WEANING

• Goal of weaning
– Extubation / decanulation
– Removal from positive ventilation
• Numerous methods of weaning
• Challenge – patients who fails to weaning
Discontinuation of respiratory support
• Method used to achieve permanent
• discontinuation depend on :
• Why the patients was intubated
• For how long the patients were on MV
• How much sedation given to the patients
 Why weaning
• Patients on MV are at risk of
– Nosocomial infection
– Barotrauma , Volutrauma , Atelectrauma ,
Biotrauma
– Airway trauma
– Need sedation
• Increased cost
 Premature extubation
• Loss airway protection – aspiration
• Hypoxemia
• Sympathetic discharge – Cardiovascular stress
• Muscular fatigue
• Acidosis
• Reintubation into an oedematous airway
Indications for weaning and extubation:
1. The patient is able to ventilate
2. The patient is able to oxygenate
3. The patient is able to protect his/her airway
Is the Patient able to Ventilate?
Alveolar ventilation is adequate to keep the PaCO2 <
50 mmHg. The production of CO2 can be controlled
by reducing the carbon load in the diet (high fat), and
minimize agitation, pain, fever, shivering and muscle
workload.
Is the patient able to oxygenate?

1. It is essential to minimize the amount of lost

oxygenation due to diffusion abnormalities, ventilation-
perfusion mismatch, dead space and shunt.
2. Certain factors may limit successful weaning –
persistent lower respiratory tract infection,
alveolar edema, airway/lobar collapse, lung fibrosis.
3. Good quality physical therapy is required to mobilize
secretions - the commonest cause of airway collapse is
absorption atelectasis, distal to mucus plugs.
Re-expansion of collapsed lung units requires
considerable work, particularly in patients with depleted
reserve.
 Adequate oxygenation (eg, PO2 >60 mm Hg
Objective measurements on FIO2 > 0.4; PEEP <5–10 cm H2O; PO2/FIO2
>150–300);

Stable cardiovascular system (eg, HR <140;

stable BP; no (or minimal) pressors)

Afebrile (temperature < 38°C)

No significant respiratory acidosis

Adequate hemoglobin (eg, Hgb >8–10 g/dL)

Adequate mentation (eg, arousable, GCS

>13, no continuous sedative infusions)

Stable metabolic status (eg, acceptable

* Hgb = hemoglobin; HR = heart rate; GCS = Glasgow coma score.
electrolytes)

Resolution of disease acute phase;

Subjective clinical assessments
physician believes discontinuation possible;
adequate cough
 Weaning strategy
• Improved oxygenation
• Increased respiratory capacity
• Decreased Ventilatory demand
 Weaning / Discontinuation :
Spontaneous Breathing Trials
• Putting the patient on a minimum pressure
support and PEEP (for example 5-7cmH2O
PS/5cmH2O PEEP performing mechanics and
extubating),
• using CPAP alone,
• using a T-piece.
 Weaning / Discontinuation :
Spontaneous Breathing Trials
• The conventional wisdom is that 7cmH2O of
pressure support is required to overcome the
resistance through a size 7.5mm (internal
diameter) endotracheal tube, and 3cmH2O
through a tracheostomy. If a smaller tube is in
place, pressure support of 10cmH2O is
required.
• If the patient tolerates a spontaneous
breathing trial with any of these modes, then
one should proceed to extubation.
General measures:
Ensure the patient is suitable for weaning
1. Conduct wean to extubation (spontaneous breathing) trials early in
the morning, when the patient is fully rested and there is a full
compliment of staff available.
2. During these trials the patient should be awake and co-operative,
apyrexial and on minimal pressor support (vasopressors are not a
contraindication to extubation, although they are a sign that the
patient may still require pulmonary support).
3. Place the patient in the upright or semi-upright position and explain
what you are attempting to do.
4. Check for a cuff leak by deflating the cuff and occluding the ett. The
absence of a cuff leak is not a contraindication to extubation, as the
tube may be snug with the trachea, but should alert the physician to
the possibility of laryngeal edema.
5. Suction out the tube, airway and oropharynx.
FACTORS THAT MAY INTERFERE WITH
WEANING:

1. Neurological
2. Muscular
3. Anatomical problem ( Airway , Chest wall ,
abdominal
Other Factors influencing Weaning
Algorithm
for weaning
Which ones should be weaned first
?
• FiO2 < 50 %
• Mean Airway Pressure
• PEEP
• Respiration rate as tolerated ( if using SIMV )
 Key points – the least you need to
know
• Removing a patient from a ventilator involves
discontinuation of mechanical ventilation and
extubation.
• There are two parts to weaning: weaning to
partial ventilator support and weaning to
discontinuation. There is little evidence that
partial modes are more effective than T-piece
trails. Of these modes, pressure support is the
best.
• The single most traumatic event for the
 Key points – the least you need to
know
• To extubated a patient, they need to be
awake, able to cough and protect their airway.

• 5. If it is possible to wean a patient to

extubation, but the patient cannot protect
his/her airway, it is best to perform
tracheotomy

• 6. Although the ventilator only appears to

support on organ system, the lungs, this is not
 Key points – the least you need to
know

• For a patient to self ventilate, many body

systems must be functioning: the
cardiopulmonary apparatus, the central
nervous system, the nerves that supply the
diaphragm (including the neuromuscular
junctions), the muscles themselves. Moreover
the patient must be willing to breath and
maintain their own functional residual
capacity (not if there is diaphragmatic
 Key points – the least you need to
know
• To overcome these problems, a holistic
approach must be adopted. Muscles must be
trained and nourished, and patient-ventilator
interaction encouraged.
• The most effective method of weaning to
discontinuation is spontaneous breathing
trials (SBT).
• One must determine suitability for SBTs before
commiting to them.
 Key points – the least you need to
know
• 12. If a patient fails an SBT, then it is important
to look for the reason and reverse it. SBTs
should not be performed more than once
daily.
• 13. A reintubation rate of 10% is acceptable.
Patients deserve a trial of extubation, and
many will do well in spite of poor mechanics
(you must use clinical judgment).