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LIBERATION “Judgement Call”

LIBERATION “Judgement Call”. Dr Ikhwan bin Wan Mohd Rubi , MD (UKM) Supervisor: Dr Mohd Ridhwan Mohd Noor. Outline. Introduction Weaning and its evolution Classification of weaning Principles, Assessment; Clinical and Objectives Spontaneous Breathing Trial

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LIBERATION “Judgement Call”

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  1. LIBERATION“Judgement Call” Dr Ikhwan bin Wan MohdRubi, MD (UKM) Supervisor: Dr MohdRidhwanMohdNoor

  2. Outline • Introduction • Weaning and its evolution • Classification of weaning • Principles, Assessment; Clinical and Objectives • Spontaneous Breathing Trial • Approach, protocol, criteria to pass • Extubation, failed extubation • Role of NIV & also tracheostomy • Causes of failed SBT • Algorithm of weaning

  3. Introduction • MV is the defining event in ICU mx • A life saving intervention in acute resp failure and other disease entities • The aim of ventilatory support is to unload the patient’s respiratory pump

  4. Major goal is actually to LIBERATE pts from MV as early as possible whileAVOIDING premature weaning Decreases the availability of ICU beds Increased cost Increased hospital length of stay Increased risk of VAP Why Wean early ??? Increased ICU length of stay Increased morbidity & mortality Can adversely affect the patient outcome

  5. Weaning • Def: A process of transition/gradual withdrawal of MV support that transfers the WOB from ventilator to the patient • Removal of a necessary (short term) but potentially damaging (prolonged) intervention as early as feasible • This period may take many forms ranging from abrupt to gradual withdrawal from ventilatory support

  6. Goal is to facilitate effective spontaneous breathing while reducing ventilatory support • BALANCE between reducing ventilatory support without increasing pt’s WOB to the point of fatigue and failure • The process of reloading the respiratory pump

  7. Weaning Minimizing support (increasing pt’s resp autonomy) Adequate ventilatory support (minimizing respiratory fatigue) Not over assisting, but not to cause fatigue

  8. Evolution of Weaning • >than a decade ago, weaning from PPV was often a slow gradual process of reduction in ventilatory support (IMV) • Introduction of SIMV mode and later PSV • Numerous studies have investigated methods and tools for identifying readiness of mechanically ventilated pts for successful liberation from MV

  9. Facts • 75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process; • Hall JB, Wood LDH:Liberation of the patient from mechanical ventilation, JAMA 1987, 257: 1621-1628 • 10-15% patients require use of a weaning protocol over a period of 24-72 hours • 5-10% require a gradual weaning over longer time • 1% of patients become chronically dependent on ventilator

  10. Classification of Weaning

  11. Classification of Patients According to the Weaning Process Boles, et al. Eur Respir J 2007

  12. Principles

  13. In Short • Consider weaning ASAP • Consider weaning once underlying causes resolved/improved • Evaluate early & at least daily • CNS/CVS/Resp(patency/protection) must intact before extubation • Minimize/discontinue sedation for daytime SBT • UNLESS in irreversible underlying disease

  14. When to begin the weaning process? • Numerous trials performed to develop criteria for success weaning, however, not useful to predict when to begin the weaning • Physicians must rely on clinical judgement • Consider when the reason for IPPV is stabilised and the patient is improving and haemodynamically stable • Daily screening may reduce the duration of MV and ICU cost

  15. Schematic Representation of the Different Stages Occurring in aMechanically Ventilated Patient Martin J. Tobin 2001

  16. Protocol Weaning is More Effective than No Protocol • Numerous studies have demonstrated that protocol weaning decreases mechanical ventilation days. • Vitacca AJRCCM 2001;164:225-30 • Henneman CCM 2001;29:297-03 • Kollef New Horizons 1998;6:52-60 • Kollef CCM 1997;25:567-74 • All studies utilized a daily screening and subsequent spontaneous breathing trial to test the patient’s potential for discontinuing mechanical ventilation.

  17. Compared with usual care, use of weaning protocols can reduce the duration of • mechanical ventilation by 25% • weaning duration by 78% • length of stay in intensive care unit by 10%

  18. Assessment of readiness to wean A Daily routine follow up should be done in every patient receiving mechanical ventilation and exploring the following condition • Clinical assessment • Objective measures • Respiratory criteria • Cardiovascular criteria • Neurological criteria

  19. Clinical Assessment • Resolution of acute phase of disease for which patient was intubated; indication of mechanical ventilation is reversed • Adequate cough (subjective) • Absence of excessive tracheobronchial secretion; frequency of trachea suctioning; characteristic of secretion

  20. Objective measures • Respiratory criteria (O2 and ventilation) • Adequate O2; PaO2≥60mmHg on FiO2≤0.5 & PEEP≤8cmH2O • No significant respiratory acidosis; pH and PaCO2 appropriate for patient’s baseline respiratory status • RR <35breaths/min • Vt >5mls/kg • MV <12l/min (<10-12)

  21. Objective measures • Cardiovascular criteria • HR <140/min • BP normal with minimal or no vasopressor support (i.e Dopamine <5mcg/kg/min) • No evidence of myocardial ischemia

  22. Objective measures • Neurological criteria • Pt is arousable or GCS ≥ 13 In isolation, none is highly predictive In cluster, acceptable high predictive capacity Once deemed ready, proceed to SBT

  23. Once ready, proceed to SBT

  24. Spontaneous Breathing Trial (SBT) • Conducted when • connected to ventilator • or being removed from ventilator (T piece) • SBT through ventilator • Use PSV of 5-7cmH2O + low PEEP 5cmH2O • Patient’s safety is ensure, back up ventilation can be provided if necessary • Vt and RR can be monitored

  25. Spontaneous Breathing Trial (SBT) • SBT through a T-piece • Deliver O2 enriched gas at high flow rates (greater than the pt’s ins flow rate) through the horizontal arm of the T-shaped circuit • The advantage is the reduced WOB with the T-shaped circuit

  26. Tobin. Principles and Practice of Mechanical Ventilation, McGraw-Hill, 1994, s1192

  27. Weaning : Selecting an Approach!!! • Many studies have compared the different methods of weaning • Common conclusions are • No clear superiority exists between T-tube weaning and pressure support based weaning • SIMV is the least efficient technique of weaning The best approach may be the one with which the clinician is most familiar and is based on a sound rationale

  28. Cuff leak test

  29. Extubation failure- need for reintubation within 72hrs of extubation • Increased Risk in advanced age, high severity of illness at ICU admission & extubation, preexisting chronic resp/CVS disease. • Reintubation also increased morbidity and mortality • Intensivist needs to identify pts at increased risk and be prepared to reinstitute ventilation early to prevent adverse outcome

  30. Good mentation, competent airway, minimal secretions, good respiratory muscle strength and adequate CVS reserve are ESSENTIAL for successful extubation • Still no validated predictors to indicate extubation failure • One need to be alert for extubation failure and intervene early to prevent further morbidity/mortality

  31. Approach to difficult to wean patient • Weaning failure; any one of: • Failure SBT • Reintubation/ resumption of ventilator within 48hrs • Death within 48hrs of extubation

  32. If patient fails SBT: • Increase ventilator setting to previously tolerated level or higher if necessary until pt stable again and wait 24hr before trying again • Search thoroughly and systematically for potentially reversible aetiologies • Use PSV as a weaning tool by gradually reducing PS by 2cmH2O once or twice a day as tolerated • Once PS is reduced to a minimal level (10cmH2O), rpt SBT daily until pt can be successfully extubated • Concept of nocturnal rest in conjunction with daytime resp ms training is important

  33. Role of NIV in weaning • As an alternative in weaning technique • Rationale: to facilitate earlier removal of ETT while still allowing a progressive stepwise reduction of ventilator support • Involves extubating the pt who has failed a SBT directly onto NIV (PS+CPAP) • ONLY in pt with good airway protection, strong cough and minimal secretions • In practice, NIV mainly used to facilitate weaning in COPD pts

  34. Role of NIV in weaning • Prophylactic measure in pt with high risk for reintubation • CAREFULLY SELECTED pt (i.e postoperative pt- abdominal/vascular surgery)

  35. Role of tracheostomy • Must be considered: • In any pt deemed difficult to wean (pt who fail initial SBT and required up to 3 SBTs or up to 7 days to pass a SBT • Certainly in all pt with prolonged wean • Potential benefits: less sedative requirement, more secure airway, reduction in oropharyngeal trauma, prevention of VAP, reduction in WOB, earlier transition to oral feeding, improved pt’s comfort and communication • Optimal timing; early or late??

  36. Caused of failed SBT/weaning

  37. Caused of failed SBT/weaning

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