ventilation weaning
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Procedure
- considerations
- parameters
- tidal volume > 5 mL/kg
- vital capacity >10 mL/kg or 1 liter
- minute ventilation < 10 L/min
- maximum voluntary ventilation > twice the minute ventilation
- peak inspiratory pressure < -20 cm H2O
- methods
- T-tube trial, T-mist trial
- IMV, SIMV
- pressure support
- spontaneous breathing trials of 30 min-2 hr using pressure support of < 8 cm H20 can identify patients for extubation[5][11]
- Failures
- increased ventilatory demands
- increased CO2 production
- sepsis
- excess carbohydrates in diet
- increased dead space
- increased CO2 production
- inadequate ventilation
- weak or discoordinated muscles
- increased work of breathing
- small endotracheal (ET) tube
- bronchospasm
- pulmonary edema
- chronic CO2 retainer who has been hyperventilated on ventilator
- adrenal insufficiency[2]
- cosyntropin stimulation testing to identify
- glucocorticoids may benefit this subset of patients
- increased ventilatory demands
- strategies
- standardized scales to assess sedation needs hourly & titration of infusions accordingly as good (if not better than daily medication interruption)[3]
- rapid shallow breathing index[5]
- early extubation to noninvasive ventilation in patients with COPD, heart failure, or hypercarbia[5][6][8]
- lowers mortality (RR=0.53)[6]
- lowers risk of weaning failure (RR=0.63)[6]
- lowers risk of ventilator-associated pneumonia (RR=0.25)
- lowers length of stay in ICU & hospital[6]
More general terms
Additional terms
- endotracheal extubation
- mechanical ventilation (assisted ventilation)
- rapid shallow breathing index
- spontaneous breathing trial (SBT)
References
- ↑ Jon D. Hirasuna, M.D. Clinical Professor of Medicine, UC Davis, Associate Clinical Professor of Medicine, UCSF, Sept 1997
- ↑ 2.0 2.1 Huang CJ, Lin HC. Association between adrenal insufficiency and ventilator weaning. Am J Respir Crit Care Med. 2006 Feb 1;173(3):276-80. Epub 2005 Nov 4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16272449
- ↑ 3.0 3.1 Mehta S et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: A randomized controlled trial. JAMA 2012 Oct 17 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23180503 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1380160
- ↑ 4.0 4.1 Dessap AM et al. Natriuretic peptide-driven fluid management during ventilator weaning: A randomized controlled trial. Am J Respir Crit Care Med 2012 Dec 15; 186:1256 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22997204
- ↑ 5.0 5.1 5.2 5.3 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018.
- ↑ 6.0 6.1 6.2 6.3 6.4 Burns KEA et al. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: A Cochrane systematic review. CMAJ 2014 Feb 18; 186:E112 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24324020
- ↑ McConville JF, Kress JP Weaning patients from the ventilator. N Engl J Med. 2012 Dec 6;367(23):2233-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23215559
- ↑ 8.0 8.1 Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2013 Dec 9;12:CD004127. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24323843
- ↑ Nava S, Ambrosino N, Clini E et al Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998 May 1;128(9):721-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/9556465
- ↑ Schmidt GA, Girard TD, Kress JP et al Liberation From Mechanical Ventilation in Critically Ill Adults: Executive Summary of an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest. 2017 Jan;151(1):160-165. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27818329
- ↑ 11.0 11.1 Subira C, Hernandez G, Vazquez A et al. Effect of pressure support vs T-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: A randomized clinical trial. JAMA 2019 Jun 11; 321:2175. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31184740 https://jamanetwork.com/journals/jama/fullarticle/2735502
Girard TD, Burns KEA. Revisiting, reframing, and casting a new light on liberation from mechanical ventilation. JAMA 2019 Jun 11; 321:2167. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31184723 https://jamanetwork.com/journals/jama/fullarticle/2735481