WEANING FROM THE VENTILATOR by Nick Mark, MD ONE onepagericu.

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Have I fixed the cause of Daily “Wean screen” Do a spontaneous

respiratory failure?
(e.g. successful diuresis of a pt with
heart failure, effects of overdose
wore off, ARDS improving, etc)
Pt should have airway reflexes
Yes
(cough, gag), require FiO2 ≤ 0.5 on
PEEP ≤ 8, breath spontaneously,
w/ stable hemodynamics (OK if on
stable dose of vasopressors)
breathing trial (SBT)
Settings: PS 5 bpm, PEEP 5 cmH2O
for 30 min. Perform once daily.
For patients with severe HF
consider zero PEEP
Combined with a Sedation
Vacation (stop sedating
medications prior to SBT)

Setting up for extubation success

• Decrease demand – correct metabolic If failure, try to
acidosis, decrease CO2 production identify root How does the patient
(fever, overfeeding, etc), reduce dead cause and try
Fail look?
space. again the next Failure if: patient looks
• Optimize mechanics - sit patient up, day. extremely distressed (anxiety,
avoid gastric distension, consider agitation) or using accessory
draining pleural effusions muscles
• Improve strength – physical therapy, Pass
wean or avoid steroids & NMB
• Respiratory drive – stop or reduce What does the monitor
long lasting pain meds, combine with show?
sedation vacation Fail
Failure if: Arrythmias including If no cuff leak present treat potential
• Optimize Nutrition – feeding w/o
tachycardia or bradycardia, airway swelling with corticosteroids
overfeeding, correct electrolyte
Hypo/Hypertension, or (methylpred 60 mg IV) then repeat test
derangements (including Mg and PO4)
Desaturation in 6 hours. Can consider extubation
• Diuresis – Dry lungs are happy lungs
Pass even if cuff leak is still absent

What does the ventilator Check for cuff leak

Fail show? Pass
Failure if consistently low TV Passing if >110 ml or <25% of
(<300) MV too high (>10 lpm) or TV lost or if audible leak is
MV too low (<2 lpm) heard
Other pro-tips
• Rapid shallow breathing index (RSBI) Pass
= freq / TV (L); RSBI >105 is a specific
but insensitive predictor of What does the ABG
extubation failure Extubate
• Drop in ScvO2 by >4.5% is a highly Fail show? (optional)

specific and fairly sensitive predictor Failure if new hypercarbia or
respiratory alkalosis
of extubation failure
Only check ABG on select patients.
v1.0 2020-03-24
Typical reintubation rate is ~10%
(if you are not reintubating you
are not extubating enough!)