36 Nursing2006, Volume 36, Number 9 www.nursing2006.com

mechanical ventilationWeaningpatients from

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PATIENTS RECEIVE mechanicalventilation for many reasons andfor varying lengths of time. Someneed ventilatory support for only afew hours; others need it forweeks, months, or even years.

In this article, I’ll focus on yourrole in caring for patients at twoextremes of the ventilatory supportweaning continuum: those who canbe considered for rapid weaningand those who are difficult to wean.But before considering these specialsituations, let’s review some basicsabout mechanical ventilation.

Reviewing ventilatory supportMechanical ventilation is indicatedwhen the body can’t meet its oxy-gen demand through spontaneousbreathing or when the body can’tadequately remove carbon dioxide(CO2). Various conditions canincrease the oxygen demand, suchas abnormalities in the respiratorysystem, neuromuscular disease, orcardiovascular system failure.

Mechanical ventilation aims toprovide adequate ventilatory sup-port to meet the patient’s oxygendemands without harming thepatient. Ventilation is delivered viaan artificial airway: an oral or nasalendotracheal tube or a surgically

placed tracheostomy tube.Tidal volume and frequency,

supplemental oxygen (FIO2), modeof ventilation, pressure support,and positive end-expiratory pres-sure (PEEP) are set on the ventila-tor. The patient may need a seda-tive or analgesic to control anxietyor pain and may also receive intra-venous fluid and nutritional sup-port. These interventions aredesigned to let the body recover,heal, and regenerate if possible. Ifthe patient recovers well enough toresume spontaneous breathing,weaning begins.

Some patients, such as thosewith acute heart failure and chron-ic obstructive pulmonary disease(COPD), may need just a fewhours of mechanical ventilationwhile being treated for heart fail-ure. For other patients, such aspremature babies or burn victims,weaning may not occur until afterdays or weeks of ventilatory sup-port. A baby’s immature lungs needtime to develop well enough tosupport spontaneous ventilation.The burn victim may need time forthe airways to heal or require fullsupport while his body recoversfrom the burn.

Some patients have trouble being

weaned from ventilatory support.When weaning is attempted, thesepatients can’t maintain spontaneousbreathing and continue to needsome degree of ventilatory support.For example, a patient with a neu-rologic injury and paralysis of thediaphragm may make some pro-gress at weaning, but not enough tobe totally free from mechanical sup-port. This patient may require mini-mal ventilation (or perhaps night-time only support).

For some patients, weaning isn’tan option because the injury, dis-ease, or system failure is too greatto overcome. These patientsremain mechanically ventilated forthe rest of their lives.

When to use rapid weaningThe rapid-wean approach is gen-erally reserved for patients with-out pulmonary disease who wereplaced on mechanical ventilationto treat an acute or postoperativecondition that’s expected torespond quickly to treatment. Theformal rapid-wean approach,which has the patient off the ven-tilator in 6 to 8 hours, is typicallyused for patients who’ve hadopen-heart surgery for coronaryartery bypass graft surgery or a

www.nursing2006.com Nursing2006, September 37

ventilationLearn to meet two common challenges: facilitating rapid weaning and helping patients who are difficult to wean from mechanical ventilation.

BY BILL PRUITT, RRT, AE-C, CPFT, MBA

2.5ANCC/AACN

CONTACT HOURS

valve repair or replacement. Mostother postoperative patients areweaned and extubated in theoperating room as soon as anes-thesia wears off (or is reversed).In essence, these patients undergoa rapid-wean procedure under thecare of the anesthesia staff beforebeing moved to the postanesthe-sia care unit.

For this article, I’ll discuss arapid-wean approach in the settingof an intensive care unit (ICU)with patients who’ve had open-heart surgery. Keep in mind thatthis approach relies on the use of aprotocol and must be initiated byphysician order.

For open-heart-surgery patients,a rapid-wean strategy has severalbenefits. Early extubation reduceslength of stay in the ICU and inthe hospital, reduces the risk ofventilator-associated pneumonia(VAP), and lowers the cost of care.Cardiac surgery, an expensive pro-cedure, is performed on more than500,000 patients each year in theUnited States. If rapid weaninggoes as planned, weaning andextubation is accomplished withfew or no problems for most ofthese patients. But if patients aremoved too quickly in being weanedand extubated and have to be rein-tubated, or suffer from other com-plications related to early weaningor extubation, they could require alonger length of stay, incur addedhealth care costs, and face a higherrisk of VAP or even death.

These three considerations arekey to the success of rapid wean-ing.

1. Choosing appropriatepatients to wean quickly. Therapid-weaning protocol shoulddetail which patients are candi-dates, based on hemodynamic,neurologic, and respiratory para-meters. (For details, see Samplerapid-weaning protocol.)

A key feature to weaning is thespontaneous breathing trial. Apatient who’s met all the readinesscriteria is placed on a T-piece. A

38 Nursing2006, Volume 36, Number 9 www.nursing2006.com

Sample rapid-weaning protocol

n 1. Initiate postoperative mechanical ventilation using ventilator settingsordered by the anesthesia provider.n 2. Obtain arterial blood gas (ABG) analysis 20 minutes after initiation ofmechanical ventilation. Correlate ABG results with pulse oximeter and end-tidal carbon dioxide (ETCO2) values. n 3. Nurse or respiratory therapist assesses patient and documents his readi-ness to begin weaning. Criteria are:• appropriate level of consciousness (alert, oriented, follows commands)• hemoglobin level greater than 9 grams/dL, electrolyte levels within normallimits, and temperature of 36° C to 38° C (96.8° F to 100.4° F)• key ABG values within normal limits (pH, 7.3 to 7.5; PaCO2, 30 to 50 mm Hg;PaO2 greater than 70 mm Hg, SaO2 of 92% or greater)• ETCO2 less than 40 mm Hg• FIO2 less than 0.5 and total patient/ventilator respiratory rate (the sum of themechanical ventilator breaths and spontaneous breaths) less than 30 breaths/minute.n 4. Decrease intermittent mandatory ventilation (IMV) rate by 2 breaths/minute when the patient is awake and alert, responding appropriately, andassisting the ventilator and his SpO2 is greater than 92%, ETCO2 is less than 40 mm Hg, and hemodynamic values are acceptable. Acceptable hemodynam-ic values are: heart rate less than 120 beats/minute with no serious arrhyth-mias, BP greater than 100 mm Hg systolic, pulmonary capillary wedge pres-sure less than 18 mm Hg, cardiac index greater than 2 liters/minute/m2

without intra-aortic balloon pump therapy, and chest tube drainage less than100 mL/hour.n 5. If the patient is stable 15 to 30 minutes after the IMV rate is changed,continue decreasing the IMV rate by 2 breaths/minute every 15 to 30 minutesas long as the patient’s SpO2 stays above 92%, his ETCO2 is less than 40 mm Hg, and his hemodynamic values are acceptable. Stop when the IMVrate equals 2 breaths/minute.n 6. Titrate the FIO2 to 0.4 in increments of 0.05 to 0.1 as long as the patient’sSpO2 is above 92%.n 7. If the patient is receiving positive end-expiratory pressure (PEEP) of morethan 5 cm H2O, decrease PEEP by 5 cm H2O every 30 minutes until PEEP isequal to 5 cm H2O, as long as the patient’s SpO2 is above 92%.n 8. Obtain an ABG analysis as needed and notify the physician or anesthesiaprovider if the patient’s SpO2 falls below 92% or ETCO2 rises above 40 mm Hgor if he shows any signs of agitation or distress. n 9. Discontinue weaning if the patient can’t maintain acceptable hemo-dynamic, neurologic, or respiratory parameters. Return to previous ventilatorsettings and notify the physician.n 10. When the IMV rate equals 2 breaths/minute, obtain an ABG analysisand correlate the results with the patient’s SpO2 and ETCO2 values. Obtain lungfunction tests; the patient’s tidal volume should be greater than 5 cc/kg, spon-taneous respiratory rate between 8 and 30 breaths/minute, vital capacitygreater than 15 cc/kg, minute ventilation less than 10 liters/minute, and maxi-mal inspiratory pressure less than -20 cm H2O. If readiness to wean criteria,hemodynamics, and lung mechanics criteria are met, place the patient on a T-piece at the current FIO2 and perform a spontaneous breathing trial.n 11. Obtain an ABG analysis if the patient tolerates the spontaneous breath-ing trial for 30 minutes (as evidenced by his ability to stay on the T-piece withacceptable neurologic, hemodynamic, and respiratory parameters).n 12. If the ABG results meet acceptable criteria, the patient will be extubat-ed. Place him on supplemental oxygen at 5 to 6 liters/minute via nasal cannu-la. Maintain his Spo2 over 92%. While he’s awake, have him use an incentivespirometer every hour.

low level of PEEP (for example, 5 cm H2O) and low levels of pres-sure support (5 to 7 cm H2O) maybe used during the spontaneousbreathing trial.

2. Careful use of analgesiaand anesthesia. Once standard,high doses of opioids (for exam-ple, more than 20 mcg/kg of fen-tanyl) are now giving way to low-dose opioids (for example, 20mcg/kg or less of fentanyl), short-acting opioids, and use of hyp-notic agents for anesthesia duringcardiac surgery, without signifi-cantly increasing the rate of rein-tubation. Using lower doses andshort-acting agents results infewer problems with depressedrespiratory drive.

3. Effective, efficient use of awell-designed protocol. Protocolsfor patients who’ve had open-heartsurgery should be designed to safe-ly reduce ventilatory support whilemaintaining stable hemodynamicvalues, adequate oxygenation andelimination of CO2, and acceptableor appropriate neurologic status. Amultidisciplinary approach involv-ing physicians, nurses, and respira-tory therapists is essential whendeveloping, testing, implementing,and evaluating the protocol.

A protocol-based weaningprocess directed by nurses and res-piratory therapists has been foundmore effective than physician-directed weaning because thenurse and respiratory therapist areat the bedside and can make moretimely changes while weaning.

Why weaning can be difficultPatients who’ve been receivingmechanical ventilation for a pro-longed time may have many barri-ers to overcome in order to wean.When going into this process, thehealth care team must take intoconsideration the reason mechani-cal ventilation was initiated andevaluate whether this has been cor-rected. Then they can address theprolonged effects of mechanicalventilation. Most patients who are

difficult to wean have problems inone or more of the following areas.• Neurologic problems. Ventilatordependence may involve problemsin the brainstem from stroke, trau-ma, or brain tumors; damage fromexcessive sedation or opioid use;or malfunction in nervous systemconduction of impulses to the res-piratory muscles due to nervedamage from trauma or disease. Inrare cases, these obstacles can beovercome or reversed by medicaltreatment or by the body’s ownhealing and reprogrammingprocess. Otherwise, these patientswill remain on mechanical ventila-tion for the rest of their lives. Evenso, caregivers can work to reducemechanical support and supple-mental oxygen as much as possi-ble while providing the best quali-ty care.• Inability to carry the respira-tory load. This may be related torespiratory muscle fatigue fromexcessive work of breathing(which may be imposed by theventilator or by the artificial air-way), muscle atrophy from inactiv-ity, or muscle damage from traumaor surgery. Bronchospasm or exces-sive secretions may also be factors.Patients with hyperinflated lungsdue to air trapping, which oftenoccurs with COPD, have flatteneddiaphragms that compromise theeffectiveness of inspiratory efforts.

How can the ventilator or artifi-cial airway increase the work ofbreathing? If the ventilator circuitcontains rain out (a collection ofwater in the low points) or the heatand moisture exchangers (HME)are clogged, the ventilator is lesssensitive to the patient’s efforts tobreathe. If the patient tries to trig-ger a breath and the machinedoesn’t respond, the patient’s workof breathing increases. Some olderventilators may not respond rapid-ly to a high respiratory rate, thusmissing delivery of a breath.

In addition, some ventilatorsmay not end the inspiratory flow atan appropriate point, resulting in a

breath that’s shorter or longer thanthe patient’s desired inspiration.This may cause the patient tobreathe out of synchronizationwith the ventilator, increasing hiswork of breathing. Other factorsthat increase the work of breathinginclude artificial airways that aretoo small, too long (which tend tokink), or in a position that allowsthe patient to bite down andocclude the lumen. Correctingproblems like these can relievemuscle fatigue, reduce the work ofbreathing, and improve thepatient’s ability to carry the respira-tory load. • Metabolic factors, such as inad-equate nutrition and electrolyteimbalances. Patients who havechronic CO2 retention from COPDhave respiratory acidosis compen-sated by bicarbonate retention.Sometimes these patients are over-ventilated during mechanical ven-tilation, which causes excessivebicarbonate excretion as the CO2is blown off. The result is a meta-bolic imbalance that may interferewith weaning. Kidney failure also may contribute to metabolicimbalances that interfere withweaning.• Inadequate oxygenation.Failure of the lung-to-cell oxygendelivery process may result fromlow blood oxygen content, inade-quate cardiac output, or impairedoxygen uptake in the cell becauseof sepsis. Physical assessment, labvalues, or chest X-rays often revealcauses for oxygenation problemsthat delay or interfere with wean-ing. Examples include anemia,ventilation-perfusion abnormalitiesdue to atelectasis, infections suchas pneumonia, shock, and pul-monary embolism.• Cardiovascular limitations.Excessive fluid in the body andineffective cardiac emptying canresult in heart failure, whichimpedes weaning. Conversely, pos-itive pressures in the thorax gener-ated by the ventilator may reducevenous return to the heart and

www.nursing2006.com Nursing2006, September 39

decrease cardiac output; this alsoimpedes weaning.• Psychological factors. Patientswho’ve been on prolonged mechan-ical ventilation are afraid of losingthis support. Because psychologicalbarriers can be significant, providecareful, frequent communicationand reassurance for the patient andfamily throughout weaning.

Making weaning workMultidisciplinary teams play a keyrole in helping patients who havedifficulty weaning succeed. Besidesthe patient and his family, an effec-tive team may include physicians,nurses, respiratory therapists,occupational and physical thera-pists, speech therapists, socialworkers, nutritionists, wound carespecialists, and chaplains. Thisgroup should interact daily at thebedside, participate in plans forcare, and conduct formal weeklydiscussions of the care plan andthe patient’s needs.

The patient can benefit from anevidence-based approach to wean-ing. (See Guidelines for weaning.)Recent studies have shown that adaily “sedation vacation” canreduce the duration of mechanicalventilation, possibly because the“awake” patient is more likely toundergo daily assessment of hisreadiness to wean and extubate. Adaily interruption in sedation alsoreduces ICU stay. (For moredetails on sedation vacations, see“Best-Practice Interventions: HowCan You Prevent Ventilator-Associated Pneumonia?” in theFebruary issue of Nursing2006.)

To rest patients’ respiratory mus-cles, use assist/control mode withappropriate trigger sensitivity.

The following interventions areappropriate for patients using therapid-weaning approach and arecrucial to weaning success forpatients who have difficulty wean-ing. For patients who’ve been onlong-term ventilation, addressingall aspects of mechanical ventila-tion and hindrances to sponta-

neous breathing will maximizeweaning success. Try these inter-ventions to help make weaningeasier:• Elevate the head of the bed at least30 degrees unless contraindicated tohelp relieve diaphragmatic pressurefrom abdominal contents andreduce the chance of aspirationpneumonia. Also, you can more

easily manage excessive secretionswhen the patient’s head is elevated.• Kinetic therapy (mechanicalrotation of patients with 40-degreeturns by a specialized bed)reduces the incidence of VAP andatelectasis.• Suctioning should be performedas often as indicated to clear secre-tions. Consider using a closed-

40 Nursing2006, Volume 36, Number 9 www.nursing2006.com

Guidelines for weaningThese guidelines, published in 2001, were developed by a collective task forcecomprising physicians, nurses, and respiratory therapists.

1. Search for all causes for the patient being ventilator-dependent and cor-rect or reverse them.

2. Perform a formal assessment about readiness to wean if the patientmeets the criteria listed below. Some patients may still be considered forweaning even if one of the following criteria isn’t met:• The cause of the respiratory failure has been partially or fully reversed.• The patient’s Pao2/FIO2 is 150 to 200, positive end-expiratory pressure isbetween 0 and 8 cm H2O, his FIO2 is less than 0.5, and pH is 7.25 or greater. • The patient’s hemodynamic status is stable, with no ischemia and no clini-cally important hypotension.• The patient can initiate an inspiratory effort.

3. Perform a formal assessment of readiness to wean. If the patient can tol-erate a 30- to 120-minute spontaneous breathing trial, he’s ready. Tolerance isbased on respiratory pattern (no retractions or obvious signs of distress andrespiratory rate less than 30 breaths/minute), adequate gas exchange, hemo-dynamic stability, and subjective comfort level.

4. Once the patient is discontinued from mechanical ventilation, assess air-way patency and his ability to clear secretions. If the airway isn’t patent, or ifhe can’t clear secretions, leave the artificial airway in place.

5. If he failed the spontaneous breathing trial, determine and correct thecause. Then evaluate him based on guideline 2. If criteria are met, perform aspontaneous breathing trial every 24 hours.

6. Between breathing trials, use a ventilator mode that provides supportthat is stable, nonfatiguing, and comfortable. Let the patient rest to avoid over-loading the ventilatory muscles.

7. Use proper analgesics and sedatives at the lowest possible dose, to avoidblunting the respiratory drive.

8. Employ properly designed weaning protocols performed by a nurse/therapist team. Use sedation protocols.

9. If the patient will clearly need prolonged mechanical ventilation, heshould have a tracheostomy. Early in the course of treatment is better thanlater.

10. A patient should be classified as permanently ventilator-dependent onlyafter 3 months of failed weaning attempts, unless he clearly has irreversibledisease or injury, such as amyotrophic lateral sclerosis or spinal cord injury.

11. If weaning attempts in the ICU have failed, transfer a medically stablepatient to a specialized facility that has a good safety and success record inaccomplishing ventilator discontinuation.

12. When a patient has been on prolonged mechanical ventilation, go slow-ly in weaning and gradually increase the time used for spontaneous breathingtrials. Respiratory muscles need to be retrained and strengthened for patientswho’ve been ventilator-dependent for prolonged periods.

system suction catheter so youdon’t have to open the patient-ventilator circuit.• Adequate humidification ofinspired air helps prevent mucusplugs.• Prevent bronchospasm with bron-chodilator therapy, either through anebulizer or the equally effectivemetered-dose inhaler with a spacerdevice.• Careful attention to proper infec-tion control practices reduces therisk of VAP and other infections.• Prophylactic antacids can helpreduce the patient’s risk of stressulcers, which occur in 25% ofpatients receiving mechanical ven-tilation. Raising the pH of gastriccontents also may protect against agreater pulmonary inflammatoryresponse to aspiration of gastro-intestinal contents.• Sleep deprivation in the ICU canimpair efforts to wean, so try tominimize noise and avoid unneces-sary interruptions when the patientis sleeping. • Fight depression and motivate thepatient to improve by making hisdaytime environment stimulating.Clocks, calendars, and an outside

view help link the patient to timeand season. Pictures, music, TV,and visits from friends and familyalso can help stimulate and moti-vate. Help him communicate usingdevices such as writing tablets orpicture and alphabet boards. If hehas a tracheostomy, he may be ableto speak by using a one-wayspeaking valve on a fenestratedtube. Also include the patient andthe family in developing careplans.

Unless contraindicated, apatient receiving prolongedmechanical ventilation should bemoved into a chair for daily peri-ods of sitting up. Better yet, helphim stand and walk if he can. Usean oxygen cylinder and bag-valve–mask to ventilate him if aportable mechanical ventilatorisn’t available. Take him outside ifweather permits so he can experi-ence sunshine and fresh air.Consider a visit by a therapy pet.

A winning teamThe rapid-wean patient and thedifficult-to-wean patient representthe two opposite ends of themechanical ventilation spectrum.

But by working with the patient,his family, and other members ofthe health care team, you can helpyour patient breathe independentlyand leave the ventilator behind. ‹›SELECTED REFERENCESEly E, et al. Mechanical ventilator weaning pro-tocols driven by nonphysician health-care pro-fessionals: Evidence-based clinical practiceguidelines. Chest. 120(6, Suppl.):454S-463S,December 2001.

Grap M, et al. Collaborative practice: Develop-ment, implementation, and evaluation of aweaning protocol for patients receiving me-chanical ventilation. American Journal of CriticalCare. 12(5):454-460, September 2003.

MacIntyre NR. Evidence-based ventilator wean-ing and discontinuation. Respiratory Care.49(7):830-836, July 2004.

MacIntyre NR, et al. Evidence-based guidelinesfor weaning and discontinuing ventilatory sup-port: A collective task force facilitated by theAmerican College of Chest Physicians, theAmerican Association for Respiratory Care, andthe American College of Critical Care Medi-cine. Chest. 120(6, Suppl.):375S-395S, Decem-ber 2001.

Marelich G, et al. Protocol weaning of mechani-cal ventilation in medical and surgical patientsby respiratory care practitioners and nurses: Ef-fect on weaning time and incidence of ventilator-associated pneumonia. Chest. 118(2):459-467,August 2000.

Sessler C. Wake up and breathe. Critical CareMedicine. 32(6):1413-1414, June 2004.

Bill Pruitt is an instructor in the department of car-diorespiratory sciences at the University of SouthAlabama in Mobile and a p.r.n. respiratory therapistat Springhill Medical Center in Mobile.

The author has disclosed that he has no significantrelationship with or financial interest in any commer-cial companies that pertain to this educational activity.

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Weaning patients from mechanical ventilationGENERAL PURPOSE To provide nurses with an overview of mechanical ventilation and weaning patients from it. LEARNING OBJECTIVES Afterreading the preceding article and taking this test, you should be able to: 1. Describe mechanical ventilation and weaning protocols. 2. Discuss problems that may occur during weaning and appropriate nursing interventions.

2.5ANCC/AACN CONTACT HOURS

1. Mechanical ventilation is indicated a. to provide adequate circulatory support.b. when the body can’t meet its oxygen demand

through spontaneous breathing.c. whenever the patient has an SpO2 less than 92%.d. when the patient’s oxygen demand drops.

2. Which isn’t used to deliver mechanicalventilation?a. oral ET tubeb. chest tubec. nasal ET tubed. tracheostomy tube

3. The FIO2 setting on the mechanical venti-lator gives you information about a. supplemental oxygen.b. tidal volume.c. mode of ventilation.d. pressure support.

4. The rapid-wean approach typically haspatients off the ventilator ina. the postanesthesia care unit. b. 1 to 2 hours.c. 6 to 8 hours.d. 24 to 48 hours.

5. A patient who’s ready to wean frommechanical ventilation should be able to tolerate spontaneous breathing ofa. 1 to 5 minutes. c. 11 to 20 minutes.b. 6 to 10 minutes. d. 30 to 120 minutes.

6. Readiness to wean criteria includea. PEEP between 10 and 15 cm H2O.b. FIO2 greater than 0.5.c. PaO2/FIO2 of 150 to 200.d. pH less than 7.25.

7. A key feature to weaning isa. a high level of PEEP.b. a high level of pressure support.c. respiratory acidosis.d. a spontaneous breathing trial.

8. Difficulty weaning and ventilator depen-dence may be caused by any of the follow-ing excepta. brainstem stroke.b. reversal of the cause of respiratory failure. c. respiratory muscle fatigue.d. brain tumor.

9. An inability to carry the respiratory loadwith resulting ventilator dependence is leastlikely to be caused bya. excessive work of breathing.b. bronchospasm.c. excessive secretions.d. oral ET intubation.

10. Overventilation on a ventilator canresult ina. respiratory acidosis.b. excessive bicarbonate excretion.c. CO2 retention.d. metabolic alkalosis.

11. A patient will need a tracheostomy a. when he needs prolonged mechanical ventila-

tion.b. if he needs short-term mechanical ventilation.c. if he needs humidification of inspired air.d. during cardiovascular surgery.

12. A patient is considered permanently ventilator-dependent after failed weaningattempts lastinga. 3 weeks.b. 6 weeks.c. 10 weeks.d. 3 months.

13. Which intervention is recommended forpatients on mechanical ventilation?a. head of bed flatb. decreased gastric pHc. kinetic therapyd. dehumidification of ventilated air

14. A daily “sedation vacation” may result ina. resting the patient’s respiratory muscles.b. a more accurate assessment of readiness to

wean.c. a prolonged ICU stay.d. lengthening the duration of mechanical ventila-

tion.

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