Mechanical Ventilation

Weaning from Mechanical

Ventilation
Kathia Ortiz-Cantillo, MD
 Mechanical Ventilation
Weaning
• When is a patient ready to be disconnected
from the ventilator?
• Numerous trials performed to develop criteria for
success weaning, however, not useful to predict
when to begin the weaning.
• Physicians must rely on clinical judgment.
• Reversal of initial process that led to respiratory
failure
• Daily screening may reduce the duration of MV
and ICU cost
 Mechanical Ventilation
factors that should be corrected before weaning

• CNS; Absence of cough, gag, level of

consciousness
• CVS; Shock, arrhythmias
• Renal; Correction of acid-base/electrolyte disorders
• Hematologic; Anemia
• Infections;
• Nutrition; Poor nutritional status, low phosphorus,
excessive nutrition.
 Mechanical Ventilation
Weaning Parameters

• Respiratory Muscle Strength:

• NIF; maximum inspiratory pressure:
• PImax generated by a patient from FRC approximately
20 sec after occluding the inspiratory circuit.
• Index of Rapid Shallow Breathing:
• RR/TV. Inspiratory muscle weakness leads to rapid
shallow breathing
• Paradoxical Breathing:
• Chest and abdomen move outward on inspiration.
• Intercostal muscle fatigue, diaphragmatic fatigue.
 Mechanical Ventilation
Weaning Parameters
• Respiratory Muscle Strength
• Vital Capacity VC >15mL/kg body weight
• The maximum amount of gas that can be inhaled from
residual volume or exhaled from total lung capacity
• Requires patient cooperation
 Mechanical Ventilation
Weaning Parameters
• Respiratory Muscle Demand
• Minute Ventilation VE;
• the amount of air that must be moved in or out of the
lungs over 1 min to maintain a given PaCO2.
<10L/min
• VE will be determined by CO2 production
• Increased on critical care illness, high fever, over
feeding, excess carbohydrate load, Increase death
space.
• RR;
• Muscle fatigue, patient resorts shallow breathing >35
 Mechanical Ventilation
Weaning Parameters
• Respiratory Muscle Demand
• Maximum Voluntary Ventilation; MVV >2 times
the VE
• Requires a motivated and cooperative patient
• The maximum amount of air that can be inhaled or
exhaled over 1 min.
• Respiratory Compliance >33ml/cmH2O
• Work must be performed by inspiratory muscles to
overcome the elastic properties of both the lungs and
chest wall.
 Mechanical Ventilation
Weaning Parameters
• Respiratory Gas Exchange

• Significant hypoxemia constitutes a relative

contraindication.
• A PaO2 <60mmHG with and FIO2>.040.
• Arterial to Inspired O2 ratio (PaO2/FIO2)
• >200
 Mechanical Ventilation
Weaning Parameters
• Respiratory Rate < 30/min
• Spontaneous Vt > 4 ml/kg
• Inspiratory Pressure > - 30 cm H2O
• Breathing Index (f/Vt) < 105
• PEEP < 8 cmH2O
• PaO2/FIO2 > 200
• FIO2 < .50
 Mechanical Ventilation
Methods of weaning
• No one or method of weaning has been
definitely found to be superior:
• Initial Trial of Spontaneous Ventilation
• T-piece trial
• Spontaneous trial on ventilator (CPAP = 0)
• Gradual Weaning
• SIMV
• Pressure Support Ventilation (PSV)
• SIMV + PSV
• Extubation + noninvasive ventilation
 Weaning
Pressure Support Ventilation (PSV)
• Fixed pressure during inspiration
• Patient initiated and terminated
• More comfortable
• Depth & length of breath controlled by patient
• Counteract work/resistance of ETT &
ventilator circuit
 SIMV Protocol
• Switch to SIMV from assist mode or decrease
RR
• Begin with RR 8/min decrease SIMV rate by
two breaths per hour unless clinical
deterioration
• if assume to fail, increase SIMV rate to
previous level, until stable
• if stable at least 1 hour of rate 0/ min extubate
• in patient without respiratory disorders,
decrease rate with half an hour interval, 2 hr
extubate
 Weaning
ACCP/AARC
A. Stable/resolved pulmonary process
B. PEEP < 8; FIO2 < .50
C. Cardiovascular stability
D. Spontaneous breathing trial
A. T-piece or PSV (~ 5 cm H2O)
B. Up to 2 hours every 24 hrs.
 Weaning
• How often will the patient need to be re-
intubated?

• Accepted rate: 5% - 15%

 Failed to Wean
• Associated with intrinsic lung disease
• Associated with prolonged critical illness
• Increased risk in patient with longer
duration of mechanical ventilation
• Increased risk of complications, mortality
 Weaning
Failure Criteria
• Rapid shallow breathing
• RR > 35/min or > 10/min increase

• Tachycardia
• > 120 bpm or > 20 bpm increase
• BP change > 20%

• Mental status change

 Weaning
Failure Criteria
• Clinical signs of distress:
• Increased dyspnea
• Diaphoresis
• Accessory muscle use
• Paradoxical breathing

• Hypoxemia and/or hypercapnea

 Fatigue Criteria
•Hypoxia (PaO2 < 60, SpO2 <90%) 11 (31%)

•Hypercarbia (PaCO2 > 50 mmHg) 9 (25%)

•Pulse rate > 120/min 17 (47%)

•SBP > 180 or < 90 mmHg 2 (6%)

•Respiratory rate > 30/min 33 (92%)

•Clinical respiratory distress 27 (75%)

 Evidence-based medicine

• Patients receiving MV who fail an SBT

should have the cause determined.
• Once causes are corrected, and if the patient
still meets the criteria of DS, subsequent
SBTs should be performed every 24 hours.
 Weaning
Failure to Wean
• Auto-PEEP
• Cardiac disease
• CHF, ischemic heart disease
• Nutrition and electrolyte imbalance
• Inadequate rest following previous trial
• May need up to 24 hours
• Muscle weakness
• Paralysis or polyneuropathy of critical illness
 Mechanical Ventilation
Complications
• Barotrauma
• 4% - 15%
• Highest in ARDS

• Reductions in cardiac output

• Impaired right ventricular preload
 Mechanical Ventilation
Complications
• Renal effects

• GI bleeding
• 20% - 30% without prophylaxis

• DVT
• 40% - 80% without prophylaxis

• Ventilator induced pneumonia

 Mechanical Ventilation
Sudden Airway Pressure
• Tension pneumothorax

• ETT/tubing obstruction
• Mucous plugging - common

• Acute bronchospasm

• Mainstem migration of ETT