Weaning From Weaning From Mechanical VentilationMechanical Ventilation

Soumya Ranjan ParidaSoumya Ranjan Parida

Basic B.Sc. Nursing 4Basic B.Sc. Nursing 4thth year year

Sum Nursing CollegeSum Nursing College

IntroductionIntroduction••The process of weaning from mechanical ventilation can be The process of weaning from mechanical ventilation can be

considered as the work of breathing from the ventilator to the considered as the work of breathing from the ventilator to the patient.patient.

••Just as patient is at increased risk if the need for mv is not Just as patient is at increased risk if the need for mv is not recognised,so also there is increased risk of complication for recognised,so also there is increased risk of complication for every extra day spent on mechanical ventilation.every extra day spent on mechanical ventilation.

••unlike the heart ,the lungs themselves are incapable of moving air unlike the heart ,the lungs themselves are incapable of moving air in and out and require other muscle and central respiratory drive in and out and require other muscle and central respiratory drive to sustain oxygen and carbon dioxide removal.to sustain oxygen and carbon dioxide removal.

successful weaning therefore depends on many factor that successful weaning therefore depends on many factor that interact .interact .

Too aggressive discontinuation of ventilatory support put the Too aggressive discontinuation of ventilatory support put the patient at risk of atelectasis and reintubation.patient at risk of atelectasis and reintubation.

This usually involves initiation of weaning mode and This usually involves initiation of weaning mode and manipulation of setting to reduce the amount of support from manipulation of setting to reduce the amount of support from the machinethe machine

Factors to consider during weaningFactors to consider during weaning General Condition of patient –Anemia, nutritional status, General Condition of patient –Anemia, nutritional status,

conscious level, and respiratory driveconscious level, and respiratory drive. . Condition of the muscle-condition of respiratory muscle Condition of the muscle-condition of respiratory muscle

after prolonged paralysis; recovery from neuromuscular after prolonged paralysis; recovery from neuromuscular illness, diaphragmatic palsy. illness, diaphragmatic palsy.

Ventilatory factors-compliance and resistance from circuit, Ventilatory factors-compliance and resistance from circuit, support provided, ease of opening of the demand valve.support provided, ease of opening of the demand valve.

Airway factors- resistance from small size endotracheal tube, Airway factors- resistance from small size endotracheal tube, secretions, upper airway obstruction. secretions, upper airway obstruction.

Markers of improved conditionMarkers of improved condition

Improving general condition, fever etcImproving general condition, fever etc Decreasing FiO2 requirementDecreasing FiO2 requirement Improving breath soundsImproving breath sounds Decreasing ET secretionsDecreasing ET secretions Improving chest xrayImproving chest xray Improved electrolyte and fluid statusImproved electrolyte and fluid status Improving hemodynamic statusImproving hemodynamic status Improving neurological statusImproving neurological status

Indices for successful weaningIndices for successful weaning

There are oxygenation and ventilatory criteria, There are oxygenation and ventilatory criteria,

as both are important for successful weaning.as both are important for successful weaning. While oxygenation criteria may be fairly useful,While oxygenation criteria may be fairly useful,

Reducing pip , fio2 and amount of minute ventilation Reducing pip , fio2 and amount of minute ventilation provided by the ventilator may help in provided by the ventilator may help in

defining low and high risk categories. defining low and high risk categories.

Criteria for weaningCriteria for weaning

Ventilation criteria Ventilation criteria

••reducing pip<reducing pip<

••peep< 6 peep< 6

••psv 5-10 psv 5-10

•• Tidal volume>6ml/kTidal volume>6ml/k

Oxygenation criteriaOxygenation criteria

• •Pao2> 60 on fio2<0.6Pao2> 60 on fio2<0.6

• •PAO2/FIO2>200PAO2/FIO2>200

• •Oxygenation index<10Oxygenation index<10

Preparation for weaningPreparation for weaning

On investigationOn investigation

••chest X raychest X ray

• • ABG ABG

• • HemoglobinHemoglobin

• •ElectrolytesElectrolytes

• •Calcium & MagnesiumCalcium & Magnesium

Clinical examination

•Respiratory distress •Rate of breathing •use of accessory muscle& muscle strength.

Methods of weaningMethods of weaning

SIMV with decreases in rateSIMV with decreases in rate Reduce the amount of Pressure support Reduce the amount of Pressure support

ventilationventilation T-piece weaning with spontaneous breathing T-piece weaning with spontaneous breathing

trials trials CPAP/PEEP of<5cm of water.CPAP/PEEP of<5cm of water.

Method of weaningMethod of weaning Before initiating of weaning a chest xray should be Before initiating of weaning a chest xray should be

done to obtain a baselinedone to obtain a baseline Increase in compliance and FRC typically heralds Increase in compliance and FRC typically heralds

recovery from pulmonary disease.recovery from pulmonary disease. The ventilator mode should be changed from control The ventilator mode should be changed from control

mode to SIMV mode with pressure support.mode to SIMV mode with pressure support. The first setting to be reduced is PIP by 1.0 cm H2O The first setting to be reduced is PIP by 1.0 cm H2O

decrements till it is brought down to 25 cm H2O.decrements till it is brought down to 25 cm H2O. Then PIP and FiO2 ( decreased 0.05 or 5%) are Then PIP and FiO2 ( decreased 0.05 or 5%) are

reduced alternately till a relative safe level of 20 PIP and reduced alternately till a relative safe level of 20 PIP and 0.6 FiO2 are reached0.6 FiO2 are reached

Method of weaningMethod of weaning

After this FiO2 and PEEP should be decreased hand in After this FiO2 and PEEP should be decreased hand in hand i.e. at 0.6 FiO2, PEEP should be 6. PIP should be hand i.e. at 0.6 FiO2, PEEP should be 6. PIP should be reduced by 1.0 cm H2O every 15- 20 mins.reduced by 1.0 cm H2O every 15- 20 mins.

Ventilatory rate is now reduced in small increments of 2 Ventilatory rate is now reduced in small increments of 2 breaths/min till it is brought down to 10breaths/minbreaths/min till it is brought down to 10breaths/min

Extubation is indicated when FiO2 is 0.4, PIP 10- 15cm Extubation is indicated when FiO2 is 0.4, PIP 10- 15cm H2O,PEEP 3 cm H2O, Ti 0.3sec and RR 10/min.H2O,PEEP 3 cm H2O, Ti 0.3sec and RR 10/min.

Some infants can be put on CPAP before extubation.Some infants can be put on CPAP before extubation.

Extubation From ventilatorExtubation From ventilator Extubation can be performed when the full criteria are Extubation can be performed when the full criteria are

met:met: Control of airway reflexes, minimal secretions.Control of airway reflexes, minimal secretions. Good breath soundsGood breath sounds Minimal oxygen requirement <0.3 with SpO2 >94.Minimal oxygen requirement <0.3 with SpO2 >94. Minimal rate 5/minMinimal rate 5/min Minimal pressure supportMinimal pressure support Adequate muscle toneAdequate muscle tone Minimal ionotropic supportMinimal ionotropic support Normal electrolytes, no fluid imbalanceNormal electrolytes, no fluid imbalance

Extubation from ventilatorExtubation from ventilator

Extubation procedure Keep NBM 4 hours before extubation Suction the ET tube, oral cavity and nostrils. Suction the nasogastric tube to deflate the stomach Keep oxygen ready Nebulization with beta stimulant and or adrenaline

should be ready immediate postextubation. IV steroids dexamethasone 0.15mg/kg may be used in

prolonged intubation. It can be started 24 hrs prior to extubation and to be continued for 48 hrs.

Extubation From ventilatorExtubation From ventilator

Aminophylline can be started as it decreases Aminophylline can be started as it decreases resistance and increases respiratory driveresistance and increases respiratory drive

ABG is usually done 20 min after extubationABG is usually done 20 min after extubation Post extubation Xray should be done Post extubation Xray should be done

conclusionconclusion Think about weaning early.Think about weaning early. Plan a clinical strategy designed for your patient.Plan a clinical strategy designed for your patient. Prepare the patients general condition.Prepare the patients general condition. Design 2-3 separate protocols that are age Design 2-3 separate protocols that are age

appropriateappropriate Medicate as neededMedicate as needed Don’t be too much of hurryDon’t be too much of hurry Avoid night extubation.Avoid night extubation.

THANK YOUTHANK YOU