Weaning from Mechanical Ventilation

Slides:



Advertisements
Similar presentations
Neonatal Mechanical Ventilation
Advertisements

Basics of Mechanical Ventilation
Mechanical ventilation
The Map Between Lung Mechanics and Tissue Oxygenation The Map Between Lung Mechanics and Tissue Oxygenation.
Occlusion Pressure P0.1. Special Procedure Negative airway pressure generated during the first 100 ms of an occluded inspiration P0.1 values reflect neuromuscular.
CPAP/PSV.
Weaning Modes and Protocol
1 Pre-ICU Training CHEST Mechanical Ventilatory Support 2008/6/20.
Mechanical Ventilaton Ramon Garza III, M.D.. Indications Airway instability Most surgical patients or trauma Primary Respirator Failure Mostly medical.
Respiratory Failure/ ARDS
Educational Resources
“… an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the.
Guidelines for Weaning From Short-Term Ventilation
Mechanical Ventilation in the Neonate RC 290 CPAP Indications: Refractory Hypoxemia –PaO2 –Many hospitals use 50% as the upper limit before changing.
Introduction to Mechanical Ventilation
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Chapter 47 Discontinuing Ventilatory Support.
Chapter 47 Discontinuing Ventilatory Support. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Objectives  List factors.
Sahar Elkaradawy Assistant Professor in Anaesthesia and Intensive Care Unite.
Accelerated Ventilator Weaning Guideline A path to excellence! Click Here A path to excellence! Click Here.
Pressure support ventilation Dr Vincent Ioos Pulmonologist and Intensivist Medical ICU, PIMS 1st International Conference Pulmonology and Critical Care.
Supplemental Oxygen & Ventilators
J. Prince Neelankavil, M.D.
ICU 101 a.k.a. “Papers You Should Know” Ashley Henderson, MD May 4, 2010.
Mechanical Ventilation Tariq Alzahrani M.D Assistant Professor College of Medicine King Saud University.
Objectives Discuss the principles of monitoring the respiratory system
Copyright 2008 Society of Critical Care Medicine Mechanical Ventilation 2.
Principles of Mechanical Ventilation
Ventilator Check It’s a thorough process that should take longer than 2 minutes!
Ventilation / Ventilation Control Tests
Noninvasive Oxygenation and Ventilation
Building a Solid Understanding of Mechanical Ventilation
Mechanical Ventilation BY: Jonathan Phillips. Introduction Conventional mechanical ventilation refers to the delivery of full or partial ventilatory support.
Protective Lung Strategy Mazen Kherallah, MD, FCCP
1 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 19 Mechanical Ventilation of the Neonate and Pediatric Patient.
Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano Disclosure: none Management of native lung on ECMO.
Dr Chaitanya Vemuri Int.Med M.D Trainee.  The choice of ventilator settings – guided by clearly defined therapeutic end points.  In most of cases :
Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 45 Respiratory Failure.
Effect of different cycling off criteria and positive end-expiratory pressure during pressure support ventilation in patients with chronic obstructive.
Weaning and Discontinuation of Ventilatory Support
Emídio Lima MD, PhD. Mortality Increases with the Duration of Mechanical Ventilation and Weaning Failure.
Spontaneous Awakening and Breathing Trials Brad Winters MD, PhD March 14, 2013.
Mechanical Ventilation Khaled Hadeli, M.D.. History.
นพ. ธรรมศักดิ์ ทวิช ศรี หน่วยเวชบำบัด วิกฤต ฝ่ายวิสัญญีวิทยา รพ. จุฬาลงกรณ์
Discontinuation and Weaning from Mechanical Ventilation
 Understand the different breath types with SIMV  Know the Phase variables of the different breath types: trigger/limit/cycle  Know the breath sequence.
Principles of Mechanical Ventilation RET 2284 Module 7.0 Discontinuation From Mechanical Ventilation.
Mechanical Ventilation 1
WEANING The Discontinuation of Ventilatory Support By Adriana Adams and Cesar Mancillas.
Mechanical Ventilation 101
3 nd LECTURE VENTILATORS Part One. Ventilators One of the major life support systems. Ventilators take over the vital role of the respiratory muscles.
 Understand the dual control concept  Understand the pressure regulation mechanism in PRVC  Demonstration of PRVC  Settings and adjustment with Servo.
APPROACH TO ASSESSMENT AND WEANING OFF THE MECHANICAL VENTILATOR AT THE BEDSIDE DR. MUNIRA DILAWER GHEEWALA.
Cenk Kirakli, MD ; Ilknur Naz, PT, MS ; Ozlem Ediboglu, MD ; Dursun Tatar, MD ; Ahmet Budak, MD ; and Emel Tellioglu, MD A Randomized Controlled Trial.
Principles of Mechanical Ventilation Mazen Kherallah, MD, FCCP.
Principles of Mechanical Ventilation Mazen Kherallah, M.D., FCCP Internal Medicine, Critical Care Medicine, and Infectious Diseases Initial Ventilatory.
PRESSURE CONTROL VENTILATION
“Top Twenty” Session Review for Mechanical Ventilation Concepts What you should remember from the Fall… RET 2264C-12.
John F. McConville, M.D., and John P. Kress, M.D. New England Journal of Medicine (2012) December Vol. 367 Weaning Patients from the Ventilator Journal.
Weaning From Mechanical Ventilation
Dr. Shelly Zubert FRCPC Emergency Medicine Fellow Critical Care Medicine Jan 17 – Jan 31, 2011 University of Manitoba Canada Liberation from Mechanical.
Mechanical Ventilation
Principles of Mechanical Ventilation Magdy M Khalil, MD, EDIC Prof. Pulmonary& Critical Care Medicine.
Interrelationship between the duration of a spontaneous breathing trial, tension-time index of the diaphragm, and predicted time to task failure in 9 patients.
Weaning From The Ventilator
APPROACH TO ASSESSMENT AND WEANING AT THE BED SIDE
Mechanical Ventilation
Mechanical ventilation .
Meets all Extubation Criteria
Flow chart of pressure support test and spontaneous breathing trial (SBT). Flow chart of pressure support test and spontaneous breathing trial (SBT). The.
Running title: NAVA may reduce weaning duration from mechanical ventilation A randomized controlled trial to compare Neurally adjusted ventilatory assist.
Presentation transcript:

Weaning from Mechanical Ventilation Mazen Kherallah, MD, FCCP Consultant Intensivist King Faisal Specialist Hospital & Research Center Assistant Professor University of North Dakota, USA www.icumedicus.com mkherallah@msn.com 1 1 1 1 1 1

Objectives Discuss physiologic variables that are used to indicate readiness to wean from mechanical ventilation Contrast the approaches used to wean patients from mechanical ventilation Discuss the use of protocols to wean patients from ventilatory support Discuss the criteria used to indicate readiness for extubation Describe the most common reasons why patients fail to wean from mechanical ventilation

Introduction 75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process 10-15% of patients require a use of a weaning protocol over a 24-72 hours 5-10% require a gradual weaning over longer time 1% of patients become chronically dependent on MV

Readiness To Wean Improvement of respiratory failure Absence of major organ system failure Appropriate level of oxygenation Adequate ventilatory status Intact airway protective mechanism (needed for extubation)

Oxygenation Status PaO2 ≥ 60 mm Hg FiO2 ≤ 0.40 PEEP ≤ 5 cm H2O

Ventilation Status Intact ventilatory drive: ability to control their own level of ventilation Respiratory rate < 30 Minute ventilation of < 12 L to maintain PaCO2 in normal range VD/VT < 60% Functional respiratory muscles

Intact Airway Protective Mechanism Appropriate level of consciousness Cooperation Intact cough reflex Intact gag reflex Functional respiratory muscles with ability to support a strong and effective cough

Function of Other Organ Systems Optimized cardiovascular function Arrhythmias Fluid overload Myocardial contractility Body temperature 1◦ degree increases CO2 production and O2 consumption by 5% Normal electrolytes Potassium, magnesium, phosphate and calcium Adequate nutritional status Under- or over-feeding Optimized renal, Acid-base, liver and GI functions

Predictors of Weaning Outcome Value Evaluation of ventilatory drive: P 0.1 < 6 cm H2O Ventilatory muscle capability: Vital capacity Maximum inspiratory pressure > 10 mL/kg < -30 cm H2O Ventilatory performance Minute ventilation Maximum voluntary ventilation Rapid shallow breathing index Respiratory rate < 10 L/min > 3 times VE < 100 < 30 /min

Maximal Inspiratory Pressure Pmax: Excellent negative predictive value if less than –20 (in one study 100% failure to wean at this value) An acceptable Pmax however has a poor positive predictive value (40% failure to wean in this study with a Pmax more than –20)

Frequency/Volume Ratio Index of rapid and shallow breathing RR/Vt Single study results: RR/Vt>105 95% wean attempts unsuccessful RR/Vt<105 80% successful One of the most predictive bedside parameters.

Measurements Performed Either While Patient Was Receiving Ventilatory Support or During a Brief Period of Spontaneous Breathing That Have Been Shown to Have Statistically Significant LRs To Predict the Outcome of a Ventilator Discontinuation Effort in More Than One Study*

Refertences 2 Tobin MJ, Alex CG. Discontinuation of mechanical ventilation. In: Tobin MJ, ed. Principles and practice of mechanical ventilation. New York, NY: McGraw-Hill, 1994; 1177–1206 4 Cook D, Meade M, Guyatt G, et al. Evidence report on criteria for weaning from mechanical ventilation. Rockville, MD: Agency for Health Care Policy and Research, 199910 Lopata M, Onal E. Mass loading, sleep apnea, and the pathogenesis of obesity hypoventilation. Am Rev Respir Dis 1982; 126:640–645 16 Hansen-Flaschen JH, Cowen J, Raps EC, et al. Neuromuscular blockade in the intensive care unit: more than we bargained for. Am Rev Respir Dis 1993; 147:234–236 18 Bellemare F, Grassino A. Effect of pressure and timing of contraction on human diaphragm fatigue. J Appl Physiol 1982; 53:1190–1195 20 Roussos C, Macklem PT. The respiratory muscles. N Engl J Med 1982; 307:786–797 24 Le Bourdelles G, Viires N, Boezkowski J, et al. Effects of mechanical ventilation on diaphragmatic contractile properties in rats. Am J Respir Crit Care Med 1994; 149:1539–1544

Approaches To Weaning Spontaneous breathing trials Pressure support ventilation (PSV) SIMV New weaning modes

Do Not Wean To Exhaustion

Spontaneous Breathing Trials SBT to assess extubation readiness T-piece or CPAP 5 cm H2O 30-120 minutes trials If tolerated, patient can be extubated SBT as a weaning method Increasing length of SBT trials Periods of rest between trials and at night

Frequency of Tolerating an SBT in Selected Patients and Rate of Permanent Ventilator Discontinuation Following a Successful SBT* *Values given as No. (%). Pts patients. †30-min SBT. ‡120-min SBT.

Criteria Used in Several Large Trials To Define Tolerance of an SBT* *HR heart rate; Spo2 hemoglobin oxygen saturation. See Table 4 for abbreviations not used in the text.

Pressure Support Gradual reduction in the level of PSV PSV that prevents activation of accessory muscles Gradula decrease on regular basis (hours or days) to minimum level of 5-8 cm H2O Once the patient is capable of maintaining the target ventilatory pattern and gas exchange at this level, MV is discontinued

SIMV Gradual decrease in mandatory breaths It may be applied with PSV Has the worst weaning outcomes in clinical trials Its use is not recommended

New Modes Volume support Automode MMV ATC

Protocols Developed by multidisciplinary team Implemented by respiratory therapists and nurses to make clinical decisions Results in shorter weaning times and shorter length of mechanical ventilation than physician-directed weaning

Mechanical Ventilation > 100 Rest 24 hrs PaO2/FiO2 ≥ 200 mm Hg PEEP ≤ 5 cm H2O Intact airway reflexes No need for continuous infusions of vasopressors or inotrops RSBI Daily SBT <100 Yes Stable Support Strategy Assisted/PSV 24 hours Low level CPAP (5 cm H2O), Low levels of pressure support (5 to 7 cm H2O) “T-piece” breathing RR > 35/min Spo2 < 90% HR > 140/min Sustained 20% increase in HR SBP > 180 mm Hg, DBP > 90 mm Hg Anxiety Diaphoresis 30-120 min Extubation No

Failure to Wean Weaning to exhaustion Auto-PEEP Excessive work of breathing Poor nutritional status Overfeeding Left heart failure Decreased magnesium and phosphate leves Infection/fever Major organ failure Technical limitation

Weaning to Exhaustion RR > 35/min Spo2 < 90% HR > 140/min Sustained 20% increase in HR SBP > 180 mm Hg, DBP > 90 mm Hg Anxiety Diaphoresis

Work-of-Breathing High airway resistance Low compliance Pressure= Volume/compliance+ flow X resistance High airway resistance Low compliance Aerosolized bronchodilators, bronchial hygiene and normalized fluid balance assist in normalizing compliance, resistance and work-of-breathing

Auto-PEEP Increases the pressure gradient needed to inspire Use of CPAP is needed to balance alveolar pressure with the ventilator circuit pressure Start at 5 cm H2O, adjust to decrease patient stress Inspiratory changes in esophageal pressure can be used to titrate CPAP

Gradient -5 -5

Gradient Auto PEEP +10 -5 -15

PEEP 10 Gradient Auto PEEP +10 5 -5

Left Heart Failure Increased metabolic demands that are associated with the transition from mechanical ventilation to spontaneous breathing Increases in venous return as that is associated with the negative pressure ventilation and the contracting diaphragm which results into an increase in PCWP and pulmonary edema Appropriate management of cardiovascular status is necessary before weaning will be successful

Nutritional/Electrolytes Imbalance of electrolytes causes muscular weakness Nutritional support improves outcome Overfeeding elevates CO2 production due to excessive carbohydrate ingestion

Infection/Fever/Organ Failure Organ failure precipitate weaning failure Infection and fever increase O2 consumption and CO2 production resulting in an increase ventilatory drive

Points to Remember The primary prerequisite for weaning is reversal of the indication of mechanical ventilation Adequate gas exchange should be present with minimal oxygenation and ventilatory support before weaning is attempted The function of all organ systems should be optimized, electrolytes should be normal, and nutrition should be adequate before weaning is attempted The most successful predictor of weaning is RSBI < 100 Maximum inspiratory pressure is the best predictor of weaning failure Ventilatory discontinuation should be done if patient tolerates SBT for 30-120 minutes Patients who fail an SBT should receive a stable, non-fatiguing, comfortable form of ventilatory support Use of liberation and weaning protocol facilitates the process and decreases the ventilator length of stay