Northeast Center for Special Care

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300 Grant Avenue
Lake Katrine, NY 12449
845-336-3500

Information Bulletin

Weaning From a Ventilator

The purpose of this article is to assist loved ones, caregivers and ventilator patients
themselves to understand the complexities of trying to wean off a ventilator. In order to
accomplish this understanding we must first understand a few basic ideas.

First lets start with the word ventilator. Many people refer to a ventilator as a respirator.
In medicine we understand when people refer to the ventilator as a respirator. The
difference is simply in the technical definition. A ventilator moves air from one place to
another a respirator exchanges gases; such as the oxygen and carbon dioxide we exhale.

It is sometimes difficult to understand why

when it seemed so easy to initiate the
ventilator; can it be so difficult to remove it.

People find themselves on ventilators for various reasons, but many utilize this
intervention because of lung disease. In certain lung diseases the ability to exchange these
gases is significantly altered. Because of this alteration the ventilator can assist the
patients breathing but not reverse the lung disease process. Therefore gas exchange
cannot be guaranteed; hence a ventilator and not a respirator.

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It is sometimes difficult to understand why when it seemed so easy to initiate the
ventilator; can it be so difficult to remove it. There are many components to returning a
patient to their own spontaneous breathing and each individual is just that an
individual, so weaning programs should be tailored for the individual need.

We must understand in the recovery and rehabilitation of a ventilator dependent patient

removal of the ventilator is often the last phase of the process. So lets start at the
beginning and work through the understanding of this process.

A ventilator patient is deemed ready to wean. This determination is usually made when
the primary reason for the initiation of the ventilator has been reversed or stabilized. It is
important to remember there are as many ways to wean a patient, as there are reasons to
place them on the ventilator. This concept works in favor of the weaning patient because
it allows for the individualization of each patients program.

A key component that is often overlooked in a weaning program is the patients

nutritional status. The patient may have been supported for days on intravenous fluids
that provide hydration but little nutrition. Often when a patient is deemed ready to wean
their serum albumin and total protein levels in the blood reveal malnutrition. It is this
writers belief that until significant gain in correcting this malnutrition has been achieved
no weaning should be initiated. It is like asking a marathon runner to not eat for a weak
and then run a 26-mile race. I am sure they wouldnt get very far or finish.

A dietician will work closely with the physician to provide the caloric intake and
nutritional values that the patient needs to support the weaning process. The dietician has
many factors to consider when determining the correct nutritional recipe for the patient.

Patients often have many diagnoses that have to be considered in the nutritional formula.
A patient with kidney disease will have difficulty with protein, a diabetic with glucose,
and the lung disease patient may have significant issues with volume, an obese patient
needs nutrition in a reduced number of calories.

Another factor that must be considered, especially for those patients who eat by mouth is
food simply has little or no taste. The reason for this is the tracheostomy tube. When a
patient has a tracheostomy tube breathing through the nose and mouth no longer occurs.
It is the nose that helps us smell and taste food. The tracheostomy patient no longer or has
little ability to smell and taste like most people. This may cause decreased appetite.
Encouragement and utilization of devices referred to as speaking valves often help with
this issue.

Once the recipe or nutritional formula has been determined and the patient is tolerating it
and nutrition is improving its time to look at the next area that can and often does
complicate the weaning process.

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Medications are like a double-edged sword; they have significant benefit in treating
disease and their symptoms but never without consequence. In medicine the physician
weighs the risk-benefit of medications carefully. The need for certain medications such
as pain and anti-anxiety medications can complicate the weaning process as well as
enhance it.

Therapists are an integral part of the

weaning process.

Lets start with pain medications. If a patient has pain they are unable to participate in
their rehabilitation process to the maximum potential. Many pain medications such as
those in the opiods family (morphine) can suppress a patients breathing. Many of the
anti-anxiety medications can cause the patient to be sleepy again reducing the ability to
participate. Some medications can even cause confusion making it even harder for the
patient to participate. The physician must look to relieve the pain and anxiety without
over sedating the patient. If the level of medication required to relieve these symptoms
cause the undesired side effects it may be necessary to postpone weaning attempts until
these issues have been resolved.

Now that the patient has improved nutritional status and has pain and anxiety well
controlled we can proceed to the active rehabilitation of the ventilator dependent patient.

Occupational, Physical and Speech therapists may begin to work with the patient one by
one or as a team. It is imperative to remember a patient must be able to follow simple
commands and participate in order for active therapy to occur.

The therapists are an integral part of the weaning process. The major component of
breathing requires muscle use, the diaphragm as well as muscles in the neck and chest.
Just like the marathon runner it takes time and training to reach the goal. No one decides
to run a marathon and succeeds the same day. Daily participation in therapies is essential
to achieving the ultimate goal of weaning off the ventilator.

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During the rehabilitation phase the Respiratory therapists will work closely with the
physician to determine a weaning program that will best suit the individual patient.
Remember no matter how much we want someone to wean it takes all or most of the
components to be successful as well as time.

It is sometimes difficult to understand why patients are hesitant to come off the ventilator
but if we look carefully we can comprehend the fear and anxiety that is associated with
this process for the patient. Imagine if you will that you couldnt breath and now you
have a machine that helped you, makes your work of breathing easier. Now suddenly
everyone wants to take that away from you. Patients wonder, what if I get short of breath,
what if I get tired, what if I go to sleep and these are just a few of the what ifs that
weigh heavily on their mind.

Together the medical team and families can help allay the patients fear. Families can
give the medical team insight to the personality and coping skills the patient had prior to
their illness. These valuable insights can help the medical team develop a successful plan
towards weaning. As family members your support in the process is essential. If you are
fearful of the process so will the patient.

Trust is the essential ingredient for the

patient.

Asking questions of the medical team will help you understand the plan. Trust is the
essential ingredient for the patient. They must have the trust and confidence in their
medical team to keep them safe and breathing easy.

Very often the medical team will see the patients and their families focusing on
numbers. They hear questions such as what is my pulse oximetry? Yesterday the
number on the machine was 10 now its 12, why? This phenomenon is very

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understandable; people want to make sense out of all this technical information. The
numbers are familiar, they flash on the ventilator screen and across the pulse oximeter
routinely. Yet the question begs to be asked, what do the numbers mean?

The numbers are used by the medical team to assess and trend information and monitor
the patients progress. People often forget to look at the patient. Is the patient
comfortable, not sweating; has good pink color, able to perform their required therapies?
These are all good indicators that the patient is doing well. The medical team will
evaluate all the numbers and adjust the plan of care accordingly.

It is important to remember that just like in the laws of physics the patient is the sum of
all its parts. Many factors and chronic conditions must be considered when initiating a
plan of care for weaning. Age, chronic conditions, anxiety, depression, previous level of
function as well as setting realistic goals are part of the planning process. It is very
important that every member of the team; which includes the patient and their family,
agrees with and understands the plan. Together, as a team with dedication and hard work
the reward of being free from mechanical ventilation awaits you.

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