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Title of Guideline (must include the word Guideline (not Guideline for weaning an adult patient from

protocol, policy, procedure etc) invasive mechanical ventilation

Author: Contact Name and Job Title Ruth Pettit, Deputy Sister

Directorate & Speciality Specialist Support, Critical Care

Date of submission 19/03/14

Explicit definition of patient group to which it applies (e.g. Adult critical care patients ventilated on invasive
inclusion and exclusion criteria, diagnosis) mechanical ventilation, through an endotracheal
tube or tracheostomy. Excluding, paediatric
patients, high cervical spine injury patients.

Version 2

If this version supersedes another clinical guideline please Supersedes version 1.


be explicit about which guideline it replaces including
version number.

Statement of the evidence base of the guideline has the Peer Reviewed by Consultant and senior
guideline been peer reviewed by colleagues? nursing staff within critical care. Guieline also
passed through critical care guidelines
process in March 2013.
Evidence base: (1-6)

1 NICE Guidance, Royal College Guideline, SIGN 1a - Burns KEA, et al (2013)


(please state which source).
1b - Jubran et al (2013) and 3 & 4
2a meta analysis of randomised controlled trials

2b at least one randomised controlled trial

3a at least one well-designed controlled study without


randomisation

3b at least one other type of well-designed quasi-


experimental study

4 well designed non-experimental descriptive


studies (ie comparative / correlation and case
studies)

5 expert committee reports or opinions and / or


clinical experiences of respected authorities

6 recommended best practise based on the clinical


experience of the guideline developer

Consultation Process Critical care senior nursing, medical and


physiotherapy staff

Ratified by: Critical Care guidelines group, March 2013


Date:

Target audience To all healthcare professionals caring for patients


(adult) requiring invasive mechanical ventilation.

Review Date: (to be applied by the Integrated Governance Team) 19/03/2019

A review date of 5 years will be applied by the Trust. Directorates


can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.

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This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST

CRITICAL CARE PRACTICE GUIDELINES

Guideline for weaning an adult patient from invasive


mechanical ventilation

Introduction

Weaning from invasive mechanical ventilation is the process of gradually


decreasing ventilatory support until such time as the patient can breathe
without mechanical assistance (Intensive Care Society 2007). Weaning is
deemed successful when the patient has been independent of the ventilator
for 48 consecutive hours (Crocker 2002).

The aim of weaning from mechanical ventilation is to maximise respiratory


function (respiratory muscle strength and endurance) without fatiguing the
respiratory muscles. If the respiratory muscles become fatigued, it may take
up to 48 hours for them to recover (Roussos et al 1996, Hadfield 1999). Prior
to extubation the use of spontaneous breathing trials may be of benefit
(Krishnan et al, 2004). Reducing respiratory support should be considered as
soon as the patient commences mechanical ventilation.

There is little evidence available to determine the most effective mode of


ventilation for weaning. A systematic review of the literature by Boles et al
(2007) revealed there was no difference between T-piece and pressure
support as methods of weaning. More recently Jubran et al (2013) have found
that utilisation of a tracheostomy mask versus pressure support weaning
liberates the patient from the ventilator faster, however at 6 and 12 months
there is no difference in mortality. The manner in which the mode of weaning
is applied may have a greater effect on the likelihood of weaning than the
mode itself. The use of a protocol leads to a decrease in weaning time (Butler,
1999 Simmonds, 2005). In those patients who are identified as having either

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weaning delay (>14 days in ICU where respiratory dependency is now the
primary problem and the patient requires invasive ventilatory support for >6
hours per day, NHS Modernisation Agency (2002)) or weaning failure (>21
days in ICU where respiratory dependency is now the primary problem and
the patient requires invasive ventilatory support for >6 hours per day, NHS
Modernisation Agency (2002)), an individualised weaning care plan approach
may be required.

This guideline provides guidance on weaning the patient from ventilation up to


the point whereby the patient is ready to be extubated. The nurse should then
refer to the separate guideline for extubation.

Indications

If no medical staff decision to the contrary weaning should commence


using the following indicators:-

Resolving medical condition

FIO2 < 50%

PaO2 > 9.0 Kpa / SaO2 >90% unless underlying chronic lung condition

Acceptable level of PEEP/CPAP (<8 cmH2O or less)

Acceptable acid/base balance (relevant to that particular patient)

Hb > 7 g/dl and haemodynamically stable

Adequate pain control

Effective neurological function/stable ICP.

In patients whose physiological parameters are outside of those outlined


above, weaning should be discussed with the medical staff and initiated as
soon as possible.

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Exclusions

Patients with high cervical cord injuries these patients should be


weaned according to individualised plans in conjunction with spinal
injury patient guidelines.

Contra-Indications (absolute)

Medical decision not to wean

Patient requiring high levels of PEEP

Acid/base imbalance (ABGs need to be acceptable for patient)

Administration of paralysing agents or patient inappropriate for


sedation hold.

Equipment

Ventilator (Evita 2 Dura, Evita 4 and Excel are the preferred choice for
weaning patients)

Ventilator tubing and filters

Humidification (HME / wet heated circuit)

Oxygen and compressed air source

Suction equipment (suction port, suction bottle, catheters of varying


sizes, yankeur, and tubing closed circuit inline suction system)

Personal protective equipment (gloves, aprons, eye protection, hand


washing facilities, alcohol rub)

Bag Valve Mask

Access to emergency intubation or resuscitation equipment

Monitoring equipment (Pulseoximetry, ECG, haemodynamic


monitoring, ETCO2 monitoring - if ABG not available).

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Principles of Care/Action/Responsibilities

PRINCIPLE RATIONALE

1. PATIENT ASSESSMENT

Physical

The patients underlying condition is Weaning is unlikely to be successful if


resolving. underlying condition is not resolving.

If weaning is predicted to be more than 7 Tracheostomy reduces dead space and may
days a tracheostomy may be required. result in reduced ventilator dependency time
(Griffiths et al. 2005).

Daily review of the patients readiness to A daily assessment will reduce any delay in
wean should be made. initiating the decision to wean (Norton,
2000). The assessment should address all
the indicators for weaning and include a
multidisciplinary approach.

Best Practice: - DAILY ASSESSMENT OF READINESS TO WEAN.

The ability of patients to be successfully weaned is often underestimated,


resulting in increased ventilator dependency, risk of developing ventilator
associated pneumonia and higher mortality (Ely et al. 1996, Boles et al 2007).

Psychological

The patient is prepared for weaning. A patients psychological readiness to wean


is just as important as physical readiness
(MacIntyre 2001). However, the patient may
remain be conscious yet still weanable.

The patient is orientated to night and day. ICU delirium can delay weaning; efforts
should be made to reduce the onset of
delirium.

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Delirium should be treated. Delirium may contribute to longer ventilation
times; national guidelines recommend the
management of delirium (Borthwick et al
2006). Refer to NUH critical care delirium
guidelines for management

Communication with the patient to ensure Good communication is essential; including


they feel supported through the weaning the patient in the weaning plan will make
process. Include the patient in the successful weaning more likely. (Newmarch,
weaning plan. 2006).

Best Practice: - COMMUNICATION.

Effective interpersonal skills are vital for successful weaning from mechanical
ventilation. Practitioners should inform and work collaboratively with patients
throughout the weaning process (Newmarch 2006).

PRINCIPLE RATIONALE

2. PRE-REQUISITES Values are given as a guideline only and should be set on an


individual basis and reviewed regularly by the multiprofessional team.

Respiratory

Patient is maintaining adequate Work of breathing is increased during


oxygenation for condition. weaning; oxygen requirements can increase
by 10%. PaO2/FiO2 ratio should be greater
than 20kPa as an indicator of the ability of
the respiratory pump to tolerate weaning
(Boles 2007).

PEEP (<8 cmH2O or less). Increased PEEP causes dynamic


hyperinflation and thus increased cardiac
load (Boles et al 2007).

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Patient has an acceptable amount of Excessive secretions results in frequent
secretions. need for suctioning, causes coughing and is
exhausting (Grap et al 2003).

A physiotherapist has reviewed the The physiotherapist can advise on weaning


patient within the previous 24 hours and strategies and assist in the weaning process
they are aware that the patient is now by treatment. However the weaning process
aiming to wean from ventilation. should not be delayed if the patient has not
been seen by a physiotherapist.

The need for a recent chest X-Ray has A chest X-Ray gives information about the
been considered and performed if patients likelihood of successful weaning
required. and eliminates pneumothorax or pleural
effusions as a cause of failure to wean.

The correct level of humidification for the Low humidification levels can lead to
patient is established utilising either a thickened sputum whilst over humidification
HME or heated wet circuit. can lead to excessive sputum.

Cardiovascular

Hb is adequate for patients condition. An adequate Hb is required for oxygenation;


the respiratory muscles need a constant
supply of oxygenated blood. Literature is
scarce regarding the correct level to
maintain Hb at whilst weaning, however
(Hebert et al 1999, Singer et al 2005)
recommend an Hb>7 is not detrimental in
critically ill patients.

Cardiovascularly stable (with or without A heart rate of above 140bpm may result in
inotropes/vasopressors). inadequate filling of the ventricles and
reduced cardiac output.

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pH > 7.25 Acidosis will result in a compensatory
increase in respiratory rate causing fatigue.

Temperature < 38.5 o C. A high temperature increases oxygen


demand. It is not a contraindication unless
increasing oxygen requirements,
compromising cardiovascular status or the
patient remains generally unwell.

Nutrition

Trace elements (K+, PO4, Mg, Ca) are Normal values of trace elements are
checked and normalised. required for muscle function (MacIntyre
2001).

Enteral/Parenteral feeding has been Inadequate nutrition leads to protein


commenced unless contraindicated and catabolism and a loss of muscle
is prescribed by a dietician. performance. Overfeeding leads to an
excess of CO2 and can also delay weaning.
(MacIntyre 2001).

Abdomen not distended. A distended abdomen will tamponade the


diaphragm and restricts breathing.

Neurological

Patient has sufficient respiratory drive. Excessive sedation will reduce respiratory
drive; the patient does not need to be
conscious but must have sufficient drive.

Pain is controlled. Pain causes an increase in heart rate, blood


pressure, respiratory rate and anxiety and
reduces the likelihood of successful
weaning.

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Patients GCS is improving and will allow The patients GCS should be 8 or greater
for protection of airway upon extubation. prior to extubation of an oral ETT. (Those
patients with a tracheostomy have a
protected airway).

Sedation is off or sedation score is Increased sedation level will impact on


greater than -4 (Richmond Agitation- respiratory drive (Crocker 2002).
Sedation Scale).

The patient is rested. Weaning can be exhausting and is more


successful if the patient has sufficient sleep;
night sedation may be required.
Consideration may wish to be given to the
fact that anxious patients may wean during
the night.

Best Practice: - DAILY CESSATION OF SEDATION.

In patients who are receiving mechanical ventilation, daily interruption of sedative


drug infusions decreases the duration of mechanical ventilation and the length of
stay in the intensive care unit (Kress et al 2000). Unless contraindicated all
ventilated patients should undergo a daily sedation hold

PRINCIPLE RATIONALE

3. MONITORING THE PATIENT. The patient should be closely monitored


throughout the weaning process for the following: -

High spontaneous respiratory rate A high respiratory rate will cause fatigue. It
is an early sign of fatigue, usually
compensating for a decreased tidal volume
or increased carbon dioxide (Tobin et al
1986).

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Small Tidal Volumes. A decrease in tidal volume is a sign of
fatigue, or maybe a sign of respiratory
failure (Fiastro et al 1988, Howie1999).

Acceptable oxygen saturations. A drop in saturations must be checked by


arterial blood gas analysis and may indicate
fatigue or respiratory failure.

Arterial blood gases within prescribed ABGs should be checked if any sign of
limits. deterioration or 20 minutes after each
change in ventilation. Deterioration in
arterial blood gases may indicate fatigue or
respiratory failure and is a late sign.

Tachycardia or hypertension. Signs of distress increase work of breathing


and fatigue.

Use of accessory muscles. Sign of fatigue or respiratory failure.

Sweating. Increased work of breathing results in


sweating, rule out other causes.

Altered conscious level. May result from decrease in oxygenation or


increase in carbon dioxide.

NOTE:- It is not possible to be prescriptive with parameters within the


guideline as they should be set on an individual basis. These should be
set and documented on the 24-hour chart or weekly ventilation weaning
plan for the patient following multiprofessional discussions.

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PRINCIPLE RATIONALE

4. PROCESS OF WEANING.

Unless a contraindication exists, a daily A lack of daily assessment of readiness to


assessment of readiness to wean should wean is a common cause of delayed
take place and be documented on 24- weaning (Boles et al 2007)
hour chart.

A protocol directed weaning method may Protocol directed weaning provides a safe
be utilised initially. Weaning protocols method of weaning for all levels of nurses
may be useful in certain circumstances. and reduces duration of mechanical
Refer to appendix one; flowcharts 1-4. ventilation (Tonnelier et al 2005)

An individualised weaning plan should be This provides a structured and consistent


created, in discussion with the patient and approach, allowing time for the patient to
multiprofessional team for those who are rest, whilst progressing overall with weaning
defined as having weaning delay or from the ventilator. The physiotherapists
failure. In addition, those who are failing should be fully involved with the weaning
to progress utilising the short - medium process. Utilise the Critical care weekly
term weaning protocols should have an ventilation weaning plan chart.
individualised plan.

The weaning plan should be written for a Different clinicians may utilise different
number of days at anyone time; this approaches to weaning. Consistency for the
allows a consistency in approach and patient is the important factor rather than the
ensure that weaning continues when less method of weaning employed. Junior staff
experienced staff are present. may not feel confident in planning weaning.

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The individualised weaning plan should The plan should be explicit to prevent
outline the mode of ventilation, settings confusion.
and period of time to be spent on each
setting. Parameters to determine patient
weaning failure should also be set.
Periods of rest should be incorporated.

A combination of weaning methods may A systematic review of the literature


be utilised. These may include gradual demonstrated that there was no superior
reduction of BiPAP rate, reduction of ASB method of weaning (Butler et al 1999).
or increasing time on CPAP ASB, CPAP,
spontaneous breathing trials or Hiflow.
Patients may be rested on BiPAP or
CPAP ASB overnight dependent on their
weaning progress.

The reason for any deviation from the To identify problems with weaning and allow
weaning plan should be documented. a new weaning plan to be created.

Any patient who has been ventilated for These provide a holistic plan of care for the
more than two weeks should be included patient which will assist in weaning.
in the long term patient ward rounds.

A consideration may be made to extubate Burns et al (2013) identify through a meta-


to Non Invasive ventilation, this may allow analysis that a weaning strategy that
a proportion of patients to be extubated includes non-invasive ventilation may
without the requirement for tracheostomy. reduce rates of mortality and ventilator-
It would require discussion with a associated pneumonia without increasing
consultant. the risk of weaning failure or reintubation.
This is predominantly in patients with
COPD.

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The guidelines should be used with flowcharts 1-4 which are attached in
appendix one and can be found in the bedside folders.

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REFERENCES

Borthwick, M, Bourne, R, Craig, M, Egan, A & Oxley, A. (2006) Detection,


prevention and treatment of delirium in critically ill patients. United Kingdom
Clinical Pharmacy Association.

Bowles, JM, Bion, J, Conners, A, Herridge, M, Marsh, B, Melot, C, Pearl, R,


Silverman, H, Stanchina, M, Vieillard-0Baron, A & Welte, T. (2007) Weaning
from mechanical ventilation. European Respiratory Journal. 29 1033-56

Burns KEA, Meade MO, Premji A & Adhikari NKJ (2013) Noninvasive
positive-pressure ventilation as a weaning strategy for intubated adults with
respiratory failure (Review). The Cochrane Collaboration. Published online
09/12/13.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004127.pub3/pdf

Butler R, Keenan S, Inman K, Sibbald W, Block G (1999) Is there a preferred


technique for weaning the difficult to-wean patient? A systematic review of
the literature. Critical Care Medicine 27 (11) 2331 2336.

Crocker, C (2002) Nurse led weaning from ventilatory and respiratory support.
Intensive and Critical Care Nursing. 18 272-9

Ely, E, Baker, A, Dunagan, d, Burke, H, Smith, A, Kelly, P, Johnson, M,


Browder, R, Bowton, D & Haponik, E. (1996) Effect on the duration of
mechanical ventilation of identifying patients capable of breathing
spontaneously. The New England Journal of Medicine. 335. 1864-9.

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Fiastro J, Habib M, Shon B, Campbell S (1988) Comparison of standard
weaning parameters and the mechanical work of breathing in mechanically
ventilated patients. Chest 94 (2) 232 238.

Grap, M, Strickland, D, Tormey, L, Keane, K, Lubin, S, Emerson, J, Winfield,


S, Dalby, P, Townes, R & Sessler, C (2003) Collaborative Practice:
Development, Implementation and Evaluation of a weaning protocol for
patients receiving mechanical ventilation. American Journal of Critical Care.
12, 454-60.

Hadfield J (1999) Respiratory support weaning from ventilation in Craft T,


Nolan J, Parr M (eds) Key Topics in Critical Care, Oxford BIOS Scientific
Publishers Ltd.

Hebert, P.C, Wells, G, Blajchman, MA, Marshall, J, Martin, C, Pagliaello, G,


Tweeddale, M, Schweitzer, I, Yetisir, E. (1999) A multicentre, randomized,
controlled, clinical trial of transfusion requirements in critical care. The New
England Journal of Medicine. 340, 409-17.

Howie A (1999) Rapid shallow breathing as a predictive indicator during


weaning from ventilator support, Nursing in Critical Care, 4:4, 171-178.

Intensive Care Society (2007) Intensive Care Society national guidelines


when and how to wean. ICS website
http://www.ics.ac.uk/icmprof/downloads/weaning.pdf Accessed 18/06/07

Jubran, A Grant, B, Duffner, Collins, E, Lanuza, D, Hoffman, L & Tobin, M.


(2013) Effect of pressure support vs unassisted breathing through a
tracheostomy collar on weaning duration in patients requiring prolonged

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mechanical ventilation. A randomized Trial. JAMA
http://jama.jamanetwork.com. Accessed 29/01/2013.

Kress, J, Pohlman, A, O'Connor, M & Hall, J. (2000) Daily interruption of


sedative infusions in critically ill patients undergoing mechanical ventilation.
The New England Journal of Medicine. 342 1471-1477

MacIntyre, NR (2001) Evidence based guidelines for weaning and


discontinuing ventilatory support. A Collective task force facilitated by the
American Association for respiratory care and the American college of Critical
care Medicine. Chest. 120. 375-96

Murciano D Boczkowski J, Lecucguic Y, Emili J, Pariente R, Aubier M (1988)


Tracheal occlusion pressure: a simple index to monitor respiratory muscle
fatigue during acute respiratory failure in patients with chronic obstructive
pulmonary disease. Annals of Internal Medicine, 108 (6) 800 805

Newmarch C (2006) Caring for the mechanically ventilated patient: part two.
Nursing Standard, 20:18, 55 64.

Norton L (2000) The role of the specialist nurse in weaning patients from
mechanical ventilation and the development of the nurse-led approach.
Nursing in Critical Care 5 (5) 220 227.

Simmonds, AK (2005) Streamlining Weaning: Protocols and weaning units


Thorax 60, 175-82

Tobin M, Perez W, Guenther S, Semmes B, Mador M, Allen S, Lodato R,


Dantzker D (1986) The pattern of breathing during successful and

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unsuccessful trials of weaning from mechanical ventilation. American Review
of Respiratory Disease. 135. 865 870.

Tonnelier, J, Prat, G, Le Gal, G, Gut-Gobert, C, Renault, A, Bowles, J & LHer,


E. (2005) Impact of a nurses protocol-directed weaning procedure in
outcomes in patients undergoing mechanical ventilation for longer than 48
hours: a prospective cohort study with a matched historical control group.
Critical Care. 9. R83-9

Date: 19/03/13

Review Date: Usually 3 years from ratification

Audit points.

Daily documentation of readiness to wean.

Daily cessation of sedation.

Documentation of reasons for not attempting wean.

Trial of CPAP ASB for all patients who fit criteria.

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Critical Care
Summary of the procedure for weaning an adult patient from invasive
mechanical ventilation
This guideline provides guidance on weaning the patient from ventilation up to the point
whereby the patient is ready to be extubated. The nurse should then refer to the separate
guideline for extubation. This is a summary of the whole guideline and should be used in
conjunction with it as required.
Indications for Weaning
If no medical staff decision to the contrary weaning should commence using the following
indicators:-
Resolving medical condition
FIO2 < 50%
PaO2 > 9.0 Kpa / SaO2 >90% unless underlying chronic lung condition
Acceptable level of PEEP/CPAP (<8 cmH2O or less)
Acceptable acid/base balance (relevant to that particular patient)
Hb > 7 g/dl and haemodynamically stable
Adequate pain control
Effective neurological function/stable ICP.
In patients whose physiological parameters are outside of those outlined above, weaning
should be discussed with the medical staff and initiated as soon as possible.

Exclusions
Patients with high cervical cord injuries these patients should be weaned according to
individualised plans in conjunction with spinal injury patient guidelines.

Absolute Contra-Indications for Weaning


Medical decision not to wean
Patient requiring high levels of PEEP
Acid/base imbalance (ABGs need to be acceptable for patient)
Administration of paralysing agents or patient inappropriate for sedation hold.

Signs of fatigue or distress


These include and are not limited to the following:-
Respiratory rate >35bpm OR an increase of 50% or more from baseline for >15minutes
Heart rate >150bpm OR an increase of 50% or more from baseline for >15minutes
Systolic BP <90mmhg
50% rise in systolic BP from baseline for more than 15 minutes
SpO2 <88% despite FiO2 increase to 0.6
PaCO2 (or end tidal CO2) >8kPa
Development of a respiratory acidosis i.e. a rise in PaCO2 causing a drop in pH below
7.3
Use of accessory muscles
Sweating
Altered conscious level
Patient states they are tired or uncomfortable.
Critical Care

Flowchart 1. Rapid wean from BIPAP/ASB and SIMV/ASB

For patients who are primarily ventilated for airway protection, i.e.
post-operative elective surgery or reduced GCS.

Does the patient meet the


Continue
indications for weaning with No current
none of the contraindications
settings
present?

Yes
No signs of fatigue
or distress
Trial of CPAP/ASB

Signs of fatigue or
distress

Return to previous settings,


review in 30 minutes

Signs of fatigue or
distress (this applies
Yes to all stages) No

Continue to
reduce frequency
Remain on
(bpm) by 2 until 8
current settings

Trial of CPAP/
ASB for
30 minutes
Patient not improving or
deteriorated, contact
Dr, consider increasing
support Refer to weaning from CPAP ASB flow
chart
Critical Care

Flowchart 2: Weaning from CPAP / ASB

Reduce ASB by 2

Signs of distress /
fatigue (this applies
to all stages)

No Yes

Continue to reduce Return to previous


ASB by 2 every 2 settings
hours

Trial period of CPAP via Discuss with Dr. re


ventilator extubation / high flow
CPAP circuit / low
flow circuit
Critical Care

Flowchart 3: Medium term wean from BIPAP/ASB

For patients who have failed Flowchart 1. Rapid wean from


BIPAP/ASB and SIMV/ASB, on several occasions.

BIPAP top
pressure below
25 Yes
No
Set total ASB to
same as Pinsp.
Dr. to assess
patient.
Set Pinsp
according to VT,
PO2, PCO2 Reduce frequency
by 2 bpm

Decrease Pinsp to Signs of fatigue or


25 in increments distress (this
of 2 applies to all
stages)

No
Yes

Continue to
Return to reduce by 2bpm
previous settings until frequency is
and allow to rest 8bpm. If patient is
for 2 hours managing well
change mode to
CPAP / ASB

Wean using
Consider the need to create an CPAP ASB flow
individualised weaning plan chart
Critical Care

Flowchart 4. Slow wean from BIPAP/ASB

For use when an individualised weaning plan has not yet been
completed. An individualised weaning plan should be completed at the
earliest opportunity.

Agree parameters with consultant Observe for signs of fatigue or


i.e. pO2, Sp02, pCO2 / pH or ETCO2 distress at any stage. If seen
rest on ASB or BIPAP/ASB as
appropriate and recommence
weaning when patient ready
When BIPAP Pinsp<25 wean
frequency by 2 until frequency is 12

Trial of CPAP/ASB for 1-4 hours

Rest on BIPAP/ASB for at least 2-4


hours

Increase duration and frequency of Discuss with consultant need for


ASB trails as tolerated until able to arterial line or ETCO2
manage CPAP/ASB all day monitoring, and parameters

Reduce ASB pressure by 1-2


every 12 hours

Trial of CPAP 1-4 hours


Rest at night on BIPAP rate of at resting on CPAP/ASB during
least 8, and Pinsp set to the same as day
total ASB during day.

or
Increase duration and frequency
Rest at night on CPAP/ASB with
of CPAP trials until able to manage
ASB increased by 2
CPAP continuously.