STEER Weaning Protocol:

Liberating Patients From Mechanical Ventilation

Julie Emerick, RRT

ICU Coordinator
Respiratory Therapy
UCSD Medical Center
 Weaning From Mechanical
Ventilation
● Can account for >40% of time on
ventilator1
● Clinical judgment often inaccurate in
predicting the success of extubation.
● Reintubation is associated with
increase in mortality and morbidity
1. Esteban Chest 106:1188-93 1994
 Purposes of Weaning

● Assure medical team that patient can

tolerate extubation
● Train respiratory muscles
 Good News! Simpler Is
Better.

Old, Complex Way New, Simple Way

● Daily clinical estimate of ● Try nearly everyone daily
weaning potential
● Weaning parameters: ● f/TV < 105
VE < 15, TV < 4ml/kg,
f < 38, MIP > 15
● Randomly reduce IMV and ● Intermittent “sprints”
PS based on bedside
assessment
 STEER Weaning Protocol

● Help clinician determine which class

patient is in at any given time.

● Give clinician more complete

information

● Continuously update data

 STEER

● Screen for contraindications

● Trial of minimum support breathing
● Exercise according to protocol
● Evaluate progress
● Report information to the clinicians.
 Classes of Mechanically
Ventilated Patients

C l a s s C1 l a s s 2C l a s s 3C l a s s 4
e x t u b a Pt i or o n g r e N s o s t P r o g r Ne so s s i np gr i n t
p r e d i c t te o d w a r d t o w a r d
f / V t < 1 e0 0x t u b a t i eo x n t u b a t ci oo nn t r a i n d i c a t e d
Screen for Contraindications
Assessment Procedure:
Step 1
M e c h a n i c a l l y
v e n t i l a t e d
p a t i e n t s
a s s e s s e d q A M .
A r e s p r i n t s
c o n t r a i n d i c a t e d
b y c l i n i c a l i n f o ? .

A l l O t h e r s C l a s s 4
p e r f o r m 1 m i n u t Ne os p s r p i nr i t n t
P S = 5 , C P A P = P E E P
c o n t r a in d ic a t e d
 Does the patient have…...
● Neuromuscular blockers
● PEEP > 5
● FiO2 > 45% or Sa02 < 92%
● Hemodynamic instability
● Increased ICP
● Sedation drip (Propofol, Ativan, Versed, etc.)
● Unstable angina
● Temp > 39
● Physician has requested patient not to be weaned
 Who Is Ready to Wean?

● 300 ventilated patients were screened daily

for four criteria.1
» pO2 / FiO2 > 200
» PEEP < 5
» adequate cough
» no pressors or sedative drips
● Randomized: physician vs protocol weaning
1. Ely NEJM 335(21):1864-9 1996
Trial of Minimum Support
Breathing
 Who Is Ready to Wean?

Traditional Method Protocol Method

● Physicians not told ● “Sprint” (CPAP) for 1
of screening results. min, if tolerated...
● Weaning entirely ● Sprint for 2 hours, if
based on clinical tolerated…
judgment. ● “Doctor, your patient is
ready to be extubated.”

Ely NEJM 335(21):1864-9 1996

 Outcomes
Traditional Protocol

0
Wean time M.V. time reintubate ICU cost
(days) (days) (percent) (X$10,000)
 “Sprintable” Patient-Days

Protocol
25%

Non-
Protocol
75%

UCSD Med CTR 10/2000 – 2/2001

 “Sprintable” Patient-Days
Protocol Protocol No
Sprint Sprint
23% 1%
Non-
protocol
Sprint
33%

Non-
protocol No
Sprint
43%
UCSD Med CTR 10/2000 – 2/2001
 Predictors of Successful
Extubation
● required VE (on ventilator)
– VCO2, VO2
– Vd/Vt
● A-a gradient
● Compliance
– Vt/(PIP-PEEP)
● Negative inspiratory force
– strength
 Weaning Predictors:
combining concepts
● Vital Capacity
– strength, compliance
● Tidal Volume
– strength, compliance
● Respiratory Frequency
– strength, compliance, ventilatory requirements
● Minute Ventilation
– strength, compliance, ventilatory requirements
 Frequency/Tidal Volume Ratio

● strength, compliance, ventilatory requirements

● high number (>105): rapid, shallow breathing
» capacity to breath >> work of breathing
 Predictors of Successful
Wean

● Multiple “weaning parameters” measured on

100 consecutive ventilated adults

● Extubation by clinicians blinded to results

Yang and Tobin. NEJM 324(21):1445-50 1991

 Definitions

● Sensitivity
(good WP and extubated for 24 hrs)
all pts extubated for 24 hrs

● Specificity
(poor WP and not extubated for 24 hrs)
all not extubated for 24 hrs
 Predictors of Extubation for
>24h
Sensitivity Specificity
97% 100% 97%
1 92%
78%
0.8
64%
0.6 54%

0.4 36%
18%
0.2 11%
0
Ve f TV MIP f/TV

Yang and Tobin. NEJM 324(21):1445-50 1991

Assessment Procedure:
Step 2
A l l O t h e r sC l a s s 4
p e r f o r m 1 m i n u t Ne os p s r p i nr i t n t
P S = 5 , C P A P = P E E P
c o n t r a in d ic a t e d

W a s f / V t a f t e r
o n e m i n u t e
< = 1 0 0 ?

C l a s s A1 l l O t h e r s
e x t u b a t i o a ns s e s s s p r i n t
e x p e c t e dp r o g r e s s f o r
p r e v i o u s 4 8 h r s .
Exercise According to
Protocol
 Sprint Procedure: Class 1
Patients

● Two hour CPAP sprint with f/Vt < 100

» extubation success highly probable
» physician notified, asked re: extubation
● Fatigue during 2 hour CPAP
» repeat sprint after a 4-6 hour rest
 Stop sprint if not tolerated
for…..
● BP < 90 or > 170 systolic
● RR > 35 X 5 minutes
● Change in HR of 20% or > 130 BPM
● SaO2 < 90/ or within MD specified limits
● 50% reduction in minute volume
● Temp > 39
● Arrhythmias* (Contact MD/RN. Don’t
repeat sprint until MD approval)
 Sprint Procedure: Class 1

C l a s s C 1l a s s C 2l a s s C 3l a s s 4
e x t u b a t i oSn p r i n t S p r i n t N o s p r i n t
p r e d i c t e pd r o g r a m p r o g r a m
f / V t < 1 0 0 p r o g r e s s i nn og p r o g r ce os sn t r a i n d i c a t e

T w o h o u r
C P A P t r i a l
t o l e r a t e d ?

y e s n o
n o t i f y Mr e . pD e. a t t r i a l
i n a f t e r n o o n
 Sprint Procedure: Class 2
Patients
C l a s s 1C l a s s 2C l a s s 3C l a s s 4
e x t u b a t i o nS p r i n t S p r i n t N o s p r i n t
p r e d i c t e dp r o g r a m p r o g r a m
f / V t < 1 0 p 0 r o g r e s s ni n o g p r o g c r eo sn st r a i n d i c a t

S p r i n t P r o t o c o l

R e c o r d P r o g r e s s
 Training Respiratory
Muscles
● partially unload muscles so that they
may grow stronger with exercise
● muscle fatigue (intended goal)
● muscle exhaustion (setback)
● clinican becomes coach
 Sprint Procedure: Class 2

● Work intervals alternating with rest

● Place patient on CPAP/PS 20 and
decrease PS until RR is in the mid 20’s
● Sprint BID X 30 min on the same PS
● Gradually increase respiratory load
» decreasing support until CPAP is tolerated
● Move to Class 1
Predictors of Extubation for >48
h
Completed sprint Stayed extubated for 48 hours

88% 85%
1 76% 73%
0.8

0.6

0.4

0.2

0
30 min sprint (n=270) 120 min (n=256)

Esteban et al. AJRCCM 159: 512-518 1999

 Classes of Mechanically
Ventilated Patients

C l a s s C1 l a s s 2C l a s s 3C l a s s 4
e x t u b a Pt i or o n g r e N s o s t P r o g r Ne so s s i np gr i n t
p r e d i c t te o d w a r d t o w a r d
f / V t < 1 e0 0x t u b a t i eo x n t u b a t ci oo nn t r a i n d i c a t e d
 Comparison of Four Weaning
Methods1

● 132 vent’d adults who did not tolerate

2 hour sprints were randomized to:
» Twice daily reduction in IMV rate
» Twice daily reduction in PS level
» Twice daily “sprints” (CPAP 5cm H20)
» Once daily “sprint” (CPAP 5cm H20)

Esteban. NEJM 332(6):345-60 1995

 Median Duration of
Weaning

IMV PS Sprint X 2 Sprint X 1

5
4
5
4
3
Days

3 3
2
1
0
Patients Weaned Within
14 Days

IMV PS Sprint X 2 Sprint X 1

100%

75%
82%
50% 69% 62% 71%
25%

0%
Evaluate Progress
 Documenting Sprint
Progress

● Evaluate after last sprint of the day

● Was best sprint > than best sprint 48

hours ago?
 Which sprint trial is
hardest?

1) PS = 15, IMV=10, duration=2 hours

2) PS = 10, IMV=15, duration=2 hours
3) PS = 5, IMV=10, duration= 30 min
4) PS = 10, IMV=5, duration=30 min
5) PS = 20, IMV=0, duration=2 hours
6) PS = 10, IMV=0, duration=1 hour
7) PS = 7, IMV=0, duration=30 min
 How to Assess Progress

● Weaning technique must be simple

● Technique must not change daily
● Duration of sprint must be constant
 Which sprint trial is
hardest?
1) PS = 20, IMV=0, duration=30 min
2) PS = 15, IMV=0, duration=30 min
3) PS = 10, IMV=0, duration=30 min
4) PS = 5, IMV=0, duration=30 min
5) PS = 5, IMV=0, duration=60 min
6) PS = 5, IMV=0, duration=90 min
7) PS = 5, IMV=0, duration=120 min
 Sprint: Class 3 Patients

C l a s s 1C l a s s 2C l a s s 3C l a s s 4
e x t u b a t i o nS p r i n t S p r i n t N o s p r i n t
p r e d i c t e d p r o g r a m p r o g r a m
f / V t < 1 0 0p r o g r e s s i nn og p r o g r c e o s n s t r a i n d i c a t e

N o t i f y M . D .
a b o u t l a c k
o f p r o g r e s s
( f u r t h e r w / u ? )

S p r i n t P r o t o c o l

R e c o r d P r o g r e s s
 Sprint Procedure: Class 3
Patients

● Same sprint routine

● Investigate causes of failure to wean

 Causes Of Weaning Failure

● Gas Exchange Inadequacies

● General Metabolic Illness
● Respiratory Pump Failure
Report Information to the
Clinicians.
 Classes of Mechanically
Ventilated Patients

M e c h a n i c a l l y
v e n t i l a t e d
p a t i e n t s
a s s e s s e d q A M .

C l a s s C1 l a s s C2 l a s s C3 l a s s 4
e x t u b a t i So np r i n t S p r i n t N o s p r i n t
p r e d i c t ep dr o g r a mp r o g r a m
f / V t < 1 0 p 0 r o g r e s s n i no g p r o g cr eo sn st r a i n d i c a