WEANING FROM

MECHANICAL
VENTILATION
WEANING
• It is the process by which patient’s dependance on Mechanical Ventilation is gradually reduced to the
point where spontaneous breathing sufficient to metabolic needs is sustained.
• Before weaning condition requiring mechanical ventilation should have resolved and patient should be :
• awake and co-operative with intact neuromuscular and bulbar function GCS >8.
• stable Cardiovascular function with minimal requirements of inotropic or vasopressors drugs.
• no ongoing respiratory metabolic acidosis.
• inspired oxygen requirements <50%.
• low sputum production.
• adequate nutritional status.
• Depnding upon these parameters patient may be given spontaneous breathing trial on air and
extubated
• If unsuccessful SBT patient is taken back on partial ventilator support or pressure support and gradually
Settings reduced and SBT repeated
WEANING CRITERIA

• Used to evaluate readiness of a patient for weaning teial

• clinical criteria
• Oxygenation criteria
• pulmonary reserve and measurements
CLINICAL CRITERIA

• Resolution of acute phase of disease

• Adequate cough
• Absence of excessive secretions
• Absence of fever (<38°)
• Adequate gas exchange by PaO2/fraction of inspired oxygen >200 with PEEP 5cmH2O
• Patient should not be in delirium or altered mental state
OXYGENATION CRITERIA

• It includes
• PaO2 without PEEP >60mmHg at FiO2 0.4
• PaO2 with PEEP (<8cmH2O) >100mmHG at FiO2 0.4
• SaO2 >90% at FiO2 0.4
• PaO2/FiO2 (P/F) ≥150mmHg
• Qs/Qt ( interpulmonary shunt ) <20%
• P(A_a)O2 <350mmHg at FiO2 1.0
VENTILATORY CRITERIA

• SBT tolerated 20-30 minutes

• paCO2 <50mmHg with pH >7.30
• Vital capacity >10ml/kg
• Spontaneous tidal volume Vt >5ml/kg
• Spontaneous respiratory rate (f) <30/ minute
• RSBI (f/Vt ) < 100 breath/minute/L
• VE (Minute Ventilation) <10L with satisfactory ABGs
PULMONARY RESERVE AND MEASUREMENTS

• vital capacity should be > 10ml/kg

• Maximum inspiratory pressure >_ 30 cmH2O in 20 second
• static compliance >30ml/cmH2O
• Airway resistance should be improving
• Vd/ Vt <60%
WEANING IN SEDATED PATIENTS

Sedation should be tapered off in patients to be given trial of weaning

• Long acting sedatives should be avoided
• Step down sedation substituting Propofol in place of Benzodiazepines
• Long time sedation with Benzodiazepines can cause delirium
• Dexmedetomidine decreases the duration of delirium
• Sedatives of GABA-ergic pathways ( Benzodiazepines, Opiates, Propofol) have adverse effects on
respiratory drive and timing.
• Remifentanil should be used in low dose 0.05ug/kg/minute in continuous infusion
ROLE OF ULTRASONOGRAPHY IN WEANING

• In addition to Echocardiography ultrasound of lungs and airway has potential use as baseline procedure
• B lines are vertical reverberation artefacts ( as opposed to horizontal A lines which are present in normal
lung ) arise from pleural line and move in synchrony with lung
• B lines shows increased lung density and decreased air content presence of B lines on USG lungs may
give early indication of heart failure and consolidation.
WEANING PROCEDURE

• Weaning can be done by using

• Spontaneous breathing trial
• Pressure support ventilation
• Synchronized intermittent mendatory ventilation.
SPONTANEOUS BREATHING TRIAL

• An evaluation of a patient readiness for weaning from Mechanical Ventilation and extubation
• It is major diagnostic test to determine if pt can be successfully extubated and weaned from Mechanical
Ventilation.
• Spontaneous breathing may be augmented with low levels ≤8cmH2O of pressure support CPAor
Augmented Tube Compensation.
• SBT may last for 30minutes.
STEPS OF SBT

1. May use T-Tube ,CPAP or Automated tube compensation

2. Let pt breathe spontaneously for upto 30 minutes
3. May use low levels of Pressure support<8cmH2O for adults and 10cmH2O for pediatric to augment
spontaneous breathing.
4. Closely monitor patient
5. If patient tolerates SBT consider extubation when ABGs and vital signs are satisfactory.
RAPID SHALLOW BREATHING INDEX

• It is ratio of respiratory rate to tidal volume in Liters

• RSBI 100- 105/min/L predictor of successful weaning
• RSBI >120/minute/L leads to weaning failure
WEANING USING SIMV

• Number of mechanical breaths is progressively decreased by 1-2 breath/minutes as long as respiratory

rate <30 and PaCO2 45-50mmHg
• Pressure support concomitantly used it should be reduced to 5-8cmH2O.
• ABGs can be checked 15-30 minutes with each new settings
• When IMV of 2-4 breath is reached disconnect Mechanical Ventilation if ABGs remain stable
* In patients with acid base disturbances and chronic CO2 retention then Arterial Blood pH >7.35 is
more useful the CO2 tension .
WEANING USING PSV

• It is done by gradually decreasing pressure support level by 2-3cmH2O whila Vt respiratory rate and
ABGs monitered
• Tidal vol should be 4-6ml/kg
• Respiratory rate should be <30
• PaO2 and PaCO2 should be in acceptable range
• P support 5-8cmH2O reached
• Disconnect Mechanical Ventilation
WEANING USING T-PIECE OR CPAP
• T-piece trials allows observation while pt breathe spontaneously without Mechanical breaths.
• T-piece is directly attached to Tracheal tube itgas corrugated tubing on other two limbs a humidified
oxygen air mixture flows into proximal limb and exits from distal limb .
• Closely monitor pt.
• If obvious new signs of Fatigue ,Chest retractions, tachypnea, tachycardia, arrhythmias , Hypertension,
Hypotension.If anny of them seen then terminate the trial.
• If pt tolerate the trial and RSBI <100 mechanical ventilation should be disconnected.
• Patient can also protect and clear airway it’s mendatory before extubation.
• If pt intubated for longer time sequential T-PIECE trials may be necessary.
• Progressive trials of 10-30min and progressively increased by 5-10min per each trial .
 DRAWBACKS OF T-PIECE TRIALS

During prolonged T-piece trials it may cause progressive Atelectasis and FRC of lung is decreased.
If this is concern SBT on low levels (5cmH2O) CPAP is used it helps to maintain FRC in normal ranges (1.8- 3L )and
prevents the lungs from Atelectasis.
DEFINITIONS
• Weaning success: Defined as a period of consecutive 1-7 ventilator free days after liberation from Mechanical Ventilation
• Difficult weaning: Defined as A patient is considered difficult to wean if pt failed their first SBT and then require upto 3 SBTs or
7 days to pass on SBT.
• Prolonged weaning: weaning in which pts who failed 3 weaning attempts or require more then 7 days for weaning after first
SBT.
• Weaning in progress: it as an intermediate category between weaning success and weaning Failure for patients who are
extubated but continue to receive ventilatory support by Non invasive ventilation (NIV)
• Weaning Failure: failure of SBT or the need of re-intubation within 48 hours following extubation.
Early signs of weaing failure include; Tachypnea > 35
Use of accessory muscle
Paradoxical abdominal movements
dyspnes , chest pain , chest abdomen asynchrony and diaphoresis.
CAUSES OF DIFFICULT WEANING

• Respiratory:
1. Poor lung compliance (Oedema , consolidation, fibrosis, atelectasis, pulmonary secretions)
2. Poor chest wall compliance ( pleural effusion,obesity)
3. Increased resistive load ( Bronchoconstriction, dynamic hyperinflation in COPD blocked artificial airway , obstruction.)
• Neuromuscular:
1. Decreased central repository drive ( coma , obesity, hypoventilation syndrome, myxoedema)
2. Decreased airway reflexes ( drugs or toxin related ,bulbar, neurological dysfunction)
3. Neuromuscular weakness ( critical illness , neuromyopathy, myasthenia gravis)
• Neuropsychiatric : (Delirium anxiety sleep deprivation )
• Metabolic ( hypokalemia, hypophosphatemia, hypomagnesemia)
• Cardiac failure
INDICATIONS OF WEANING FAILURE
• Blood Gases :
• Increased PaCO2 (>50mmHg)
• Decreasing pH (< 7.30)
• Decreasing PaO2 ( <60mmHg)
• Decreasing PaO2/FiO2 ( <150mmHg)
• Vital Signs:
• Changing BP (20mmHg systolic or 10mmHg diastolic)
• Increasing HR ( by 20/min or > 110/ min
• Abnormal ECG ( presence of Arrhythmias)
• Respiratory parameters:
• Decreasing Tidal volume <250 ml
• Increasing f >30/ min
• increasing f/Vt > 100/min/ L
• Decreasing MIP ( -20 cmH2O )
• Decreasing static compliance (<30ml/ cmH2O )
• Increased VD/ VT (>60%)
CAUSES OF WEANING FAILURE

1. Increased air flow resistance

2. Decrease of thoracic compliance
3. Respiratory muscle fatigue
•
STRATEGIES FOR DECREASING AIRWAY
RESISTANCE

• Periodic monitering of Endotracheal tube for kinking or obstruction by secretions

• Other devices attached to ETT such as suction catheter, heat and moisture exchanger , ETCO2
monitering
• ETT suctioning to remove retained secretions
• Use of Bronchodilators to relieve Bronchospasm
• In COPD patients airway resistance is increased from 9±2cmH2O tp 15±2cmH2O within 45 monutes of
SBT
 CONT.

• Low lung or Thoracic compliance will lead to increase in airway resistance

• Muscle disuse will lead to respiratory muscle dysfunction and diaphragmatic Atrophy
• ≥ 5-6 days of Mechanical Ventilation the force generating capacity of diaphragm is reduced by 2/3.
• Retraining of Atrophied muscles may be accomplished by short T-piece trials which improves respiratory muscle strength
• PSV increases Diaphragmatic endurance.
TERMINAL WEANING

• Withdrawal of Mechanical ventilation that results in death of the patient who is terminally ill or brain
dead .
• Different from Euthanasia or Mercy killing as disease is allowed to take natural course of death
• Ethical and moral issue's arise before ending mechanical ventilation support
• Only done after detailed discussion with family members and taking their consent and patient s consent
if conscious when medical intervention is futile or hopeless in treating illness.
• In Pakistan such a move requires permission from High Court .
THANK YOU