Liberation

from
Mechanical Ventilation
(Weaning)

By:RINCY OPPUTTIL CHACKO,RN(CSICU)

WEANING
In the intensive care, weaning from the
following 5 modalities has to be
independently assessed:
Supplemental Oxygen
PEEP
Mechanical Ventilation
Artificial Airway (endotracheal
tube/tracheostomy)
Inotropes

Weaning
Weaning should be based on accurate
concepts the capacity to breathe
spontaneously occurs when the
underlying condition improves. This has
more to do with accurate diagnosis and
effective treatment of the underlying
condition and less to do with
manipulation of ventilator settings.

Weaning
Delayed extubation is associated with
increased risk for ventilator associated
pneumonia, increased ICU and hospital
length of stay and increased mortality.
Failed extubation may occur in 20% of
patients - hence there is a need for
improving the prediction of extubation
outcome.

WEANING
versus
LIBERATION
Weaning
graded removel of a therapeutic modality on which
the patient has become dependent .The term gradual
removal of a benevolent process.
In actual fact, weaning from many of the life support
interventions instituted in the intensive care is not
removal of a benevolent life sustaining process but
the removal of a necessary (in the short term) but
potentially damaging (when prolonged) intervention
as early as feasible.
In this context it is appropriate to name this process as
liberation from mechanical ventilatory and other
life support measures.

Domains of Criteria
Respiratory
Cardiovascular
Neuromuscular
There are two types of criteria used to
determine whether a patient passes or fails a
spontaneous breathing trial: objective criteria
(abnormal arterial blood gas measurements)
and subjective criteria (diaphoresis, evidence
of increasing effort, tachycardia, agitation,
anxiety).

RESPIRATORY
CLINICAL SIGNS of increased work of breathing
intercostal retraction
accessory muscle use
nasal flaring, sternomastoid / trapezius use
paradoxical or asynchronous rib cageabdominal breathing movements

VENTILATION / OXGENATION
- respiratory frequency > 35 breaths/min
- arterial oxygen saturation below 90%
- f / VT ratio (Tobin Index) less than 100 predicts
successful weaning. f is respiratory rate in
breaths per minute and VT is tidal volume in
litres.

CARDIOVASCULAR
Heart rate
> 140 beats/minute or
sustained increase or decrease in
the heart rate of more than 20%
Systolic blood pressure
>180 mmHg or
< 90 mmHg

NEUROLOGICAL
Glasgow Coma Score > 8
If < 8, consider tracheostomy
Diaphoresis / anxiety / agitation

Weaning - Preconditions

Weaning - Preconditions
- off sedation for a sufficient length of time (depending
on the half life of the sedative given)
- propped up (to allow easier diaphragmatic
movement)the airway is to be cleared by suctioning
secretions
- FiO2 should be increased by 0.1 (if not COPD)
- baseline values for pulse, respiratory rate, blood
pressure, SaO2 and PaCO2 should be obtained.

Modes of Weaning
1.
2.
3.
4.

T-tube
CPAP
SIMV
Pressure Support
Because the endotracheal tube imposes a resistive
load on the respiratory muscles that is inversely
related to its cross-sectional diameter, some
clinicians advocate use of 5-8 cmH2O pressure
support to offset this imposed load.

5. SIMV + PS

Weaning : which mode?

T-piece weaning is more efficient than pressure
support based weaning which in turn is better
than one based on SIMV.
protocol based weaning is more efficient than
one based on subjective evaluation because
subjective judgment is not sensitive enough
to detect the fact that a patient is ready for
extubation.
successful extubation was achieved equally
effectively with trials targeted to last 30 and
120 min.

Failure of Weaning
Indicators of deterioration are:
1. respiratory rate >35/mt.
2. falling tidal volume <5ml/kg
3. PaO2 <55mm Hg; Rising PaCO2
4. fall in blood pressure
5. tachycardia, cardiac arrhythmias,
sweating -increased sympathetic activity
6. altered mental status - restlessness,
anxiety, confusion

FAILURE TO WEAN OFF VENTILATOR:

CAUSES - 1
Respiratory:

wider bore artificial airway

ET tube / tracheostomy
- Treat bronchospasm adequately
- Improve lung compliance by removing excess
fluid (wet lungs) by using diuretics if volume
overloaded / congestive cardiac failure is the cause.
- Improve diaphragmatic function by using xanthines.
- Use

FAILURE TO WEAN OFF

VENTILATOR: CAUSES - 1
Cardiovascular:
left ventricular dysfunction
- pulmonary oedema (backward failure)
- inability of the cardiovascular system to
provide the increase in delivery of oxygen
needed by the respiratory
muscles during weaning
(forward failure)
Appropriate therapy (diuretics / vasodilators / inotropes)
Wean the inotropes only after successful weaning from
mechanical ventilatory support.
Haemoglobin must also be optimized
> 8g%
> 10g% with myocardial ischemia / cerebral ischemia

FAILURE TO WEAN OFF VENTILATOR:

CAUSES - 2
Neurological:
-brain stem dysfunction due to trauma, hypoxia or
infection, critical illness polyneuropathy
-intermediate syndrome due to organophosphorus
insecticides
Fluid Balance:
Positive cumulative fluid balance is associated with
failure to wean and a negative fluid balance was
predictive of a successful weaning in a recent study.
Infection:
any sepsis and/or respiratory infection should have
resolved

FAILURE TO WEAN OFF VENTILATOR: CAUSES - 3

Drugs
- stop sedatives and drugs likely to impair
neuromuscular function.
- give antidotes ( flumazenil, nalorphine, neostigmine)
as indicated
Electrolytes - maintain normal serum potassium and
phosphorous
Alkalosis
- respiratory dont chase the PaCO2
- metabolic reduce base excess (?acetazolamide)
PaO2
Endocrine - hypothyroidism

Post Extubation Stridor

The Cuff leak test:
The ventilator is used in Assist Control mode with a tidal
volume of 10-12ml/kg. The expired tidal volume is measured
with the cuff inflated. The cuff is then deflated and after
elimination of artefacts due to cough, four to six consecutive
breaths are used to compute the average value for the
expiratory tidal volume. The difference in the tidal volumes
with the cuff inflated and deflated is the leak. A value of
130ml (12% of inspiratory tidal volume) gave a sensitivity of
85% and a specificity of 95% to identify patients with an
increased risk of post extubation stridor.

Post Extubation Stridor

Cough / Leak test: In spontaneously breathing patients
the tracheal cuff is deflated and monitored for the first
30 seconds for cough. Only cough associated with
respiratory gurgling (heard without a stethoscope and
related to secretions) is taken into account.
The tube is then obstructed with a finger while the
patient continues to breath. The ability to breathe
around the tube is assessed by the auscultation of a
respiratory flow.