAP occurs in 10-20% of all patients mechanically ventilated for more than 48
hours. Crude mortality rates in patients with VAP range from 24-50%, increasing
to 76% if infection is caused by multi-resistant organisms (Safdar et al, 2005).
Patients who develop VAP are twice as likely to die as those without VAP
(Bercault & Boulain, 2001). It is also associated with prolonged length of stay
and increased health care costs (Muscedere et al, 2008). Therefore prevention of
VAP is paramount to improve patient outcomes and to improve healthcare
efficiency. See appendix I for VAP Bundle.
The overall purpose of this protocol is to give structure to the weaning process
and to aid evaluation and audit of the process. The overall objective is to:
 Formulate clinical practice instructions for the weaning of patients from
Mechanical Ventilation based on best evidence available.
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 To streamline and standardise the weaning process of patients from
Mechanical Ventilation in the Adult Intensive Care Unit, Our Lady Of
Lourdes, Drogheda.
The guideline will be applied to all adult patients who are intubated and on
Mechanical Ventilatory support within Our Lady of Lourdes hospital Drogheda.
Those who are ‘end of life care’ will not be included. It will involve a collaborative
approach between the multidisciplinary team ie. Nursing, Physiotherapists,
Dietician, Speech and Language therapist (SALT) and Anaesthetic team.
Constant monitoring and evaluation will be required. See appendix I&II for
algorithms.
Through collaboration with the Anaesthetic team, Clinical education facilitator in

the Royal Victoria, Nursing team in Tallagh Hospital, Beaumont Hospital, Galway
University hospital, Physiotherapists (OLOL Drogheda), Speech and Language
therapists (OLOL Drogheda) and the Research and Development group in ICU
(OLOL Drogheda), the protocol was researched and developed.
The protocol will be divided into four sections.
 Section one involves identifying patients who are ready to wean.

 Section two of the protocol will be initiating a Spontaneous Breathing Trial.
All patients must pass readiness to wean criteria before initiating this
aspect of the protocol.
 The third section will deal with the Extubation process. Once a patient is
able to sustain spontaneous breathing a second judgement must be made
regarding whether the artificial airway can be removed.
 Section 4 will deal with difficult and prolonged weaning.
Section 1
Readiness to Wean
7.1.1 Weaning should begin as soon as the patient has recovered adequately
from respiratory failure.
7.1.2 The decision to wean should be taken by the multidisciplinary team and
then documented in the patients notes by the attending
intensivist/anaesthetist.
7.1.3 At 7:00-8:00am the patient will be assessed daily for spontaneous

breathing readiness also known as:
Readiness to wean (See appendix III)
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7.1.4 The following parameters are suggested as Ideal, although clinical
judgement remains paramount and the clinician may decide to
wean/extubate without meeting the following criteria.
7.1.5 Patients readiness to wean is determined by clinical assessment which

should include:
 Adequate cough
 Absence of Excessive Secretions
 Resolution of acute disease for which patient was intubated
7.1.6 Furthermore, objective clinical measurements should be taken into

consideration including:
 Stable cardiovascular status-

HR >50, HR <140 beats/min,
Systolic BP 90-160 mmHg,
 No or minimal vasopressors
 Adequate oxygenation
SaO2>90%
FiO2 <0.4
 Peep <8cmH20
 RR <35 breaths/min
 No sedation or adequate mentation on sedation (RASS 0 to-
3/stable neurologic patient)
 No evidence of cardiac ischaemia (i.e. chest pain, ST changes
or new arrythmias)
 Stable metabolic status
 Adequate pulmonary function
 Peak airway pressure 20-25 cmH2O
 VT>5mls/kg
 VC>10ml/kg
 No significant respiratory acidosis
7.1.7 Where patients meet the above criteria their rapid shallow breathing
index (RSBI/Tobin Index) should be calculated (RR/VT). For example
RR=20bpm, Vt=0.3L 20/0.3=66. RSBI<105 indicates readiness to
wean. The nurse at the bedside will calculate RSBI and document in the
daily ICU chart. This will be reported to the anaesthetic team.
Page 10 of 36
Section 2
Spontaneous Breathing Trial
7.1.7 Spontaneous breathing trial (SBT)

A spontaneous breathing trial or ‘wake up and breathe trial’ is a
diagnostic test to determine the likelihood of successful extubation.
All patients must pass readiness to wean criteria before initiating this
aspect of the protocol.
7.1.9 Inform the patient as to the plan of care providing reassurance and
support. Provide assurance to the patient and/or family as needed to
gain cooperation and to minimise anxiety.
7.1.10 Maintain Nasogastric feeding rest period (0800-12pm).
7.1.11 Stop sedation as per sedation protocol (Spontaneous Awakening

trial). Aim RASS score 0 to -2.
7.1.12 Conduct Spontaneous Breathing Trial (SBT) for 1 minute on:
 Mode: CPAP +/- PS

 PEEP: 5 or below
 PSV: 5-7 or below
 FiO2: Unchanged
7.1.13 After 1 minute, calculate RSBI. If RSBI<105, continue to conduct SBT

for 20minutes up to 2 hours continuously assessing patient.
7.1.14 SBT to be terminated if patient demonstrates any of the following criteria:

SBT termination criteria:
 RR>35/min for >5mins
 SaO2 <90% for >2mins
 HR change 20% from baseline
 Blood Pressure change 20% from baseline
 Increased anxiety or diaphoresis
 RSBI>105 for 5mins.
 Poor or no cough on command.
7.1.15 Return to previous ventilator settings and consult physician.
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7.1.16 If successful with spontaneous breathing trial and RSBI <105 discuss
ABG and EXTUBATION plan with physician. (See extubation critertia
below).
Extubation criteria:
 Ability to maintain patent airway.
 Ability to protect airway
 Ability to cough and clear secretions.
Section 3
Extubation
7.1.17 Meets criteria- EXTUBATE
Prior to extubation ensure:

 Cuff leak is audible.
 Gastric feed should be held for least 2 hours
 Have nasal prongs or face mask available
 A mask for non-invasive ventilation should be immediately available.
Extubation Process
 When possible, the head of the bed should be at a 30 to 90 degree angle
from horizontal.
 The endotracheal tube, mouth and upper airway are suctioned, paying
attention to the collection of secretions above an inflated cuff. Inadequate
clearing of secretions can result in post extubation laryngospasm.
 The cuff is then deflated and the endotracheal tube is withdrawn. After
removal of the endotracheal tube the patient is given supplemental
oxygen, titrated to oxygen saturation; however, caution must be taken
with a patient who is at risk of carbon dioxide retention.
 Discuss with Anaesthetic Consultant re electively extubating to High Flow
Optiflow post extubation as it reduces the incidence of reintubation
(Zhiheng et al 2018).
Post extubation ensure:

 Patients are monitored for signs of respiratory failure- if signs and
symptoms of respiratory failure ensue, manage expeditiously. Try NIV
before reintubating.
 Patients may have impaired airway protection reflexes immediately after
extubation and aspiration can be silent (i.e. aspiration without coughing). If
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speech is impaired for more than 24 hours, indirect laryngoscopy should be
undertaken to assess vocal cord function.
 Oral intake should be delayed in patients who have been intubated for a
prolonged period and patients should be referred to Speech and Language
Therapy. Dysphagia should be considered in all patients with existing
neurological conditions.
7.1.18 Fails criteria- Is reason for failure reversible? Once reversible

causes for failure are corrected, subsequent SBT should be
performed every 24hours.
Section 4
Difficult to wean and Prolonged weaning
8.0 Management of the difficult to Wean Patient
Classification of weaning according to the weaning process
1. Simple weaning- Patients who proceed from initiation of weaning to

successful extubation on the first attempt without difficulty
2. Difficult weaning- Patients who fail initial weaning and require up to three
SBT or as long as 7 days from the first SBT to achieve successful weaning
3. Prolonged weaning Patients who fail at least three weaning attempts or
require >7 days of weaning after first SBT (Boles et al, 2007).
Patients who fail attempts at weaning constitute a unique problem in critical care.
When initial attempts fail clinicians must choose appropriate ventilator modes
which maintain a favourable balance between respiratory system capacity and
load, attempt to avoid diaphragm muscle atropathy, and aid in the weaning
process.
Most fail the transition from ventilator support to sustain spontaneous breathing
because of failure of the respiratory muscle pump. They typically have a
respiratory muscle load that exceeds the respiratory neuromuscular capacity
(See appendix IV).
Patients with reversible disease who are unable to wean in 10-14 days are
usually considered for tracheostomy insertion.
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If the patient is unlikely to be weaned due to neurological/chronic pulmonary
process, a decision on tracheostomy can often be made within a few days of
intubation.
Unless there is evidence for clearly irreversible disease, a patient requiring

prolonged mechanical ventilation should not be considered permanently
ventilator-dependant until 3 months of weaning attempts have failed.
8.0 Difficult-to Wean Patients
8.1 Weaning trials in patients who are difficult to wean are the same as those
in patients who are weaning for the first time. This includes selection of a
weaning mode, identifying readiness to wean criteria, performing
Spontaneous breathing trial, identifying weaning success or failure and
deciding whether or not to extubate the patient.
8.2 It is recommended to use once daily spontaneous breathing trials. It allows

a prolonged period of rest, which may be the most effective method to
permit adequate time for muscle recovery (Alia & Esteban 2000).
9.0 Prolonged Mechanical Ventilation (PMV)
Guidelines issued by a collective task force organized by the American College of

Chest Physicians (Cook et al, 2001) recommend that weaning be gradual in the
patient requiring PMV.
9.1 Prior to weaning a patient who has required Prolonged Mechanical
Ventilation, all potential causes of ventilator dependence should be
identified and either corrected or optimized. In addition, factors that might
not be the cause of the patient's respiratory failure, but could impair the
weaning process, should be identified and managed.
9.3 Once it is felt that the likely cause of ventilator dependency has been
corrected, readiness testing can be performed to determine whether
weaning is ready to resume (See criteria 7.1.4).
9.2 To aim for a RSBI of less than 97 as this has been identified as the most
accurate predictor of a successful spontaneous breathing trial in patients
with PMV.
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9.2 Patients who are deemed ready to resume weaning should be
psychologically prepared for the weaning process.
9.3 There is no preferred mode of mechanical ventilation between weaning

trials. Any mode may be used, as long as the settings (ie, tidal volume,
respiratory rate, and/or pressure level) are such that the patient is
comfortable and performing minimal work. Reasonable goals are settings
that result in a respiratory rate between 12 and 20 breaths per minute, a
tidal volume between 6 and 8 ml/kg, and a minute volume between 6 and
12 L/min.
9.4 Once patients can tolerate spontaneous breathing trials, we gradually
increase the duration of the daily spontaneous breathing trials.
9.5 Criteria used to assess patient tolerance during spontaneous breathing
include the respiratory pattern, adequacy of gas exchange, hemodynamic
stability, and subjective comfort. (See 7.1.12 for Spontaneous Breathing
Trial Termination criteria). Patients who fail spontaneous breathing should
be placed on a non-fatiguing, comfortable mode of ventilation and the
cause of failure determined and corrected.
*NOTE: Significant changes in HR and BP may not be seen in Spinal Cord
Injuries due to the loss of sympathetic tone.
9.6 Continuous ETCO2 monitoring to assess tolerance during these trials are
important. Hypercapnia is often an early warning sign of respiratory failure.
9.7 When signs of intolerance are noted, return patient to previous supportive
ventilation and document.
9.8 Communicate with physiotherapist regarding abdominal binder

appropriateness.
9.9 If tracheostomy present graduated ventilator free breathing with trachy

mask or t-piece and added Oxygen and humidification as necessary.
9.10 Cuff deflation is the next process of weaning. If patient have problems
controlling their cough re-inflate the cuff.
9.11 Once patient tolerates cuff deflation, utilise a passy muir speaking valve
with SALT input. Follow appropriate cuff deflation protocol, suctioning
before cuff deflation and again following cuff deflation. The cuff must be
fully deflated to use a speaking valve (refer to tracheostomy guidelines,
2015). If patient has difficulty breathing, unable to vocalise, sound wheezy
Page 15 of 36
or stridous, remove at once and report. If the patient is unable to tolerate
a speaking valve SALT can provide alternative communication options.
9.12 Next stage is decannulation cap. The cuff must be deflated for this stage as
inspiration and expiration has to go via the nose and mouth
9.13 The patient must be able to:
Tolerate decanulation cap for four hours or more breathing around

a tracheostomy of a least size 7.0mm. This suggests that they will
tolerate decannulation without suffering from airway obstruction.
The patient can tolerate four hours with the decannulation cap and
is able to expectorate pulmonary secretions effectively. Removal
of the tracheostomy is indicated.
9.14 Adopt Supine position.
9.15 Explain clearly to the patient the procedure for removing the
Tracheostomy.
The tracheostomy tube is removed and air occlusive dressing applied to stoma.
*NOTE see Guideline on Tracheostomy Care (2014) on Unit.
Optimizing Respiratory status during and between weaning trials
 Ventilator circuit — Ventilator circuit-related problems can increase

respiratory work and, therefore, the circuit should be closely monitored and
problems quickly identified and corrected. For example increased peak
airway pressure with little or no change in the plateau pressure indicates
increased resistance in the endotracheal tube or respiratory circuit.
 Airway management — Airway management encompasses secretion
management, bronchodilation, and tracheostomy:
 Airway secretions should be suctioned before every weaning trial.
 Bronchodilators may facilitate weaning in patients with airway obstruction
by reducing airway resistance and the work of breathing. Discuss with
Anaesthetic team. We use short-acting aerosolized beta-adrenergic and/or
anticholinergic agents prior to a weaning trial in most patients.
 A tracheostomy can be advantageous in the difficult-to-wean patient
because it increases patient comfort (i.e., decreases the work of breathing,
Page 16 of 36
decreases intrinsic PEEP, and improves patient-ventilator synchrony) and
oral hygiene. It also facilitates verbal communication, which is beneficial
since the inability of patients to speak while intubated is a major cause of
fear and anxiety.
 Posture — Patients should be placed in the posture that they prefer during
a weaning trial, which may vary according to the pathophysiology. Patients
with diaphragmatic paralysis generally prefer and perform better in an
upright position because their vital capacity decreases when they are
horizontal. In contrast, patients with intercostal muscle weakness (eg, due
to a low cervical cord lesion) may prefer being supine because their lung
volumes tend to increase when they move from an upright to a supine
position. In patients with chronic obstructive pulmonary disease, the
optimal posture varies. Some patients have less dyspnoea when they are
lying supine, whereas others prefer to lean forward.
 Physical therapy — Early mobilisation of mechanically ventilated patients
appears to improve clinical outcomes including weaning. Mobilization
activities include sitting at the edge of the bed, engaging in simulated
activities of daily living, transfer training, and ambulation. Patients who
received progressive physical therapy had more ventilator-free days (24
versus 21 days), are more likely to go directly home after hospitalization,
have fewer days with delirium, and had better walking distances while in
the hospital than patients who do not receive mobilisation.
 Nutrition — Protein catabolism induced by critical illness leads to
decreased respiratory muscle mass, strength, and endurance, which may
lead to difficulty weaning from mechanical ventilation. Nutrition support
may minimise these effects and improve both weaning success and other
clinical outcomes, as long as the amount of nutrition support is adequate
without being excessive.
 Communication-Restoring or facilitating communication enables the
patient to participate more effectively in treatment. The patient can
consent or decline interventions, provide feedback regarding pain, and
participate in end of life /quality of life treatment options. Effective
communication promotes the psychological wellbeing of the patient.
 VAP Bundle: Adhere to VAP Bundle when ventilated.
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of Medicine, 344(26), 1986-1996.
29 Zhiheng, X; Yimin, Li., Jianmeng, Z., Yongbo, H., Nanshan, Z., Haibo, Z.
(2018) High-Flow nasal cannula in adults with acute Respiratory Failure
and after extubation: a systematic review and meta-analysis. Respiratory
Research, 19; 202.
Page 19 of 36
11. Appendices
Appendix I Ventilator Associated Pneumonia (VAP) Bundle
Appendix II Weaning Guideline Algorithm
Appendix III Weaning readiness assessment/Weaning
Appendix IV Conditions associated with failure to wean
Appendix V Signature Sheet
Appendix VI Members of the Research and Development Group
Appendix VII Members involved in the development of the Weaning

Protocol
Page 20 of 36
Appendix I
VAP BUNDLE
VAP Bundle Yes No

Head up 30 degrees or more
Daily awakening trials
Daily Spontaneous Breathing
Trials
2% chlorhexidine Mouthwash
Subglottic Suctioning
Peptic Ulcer Prophylaxis

DVT Prophylaxis
Elevate the head of the bed at an angle of 30 degrees or more to prevent VAP
and aspiration.
Contraindications:
Unstable shocked patients eg requiring high dose inotropes or requiring fluid challenges
Unstable pelvic or spinal injury (it may be possible to tilt the whole bed)
Daily cessation of sedation and Awakening trial.

 Aim RASS score 0 to -2.
 Weaning trial to be carried out when readiness to wean assessment confirms
suitability.
 Combining daily sedation cessation followed by spontaneous breathing trials is
more effective than performing spontaneous breathing trial alone.
Contraindications:
Paralysed patients
Brain injury, sedated patients with possible ICP problems
Patients who is difficult to ventilate-coughing, asynchrony
Patient who is difficult to Oxygenate (FiO2 >.7 or >/PEEP 10)
Patients receiving therapeutic hypothermia
Patient receiving terminal/palliative care
Use of Chlorhexidine (0.12%-2%) as part of daily oral care (using the Oral Care Q
Care system).
 The oral cavity is to be assessed daily
 Oral care is to be provided every 4 hours and PRN
 Intubated patients will be assessed to determine the need for removal of
oropharyngeal secretions every 8 hrs as well as prior to repositioning the tube or
deflation of the cuff.
Contraindications:
Oropharyngeal trauma or surgery
Page 21 of 36
Known sensitivity to chlorhexidine
Subglottic secretion removal have lower rates of ventilator associated pneumonia

and can reduce the duration of mechanical ventilation. (Collard, 2003)
See VAP Guideline
Contraindications:
Intubated prior to ICU admission
Endotracheal tube with subglottic drainage not available in hospital
While it is unclear if there is any association between PUD prophylaxis and decreasing
rates of ventilator-associated pneumonia, it has been shown that when PUD prophylaxis
is applied as part of a package of interventions for ventilator care, the rate of pneumonia
decreases.
 Aspiration causes either pneumonitis or pneumonia and can be prevented.
 Critically ill patients who require mechanical ventilation are at increased risk for
gastrointestinal bleeding from stress ulcers
 Decreasing pH of gastric contents may protect against a greater pulmonary
inflammatory response to aspiration of gastrointestinal contents. The effects of
aspirating acidic contents may be worse than those with a higher pH.
 H2 receptor inhibitors are more effective in preventing stress ulcers.
Contraindication:
Avoid PUD prophylaxis in patients low risk for gastrointestinal bleed
While it is unclear if there is any association between DVT prophylaxis and

decreasing rates of ventilator-associated pneumonia, it has been shown that
when DVT prophylaxis is applied as part of a package of interventions for
ventilator care, the rate of pneumonia decreases.
Prophylaxis is recommended for patients undergoing surgery, trauma patients,
acutely ill medical patients, and patients admitted to the intensive care unit.
 All patients categorised low to high risk will has brevet stockings applied.
 Patients legs must be measured to ensure proper fitting.
 Pneumatic compression devices may be used in patients at high risk of DVT
 Low molecular weight heparin (LMWH)-use in medium and high risk patients or
Clexane (See OLOL Surgical policy)
 Ensure patient is hydrated
Contraindication for Stockings:

Skin disease
Recent skin graft
Gangrene
Deformity of the leg
Severe Peripheral Vascular Disease
Amputation
Severe Limb Oedema or lymphoedema
Operations on the limb
Patient with a calf measurement exceeding the available size.
Page 22 of 36
Contraindication for LWMH or Clexane:
Active bleeding
Acquired bleeding disorders (e.g Chronic liver disease)
Congenital bleeding disorders (e.g. haemophilia)
Acute head injury with intracranial haemorrhage
Abdominal Trauma with liver/spleen haematomas
Traumatic haematuria
Thrombocytopenia
Anticoagulants (e.g Warfarin)
Adapted from Sari Guidelines 2011 and the following research

 Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the
Seventh ACCP
Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sep
2004;126(3 Suppl):338S-400S.
 Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for
management of severe sepsis and septic shock. Crit Care Med. Mar
2004;32(3):858-873.
 www.ihi.com
Page 23 of 36
Appendix II
Page 24 of 36
Appendix II Weaning Guideline
Receiving Mechanical Ventilation
Treat underlying cause of respiratory

failure
Monitor weaning readiness criteria daily
Patient meets criteria
NO Return to previous
YES settings. Review in
24hrs
Spontaneous
awakening trial and
spontaneous breathing
trial
PASS?
YES
Meets NO
Has patient tracheotomy? extubation
NO criteria
YES
Place on tracheostomy mask
EXTUBATE
Page 25 of 36
Appendix III Weaning readiness assessment/weaning guideline
Assess patient for readiness to wean:

Resolution of acute disease for which pt was intubated
Adequate cough
Absence of excessive secretions
Hr<140bpm, systolic BP 90-160mmHg, no or minimal
vasopressors
SaO2 >90% on FiO2 <0.4
Peep <8cmH2O
RR <35/min
Peak airway pressure 20-25cmH2O
VT>5mls/kg
No significant respiratory acidosis
No or minimal sedation (Rass 0 to -3/stable neurological
pt.
Meet criteria?
Yes No
Calculate RSBI (RR/VT)

If RSBI <105 indicates readiness to wean
Terminate breathing trial if:
Yes RR>35/min for >5mins
SaO2 <90% for >2mins
HR>140bpm or sustained
Conduct SBT: Following change of +/-20% from baseline
anaesthetic approval Systolic BP <90 or >180mmHg
CPAP Pressure support or a change of 20% from
Peep 5 or below baseline
PSV 5-7 or below Increased anxiety or diaphoresis
FiO2 unchanged RSBI >105
After 1 min calculate RSBI. No

If RSBI<105, conduct SBT for 20-120mins
Page 26 of 36
No Return to previous setting. Re-evualate
Tolerated? Contact anaesthetist and discuss ABG in 24hrs. Consult anaesthetist
Ability to maintain patent airway No

Ability to protect airway
Ability to cough and clear secretions
If yes-EXTUBATE-
Page 27 of 36
Page 28 of 36
Appendix IV
Conditions associated with failure to wean
Load: Drive Capacity of
Respiratory Pump
Bronchospasm sedation/hypnotic Pain/discomfort
medication
Left-ventricular failure CNS disease Abdominal
distention/discomfort
Sepsis Hypercapnia Positioning
Fever metabolic alkalosis Diaphragmatic paralysis
Seizures Psychological Use of muscle
Dysfunction: relaxants
Excessive secretions anxiety/depression Muscle weakness
Hyperinflation delerium Neuropathy
Pleural sensory Diffuse atropathy
effusion/Pneumothorax overload/deprivation
Pulmonary oedema communication Nutrition-overweight/
undernourished
Myocardial dysfunction Motivation Rest/sleep
Self-esteem metabolic deficiencies
Page 29 of 36
Appendix V
Signature Sheet:
I have read, understand and agree to adhere to the attached Policy, Procedure,
Protocol or Guideline:
Date Name (Capital letters) Signature Employee No.
Page 30 of 36
Appendix V
Signature Sheet:
I have read, understand and agree to adhere to the attached Policy, Procedure,
Date Name (Capital letters) Signature Employee No.
Page 31 of 36
Appendix VI
Members of the Research and Development Group involved in developing
the Guideline.
Research and Development Group ICU/HDU
Caroline O Donnell CNM 2
Fionnuala Monaghan CNM 1
John Gilmore Staff Nurse
Page 32 of 36
Appendix VII
Members involved in reviewing the Guideline
Dr Dinesh Kuriakose (Anaesthetic Consultant)
Karen Clarke (CPC)
Dr Rosemary Moriarty (Anaesthetic Consultant)
Dr Catriona Murphy (Anaesthetic Consultant)
Dr James Freeman (Anaesthetic Registrar)
Agnes Corrigan (Physiotherapist)
Una Mulligan (Senior Dietician)
Maura Reynolds (Speech and Language Therapist)
Page 33 of 36
Appendix VI Peer Review of Guidance
Reviewer: The purpose of this statement is to ensure that a Policy,

Procedure, Protocol or Guideline (PPPG) proposed for implementation in the
HSE is circulated to a peer reviewer (internal or external), in advance of
approval of the PPPG. You are asked to sign this form to confirm to the
committee developing this Policy or Procedure or Protocol or Guideline that
you have reviewed and agreed the content and recommend the approval of
the following Policy, Procedure, Protocol or Guideline:
Title of Guideline
Weaning from Mechanical Ventilation; Intensive Care Unit; Our Lady of

Lourdes Hospital Drogheda
I acknowledge the following:
 I have been provided with a copy of the Policy, Procedure, Protocol or

Guideline described above.
 I have read the Policy, Procedure, Protocol or Guideline document.
 I agree with the Policy, Procedure, Protocol or Guideline and
recommend its approval by the committee developing the PPPG.
______________________ ________________ ___________

Name Signature Date
Please return this completed form to: Caroline O Donnell (CNM2)

ICU/HDU
Page 34 of 36
Appendix VII Key Stakeholders Review of Policy, Procedure, Protocol
or Guidance Reviewer Statement
Reviewer: The purpose of this statement is to ensure that a Policy,

Procedure, Protocol or Guideline (PPPG) proposed for implementation in the
HSE is circulated to Managers of Employees who have a stake in the PPPG,
in advance of approval of the PPPG. You are asked to sign this form to
confirm to the committee developing this Policy or Procedure or Protocol or
Guideline that you have seen and agree to the following Policy, Procedure,
Weaning from Mechanical Ventilation; Intensive Care Unit; Our Lady of

Lourdes Hospital Drogheda
I acknowledge the following:
 I have been provided with a copy of the Policy, Procedure, Protocol or

Guideline described above.
 I have read the Policy, Procedure, Protocol or Guideline document.
 I agree with the Policy, Procedure, Protocol or Guideline and
recommend its approval by the committee developing the PPPG
______________________ ________________ ___________

Name Signature Date
Please return this completed form to:
Caroline ODonnell (CNM2)
Page 35 of 36
Appendix Revision History Sheet:
Document Control No. - (Revision No. )
Section Changes Made
Page 36 of 36

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Our Lady of Lourdes

Weaning from Mechanical Ventilation

Intensive Care Unit

Our Lady of Lourdes Hospital Drogheda

Document Cli/Nurs/ICU001 Document Caroline O Donnell

Revision 0 Document Dr Dinesh Kuriakose

1.0 Policy Statement......................................................4

Members of the Research and Development Team

Dr Dinesh Kurikose (Anaesthetic Consultant)

2.1 The purpose of this guideline is to provide a standardised methodology for

2.2 This document has also been developed to:

Sari guidelines (2011) has emphasised the importance of reducing ventilator-

5.1 Clinical Audit

5.4 Evidence Based Practice

5.5 Healthcare Audit

5.9 Weaning from Mechanical Ventilation

6.0 Ventilaor Associated Pneumonia (VAP)

Mechanical Ventilation (MV) is a life-supporting modality and is deemed to be the

Through collaboration with the Anaesthetic team, Clinical education facilitator in

The protocol will be divided into four sections.

 Section one involves identifying patients who are ready to wean.

7.1.3 At 7:00-8:00am the patient will be assessed daily for spontaneous

7.1.5 Patients readiness to wean is determined by clinical assessment which

7.1.6 Furthermore, objective clinical measurements should be taken into

 Stable cardiovascular status-

7.1.7 Spontaneous breathing trial (SBT)

7.1.10 Maintain Nasogastric feeding rest period (0800-12pm).

7.1.11 Stop sedation as per sedation protocol (Spontaneous Awakening

7.1.12 Conduct Spontaneous Breathing Trial (SBT) for 1 minute on:

 Mode: CPAP +/- PS

7.1.13 After 1 minute, calculate RSBI. If RSBI<105, continue to conduct SBT

7.1.14 SBT to be terminated if patient demonstrates any of the following criteria:

7.1.15 Return to previous ventilator settings and consult physician.

7.1.17 Meets criteria- EXTUBATE

Prior to extubation ensure:

Post extubation ensure:

7.1.18 Fails criteria- Is reason for failure reversible? Once reversible

8.0 Management of the difficult to Wean Patient

Classification of weaning according to the weaning process

1. Simple weaning- Patients who proceed from initiation of weaning to

Unless there is evidence for clearly irreversible disease, a patient requiring

8.0 Difficult-to Wean Patients

8.2 It is recommended to use once daily spontaneous breathing trials. It allows

9.0 Prolonged Mechanical Ventilation (PMV)

Guidelines issued by a collective task force organized by the American College of

9.3 There is no preferred mode of mechanical ventilation between weaning

9.8 Communicate with physiotherapist regarding abdominal binder

9.9 If tracheostomy present graduated ventilator free breathing with trachy

9.13 The patient must be able to:

Tolerate decanulation cap for four hours or more breathing around

9.14 Adopt Supine position.

*NOTE see Guideline on Tracheostomy Care (2014) on Unit.

Optimizing Respiratory status during and between weaning trials

 Ventilator circuit — Ventilator circuit-related problems can increase

1 Alia I. & Esteban, A. (2000) Weaning from Mechanical Ventilation, Critical

Appendix I Ventilator Associated Pneumonia (VAP) Bundle

Appendix II Weaning Guideline Algorithm

Appendix III Weaning readiness assessment/Weaning

Appendix IV Conditions associated with failure to wean

Appendix V Signature Sheet

Appendix VI Members of the Research and Development Group

Appendix VII Members involved in the development of the Weaning

VAP Bundle Yes No

____________ _

____________ _