Weaning from mechanical ventilation

1. Weaning FromWeaning From
Mechanical VentilationMechanical Ventilation
Soumya Ranjan ParidaSoumya Ranjan Parida
Basic B.Sc. Nursing 4Basic B.Sc. Nursing 4thth
yearyear
Sum Nursing CollegeSum Nursing College

2. IntroductionIntroduction
••The process of weaning from mechanical ventilation can beThe process of weaning from mechanical ventilation can be
considered as the work of breathing from the ventilator to theconsidered as the work of breathing from the ventilator to the
patient.patient.
••Just as patient is at increased risk if the need for mv is notJust as patient is at increased risk if the need for mv is not
recognised,so also there is increased risk of complication forrecognised,so also there is increased risk of complication for
every extra day spent on mechanical ventilation.every extra day spent on mechanical ventilation.
••unlike the heart ,the lungs themselves are incapable of moving airunlike the heart ,the lungs themselves are incapable of moving air
in and out and require other muscle and central respiratory drivein and out and require other muscle and central respiratory drive
to sustain oxygen and carbon dioxide removal.to sustain oxygen and carbon dioxide removal.
 successful weaning therefore depends on many factor thatsuccessful weaning therefore depends on many factor that
interact .interact .
 Too aggressive discontinuation of ventilatory support put theToo aggressive discontinuation of ventilatory support put the
patient at risk of atelectasis and reintubation.patient at risk of atelectasis and reintubation.
 This usually involves initiation of weaning mode andThis usually involves initiation of weaning mode and
manipulation of setting to reduce the amount of support frommanipulation of setting to reduce the amount of support from
the machinethe machine

3. Factors to consider during weaningFactors to consider during weaning
 General Condition of patient –Anemia, nutritional status,General Condition of patient –Anemia, nutritional status,
conscious level, and respiratory driveconscious level, and respiratory drive..
 Condition of the muscle-condition of respiratory muscleCondition of the muscle-condition of respiratory muscle
after prolonged paralysis; recovery from neuromuscularafter prolonged paralysis; recovery from neuromuscular
illness, diaphragmatic palsy.illness, diaphragmatic palsy.
 Ventilatory factors-compliance and resistance from circuit,Ventilatory factors-compliance and resistance from circuit,
support provided, ease of opening of the demand valve.support provided, ease of opening of the demand valve.
 Airway factors- resistance from small size endotracheal tube,Airway factors- resistance from small size endotracheal tube,
secretions, upper airway obstruction.secretions, upper airway obstruction.

4. Markers of improved conditionMarkers of improved condition
 Improving general condition, fever etcImproving general condition, fever etc
 Decreasing FiO2 requirementDecreasing FiO2 requirement
 Improving breath soundsImproving breath sounds
 Decreasing ET secretionsDecreasing ET secretions
 Improving chest xrayImproving chest xray
 Improved electrolyte and fluid statusImproved electrolyte and fluid status
 Improving hemodynamic statusImproving hemodynamic status
 Improving neurological statusImproving neurological status

5. Indices for successful weaningIndices for successful weaning
 There are oxygenation and ventilatory criteria,There are oxygenation and ventilatory criteria,
as both are important for successful weaning.as both are important for successful weaning.
 While oxygenation criteria may be fairly useful,While oxygenation criteria may be fairly useful,
Reducing pip , fio2 and amount of minute ventilationReducing pip , fio2 and amount of minute ventilation
provided by the ventilator may help inprovided by the ventilator may help in
defining low and high risk categories.defining low and high risk categories.

6. Criteria for weaningCriteria for weaning
Ventilation criteriaVentilation criteria
••reducing pip<reducing pip<
••peep< 6peep< 6
••psv 5-10psv 5-10
•• Tidal volume>6ml/kTidal volume>6ml/k
Oxygenation criteriaOxygenation criteria
••Pao2> 60 on fio2<0.6Pao2> 60 on fio2<0.6
••PAO2/FIO2>200PAO2/FIO2>200
••Oxygenation index<10Oxygenation index<10

7. Preparation for weaningPreparation for weaning
On investigationOn investigation
••chest X raychest X ray
•• ABGABG
•• HemoglobinHemoglobin
••ElectrolytesElectrolytes
••Calcium & MagnesiumCalcium & Magnesium
Clinical examination
•Respiratory distress
•Rate of breathing
•use of accessory muscle&
muscle strength.

8. Methods of weaningMethods of weaning
 SIMV with decreases in rateSIMV with decreases in rate
 Reduce the amount of Pressure supportReduce the amount of Pressure support
ventilationventilation
 T-piece weaning with spontaneous breathingT-piece weaning with spontaneous breathing
trialstrials
 CPAP/PEEP of<5cm of water.CPAP/PEEP of<5cm of water.

9. Method of weaningMethod of weaning
 Before initiating of weaning a chest xray should beBefore initiating of weaning a chest xray should be
done to obtain a baselinedone to obtain a baseline
 Increase in compliance and FRC typically heraldsIncrease in compliance and FRC typically heralds
recovery from pulmonary disease.recovery from pulmonary disease.
 The ventilator mode should be changed from controlThe ventilator mode should be changed from control
mode to SIMV mode with pressure support.mode to SIMV mode with pressure support.
 The first setting to be reduced is PIP by 1.0 cm H2OThe first setting to be reduced is PIP by 1.0 cm H2O
decrements till it is brought down to 25 cm H2O.decrements till it is brought down to 25 cm H2O.
 Then PIP and FiO2 ( decreased 0.05 or 5%) areThen PIP and FiO2 ( decreased 0.05 or 5%) are
reduced alternately till a relative safe level of 20 PIP andreduced alternately till a relative safe level of 20 PIP and
0.6 FiO2 are reached0.6 FiO2 are reached

10. Method of weaningMethod of weaning
 After this FiO2 and PEEP should be decreased hand inAfter this FiO2 and PEEP should be decreased hand in
hand i.e. at 0.6 FiO2, PEEP should be 6. PIP should behand i.e. at 0.6 FiO2, PEEP should be 6. PIP should be
reduced by 1.0 cm H2O every 15- 20 mins.reduced by 1.0 cm H2O every 15- 20 mins.
 Ventilatory rate is now reduced in small increments of 2Ventilatory rate is now reduced in small increments of 2
breaths/min till it is brought down to 10breaths/minbreaths/min till it is brought down to 10breaths/min
 Extubation is indicated when FiO2 is 0.4, PIP 10- 15cmExtubation is indicated when FiO2 is 0.4, PIP 10- 15cm
H2O,PEEP 3 cm H2O, Ti 0.3sec and RR 10/min.H2O,PEEP 3 cm H2O, Ti 0.3sec and RR 10/min.
 Some infants can be put on CPAP before extubation.Some infants can be put on CPAP before extubation.

11. Extubation From ventilatorExtubation From ventilator
 Extubation can be performed when the full criteria areExtubation can be performed when the full criteria are
met:met:
 Control of airway reflexes, minimal secretions.Control of airway reflexes, minimal secretions.
 Good breath soundsGood breath sounds
 Minimal oxygen requirement <0.3 with SpO2 >94.Minimal oxygen requirement <0.3 with SpO2 >94.
 Minimal rate 5/minMinimal rate 5/min
 Minimal pressure supportMinimal pressure support
 Adequate muscle toneAdequate muscle tone
 Minimal ionotropic supportMinimal ionotropic support
 Normal electrolytes, no fluid imbalanceNormal electrolytes, no fluid imbalance

12. Extubation from ventilatorExtubation from ventilator
 Extubation procedure
 Keep NBM 4 hours before extubation
 Suction the ET tube, oral cavity and nostrils.
 Suction the nasogastric tube to deflate the stomach
 Keep oxygen ready
 Nebulization with beta stimulant and or adrenaline
should be ready immediate postextubation.
 IV steroids dexamethasone 0.15mg/kg may be used in
prolonged intubation. It can be started 24 hrs prior to
extubation and to be continued for 48 hrs.

13. Extubation From ventilatorExtubation From ventilator
 Aminophylline can be started as it decreasesAminophylline can be started as it decreases
resistance and increases respiratory driveresistance and increases respiratory drive
 ABG is usually done 20 min after extubationABG is usually done 20 min after extubation
 Post extubation Xray should be donePost extubation Xray should be done

14. conclusionconclusion
 Think about weaning early.Think about weaning early.
 Plan a clinical strategy designed for your patient.Plan a clinical strategy designed for your patient.
 Prepare the patients general condition.Prepare the patients general condition.
 Design 2-3 separate protocols that are ageDesign 2-3 separate protocols that are age
appropriateappropriate
 Medicate as neededMedicate as needed
 Don’t be too much of hurryDon’t be too much of hurry
 Avoid night extubation.Avoid night extubation.

15. THANK YOUTHANK YOU