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ventilation weaning

Procedure: 1) considerations a) ability to clear secretions b) ability to protect airway c) no PEEP & reasonable arterial blood gas (ABG) for fiO2 <40% d) pH & pCO2 at baseline for COPD patients e) volume status - diuresis in patients with LV systolic dysfunction - diuresis guided by serial serum BNP [4] 2) parameters - tidal volume > 5 mL/kg - vital capacity >10 mL/kg or 1 liter - minute ventilation < 10 L/min - maximum voluntary ventilation > twice the minute ventilation - peak inspiratory pressure < -20 cm H2O 3) methods a) T-tube trial, T-mist trial b) IMV, SIMV c) pressure support - spontaneous breathing trials of 30 min-2 hr using pressure support of < 8 cm H20 can identify patients for extubation [5,11] 4) Failures a) increased ventilatory demands - increased CO2 production - sepsis - excess carbohydrates in diet - increased dead space b) inadequate ventilation - weak or discoordinated muscles - increased work of breathing - small endotracheal (ET) tube - bronchospasm - pulmonary edema - chronic CO2 retainer who has been hyperventilated on ventilator - adrenal insufficiency [2] - cosyntropin stimulation testing to identify - glucocorticoids may benefit this subset of patients 5) strategies - standardized scales to assess sedation needs hourly & titration of infusions accordingly as good (if not better than daily medication interruption) [3] - rapid shallow breathing index [5] - early extubation to noninvasive ventilation in patients with COPD, heart failure, or hypercarbia [5,6,8] - lowers mortality (RR=0.53) [6] - lowers risk of weaning failure (RR=0.63) [6] - lowers risk of ventilator-associated pneumonia (RR=0.25) - lowers length of stay in ICU & hospital [6]

Related

endotracheal extubation mechanical ventilation (assisted ventilation) rapid shallow breathing index spontaneous breathing trial (SBT)

General

clinical procedure

References

  1. Jon D. Hirasuna, M.D. Clinical Professor of Medicine, UC Davis, Associate Clinical Professor of Medicine, UCSF, Sept 1997
  2. Huang CJ, Lin HC. Association between adrenal insufficiency and ventilator weaning. Am J Respir Crit Care Med. 2006 Feb 1;173(3):276-80. Epub 2005 Nov 4. PMID: 16272449
  3. Mehta S et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: A randomized controlled trial. JAMA 2012 Oct 17 PMID: 23180503 http://jama.jamanetwork.com/article.aspx?articleid=1380160
  4. Dessap AM et al. Natriuretic peptide-driven fluid management during ventilator weaning: A randomized controlled trial. Am J Respir Crit Care Med 2012 Dec 15; 186:1256 PMID: 22997204
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018.
  6. Burns KEA et al. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: A Cochrane systematic review. CMAJ 2014 Feb 18; 186:E112 PMID: 24324020
  7. McConville JF, Kress JP Weaning patients from the ventilator. N Engl J Med. 2012 Dec 6;367(23):2233-9. PMID: 23215559
  8. Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2013 Dec 9;12:CD004127. Review. PMID: 24323843
  9. Nava S, Ambrosino N, Clini E et al Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998 May 1;128(9):721-8. PMID: 9556465
  10. Schmidt GA, Girard TD, Kress JP et al Liberation From Mechanical Ventilation in Critically Ill Adults: Executive Summary of an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest. 2017 Jan;151(1):160-165. PMID: 27818329
  11. Subira C, Hernandez G, Vazquez A et al. Effect of pressure support vs T-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: A randomized clinical trial. JAMA 2019 Jun 11; 321:2175. PMID: 31184740 https://jamanetwork.com/journals/jama/fullarticle/2735502 - Girard TD, Burns KEA. Revisiting, reframing, and casting a new light on liberation from mechanical ventilation. JAMA 2019 Jun 11; 321:2167. PMID: 31184723 https://jamanetwork.com/journals/jama/fullarticle/2735481