Transcript Mechanical Ventilation Weaning Protocol

Mechanical Ventilation Weaning
Protocol
Education for Nurses, Respiratory
Therapists and Physicians
The SLRH Ventilator Weaning Protocol
Workgroup
Objectives of this program
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Provide education about ventilator weaning in
the Critical Care Units and Medical
Progressive Care and Step down Units
Provide rationale and benefits for using a
ventilator weaning protocol
Review the assessment tool for ventilator
weaning in critically ill patients
Review SLRH vent weaning protocol:
◦ Revised acute vent weaning protocol
◦ New chronic vent weaning protocol
Explain tracheostomy decisions and care
Demonstrate how weaning is integrated into
the total care of the patient
A Weaning Protocol:
Promotes a standardized assessment of
each patient’s readiness to wean as part
of the daily assessment by the nurse and
respiratory therapist
 Empowers the nurse and respiratory
therapist to initiate the process of early
weaning from the ventilator by identifying
patients who are ready
 Facilitates collaboration between the
RN/RT and physician or nurse
practitioner
 The Physician can order the weaning
protocol based on the assessment by the
RN/RT and MD/DO
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Benefits of a Weaning Protocol
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Studies have shown that weaning protocols
lead to a DECREASE IN:
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Duration of mechanical ventilation
ICU and hospital length of stay
Number of tracheostomies performed
Complications associated with mechanical
ventilation
 Ventilator-associated pneumonia and lung injury
 Venous thromboembolic disease
 Gastrointestinal hemorrhage
Improving weaning from mechanical
ventilation
Early morning daily awakening and daily
spontaneous breathing trial decrease
duration of mechanical ventilation
 Both nurse-driven and respiratory therapistdriven weaning protocols lead to earlier
weaning and extubation, compared to
physician-driven protocols
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Wesley,E et al; N Engl J Med 1996; 335:1864-1869
Kollef,Marin et al;Crit Care Med 1997; 25:567-574
Why do we need a weaning protocol in
our critical care units?
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Weaning Protocols are the Standard of Care in Intensive
Care Units
We can REDUCE:
◦ Duration of mechanical ventilation
◦ ICU and hospital length of stay
◦ ICU and hospital mortality
◦ Sedation
◦ ICU complications such as ventilator-associated
pneumonia (VAP), ventilator-associated lung injury venous
thromboembolism and GI hemorrhage
◦ Neuromuscular dysfunction, delirium, and cognitive
dysfunction
◦ Weakness due to delay in mobilization
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We need to standardize our goals and
management of mechanically ventilated
patients in order to provide the best care
for our patients.
W.E.A.N.! at SLRH
Work together – RN, RT, NP, PA, MD/DO
 Early identification – Early in the day, early
in the course
 Assessment by RN and RT in daily screen
and protocol
 Notify physician to start protocol and
how patient tolerates weaning
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Weaning: working together - clinicians
and patients
The ICU and stepdown nurse and the
respiratory therapist for the patient have the
important role of timely assessment of weaning
readiness
 The Physician needs to make the overall
decision about whether the patient should
undergo the weaning protocol
 There are different ways of weaning and this
process is individualized. So different modes of
weaning may be chosen based on the patient’s
disease and course.
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Weaning protocols in different units
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Our protocols will take into account the
resources of the different units – critical
care and stepdown units - so that the
presence and support of nursing and
respiratory care are optimal.
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In addition to the early morning protocol,
weaning assessment can be done at any
time during the day.
Acute and Chronic Weaning
What is the difference?
Acute generally refers to patients with an
endotracheal tube who have been on the
ventilator for less than 2-3 weeks
 Chronic generally refers to patients who have
been on the ventilator for longer periods and
who have a tracheostomy
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◦ Patients with a tracheostomy may require a more
prolonged process
◦ However, even some patients with a tracheostomy
may be weaned in a short period of time
The weaning protocols
The protocols are found on Forms on
Demand
 We will go through the steps of the
protocols for acute and chronic weaning
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Step 1: Assessment for Weaning
Readiness
Initial assessment is the “screening” based on patient
factors, ventilator factors and sometimes ABG. This is
the daily screening to be done by the RN and RT to
see if the patient is ready for a weaning trial.
 This screening does not involve any ventilator
changes.
 Screening facilitates early morning weaning trial and
extubation and does not have to wait for physician
rounds
 This assessment ties in with the sedation policy: using
the sedation protocol to achieve a RASS of 0 or a
daily interruption of sedation is appropriate for
weaning patients
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Early assessment for weaning
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The screening is done in the ICU daily by
the night shift (between 5:30 and 7 am)
so that, if the patient passes, weaning can
be started early
◦ Document readiness on ICU flowsheet
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If a barrier is found, such as the patient is
too sedated, this is the opportunity to
reduce/stop sedatives to achieve the
RASS goal and score
◦ The screening can be repeated at any point if
the condition changes
STEP 1: Assessment for weaning readiness
The patient meets the following criteria:
PATIENT FACTORS
□ Hemodynamically stabilizing:
□ Vital signs acceptable ( BP ≥ 90 systolic, HR ≈ 55 to 135 bpm)
□ Tapering/low doses of vasopressors
□ Sp02 > 92%
□ Can follow simple commands
□ Adequate cough on command
□ Initiate good inspiratory effort
□ Patient is not expected to follow commands
VENTILATOR PARAMETERS
□ FiO2 < 50%
□ PEEP ≤ 5 cm H20
ABG PARAMETERS
□ PaO2 ≥ 75 mmHg
□ pH > 7.25
STEP 2: Criteria met, Notify Physician for
initiation of protocol
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RN and RT communicate the weaning readiness with
the MD/DO ( fellow/housestaff/attending)
Physician decides whether weaning should be
initiated. Some situations in which the patient meets
criteria but weaning will not be done include –
procedure or test that will require ventilation,
concerning lab test or change in stability.
Physician decides on the vent weaning mode,
completes orders and places order in Prism to
initiate weaning protocol
Feedings held
Sedation goal RASS of 0 achieved or hold sedation
Explain to the patient
Physician Order for Weaning
The MD/NP needs to place the order for
weaning only once
 This order will remain active for daily
weaning unless cancelled due to change in
patient condition
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Please note…
There are some patients who have a
neurologic injury or baseline dysfunction
– who are not expected to follow
commands, but who still may be able to
wean from the ventilator.
 The clinicians may decide to proceed with
a trial of weaning in patients who do not
pass all readiness criteria.
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Start weaning protocol early
Between 5:30 and 7 am in the ICUs
 By 9 am for chronically-ventilated patients
in the stepdown units
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STEP 3: Method of weaning
chosen by physician
SPONTANEOUS
BREATHING
TRIAL METHOD
(SBT)
□ PS=____
□ CPAP = ___
□ FI02 ___%
□ T-piece
□ Duration ___minutes
□ ABG needed ( )Y( ) N
GOAL : ____ min
SIMV METHOD
□ Set IMV___ PS___
□ FiO2___%
□ Decrease IMV rate by
__ q __ h
□ Decrease PS by ___
q ___ h
□ ABG needed ( ) Y ( )
N
GOAL: IMV ≤ 4 AND
PS ≤ 8 for ___min
PRESSURE
SUPPORT
VENTILATION
METHOD (PSV)
□ Set PS___
□ FiO2___ %
□ Decrease PS by
___q ___h
□ ABG ( ) Y ( ) N
GOAL : PS ≤ 5 for
____ min
SICU METHOD
□ CPAP = 5, PS=0
□ FI02 21%
□ Tolerates 20 min
□ Then ABG:
GOAL:
Pa02 >50mmHg
PaC02 <50 mmHg
RR < 35/min
Acute weaning – Spontaneous Breathing
Trial “SBT”
The most common method is the SBT: CPAP
mode, pressure support 5-8 cm H20. Duration
30-120 minutes.
 Other methods include:
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◦ SIMV with gradual reduction in respiratory rate
◦ Pressure support with gradual reduction in amount
of pressure support
For SICU patients, CPAP trial for 20 min
 Physician Order: must complete method,
settings, and duration
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STEP 4: Assessing patient tolerance of weaning
•Respiratory Rate <35 breaths per minute
•Heart rate between 50 and 130 bpm and within ± 20% of pre-trial HR
•Systolic Blood Pressure (SBP) between 90-170 mmHg and within ± 20% of
pre-trial SBP
•Exhaled TV ≥ 5 cc/ kg IBW ( ≈ 300 – 400 ml )
•SpO2 ≥ 92 %
•Patient showing no diaphoresis, paradoxical respiration, retractions, nasal
flaring, agitation, or complaining of SOB, or use of accessory muscles
•Serial assessments of tolerance are made 5,15,30,60,and 120 minutes after
the INITIAL setting and following any subsequent ventilator changes.
STEP 5:Tolerating weaning trial –
success! Notify physician and team
 Arterial blood gas, if ordered
 Physician informed about the successful
weaning
 RT - set up for extubation
 Physician will be present for extubation
 The patient is monitored following
extubation:
◦ In addition to vital signs including Sp02 ,always
check for stridor, breath sounds, secretions
Not tolerating weaning today…
If not tolerating weaning go to pre-trial
settings
 Document on Weaning Flow record – in
what way the patient did not tolerate
weaning, duration of weaning, level of
support used
 This will improve our communication and
plan for the next weaning trial so that we
can move forward with weaning the
patient
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Documentation
The daily outcome will be written in the
weaning flow record which will be kept in the
Respiratory Care book. The RN and RT
document the progress
 The medical, nursing and respiratory staff will
view the flow record in making further
decisions about weaning
 Vital signs, ventilator settings, extubation are
charted in the ICU flow record as usual
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Weaning Flow Sheet
Documentation
Chronic Vent Weaning
This protocol applies to patients with
tracheostomies who are undergoing
weaning in the Critical Care Units, MPCU,
stepdown vent units RH 10B, SL 10E
 The early assessment is the same
 Screening by nurse or respiratory
therapist for readiness
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◦ Document in nursing/respiratory notes or
ICU flow record
Only one order to wean is needed and
will apply until the order is discontinued
 Weaning will be started by 9 am daily
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Methods of Chronic Vent Weaning
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Some patients who have been on a
ventilator for a prolonged period or have a
tracheostomy may need a more progressive
program for weaning
The two general methods are:
◦ Pressure support PS– gradually decrease the PS
amount and prolong the time
◦ Trach collar – use trach mask for progressively
longer periods of time
◦ Other methods such as volume support may also
be used
Chronic Weaning
Documentation
The duration of weaning is documented
on the flow record. This will be kept in
the respiratory folder. The RN or RT may
document the progress
 The medical, nursing and respiratory staff
will view the flow record for further
decisions about weaning
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Tracheostomy: Indications
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Prolonged ventilator requirement and inability to
wean due to
◦ Generalized weakness, such as critical illness
polyneuropathy
◦ Multiple comorbid conditions that require prolonged
ventilation
◦ Chronic critical illness
Inability to clear secretions
 Severe neurologic dysfunction
 Airway obstruction
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◦ Tumor, upper airway injury, edema
◦ Severe obstructive sleep apnea with complications, not
amenable to usual treatments
Patients not expected to wean
- Addressing goals of care
Some patients are not expected to be
weaned from a ventilator so
tracheostomy would be considered for
indefinite ventilator-dependence
 In these patients, this decision point for
tracheostomy would be an appropriate
time to readdress life support/end-of-life
decisions
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Benefits of tracheostomy
Ability to mobilize patients with
prolonged need for ventilator with a
more secure airway
 Potential for patient to require less
sedatives and communicate
 Allows transfer to a chronic ventilator
facility
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Planning for Tracheostomy
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Clinician assesses the potential for liberation from
ventilator based on the patient’s illness, prognosis,
and patient preference
Tracheostomies can be performed early (within 7
days) or later (at 2-3 weeks)
If the patient is unlikely to be weaned due to
neurological/chronic pulmonary process, a
decision on tracheostomy can often be made
within few days of intubation
Patients with reversible disease who are unable to
wean in 10-14 days are usually considered for
tracheostomy at that time
Tracheostomy is not performed in unstable or
dying patients
Timing of Tracheostomies
Based on individual patient situation
 Benefits of early tracheostomy include:
improved comfort and decreased
sedation, improved mobility
 In some patients, early tracheostomy may
facillitate weaning, so may decrease
duration of mechanical ventilation
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Patients with tracheostomies
Assess for speech and swallowing – may
be candidate for speech valve
 MOBILITY – out of bed, sit, stand, walk
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Decannulation – removal of tracheostomy
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Patients are completely off ventilator for sufficient
number of days to assure that the primary process
is resolved
Able to cough secretions
Tolerate speech valve
Tolerate capping of the tracheostomy
Clinically assure there is no upper airway
obstruction
Patient requires close monitoring in the first 24
hrs
If patient develops distress – consider secretions,
airway obstruction
Respiratory distress in patients with
endotracheal tubes and tracheostomies
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Secretions and mucous plugging
Dislodgement of tracheostomy/ ETT
Pneumothorax
Ventilator dyssynchrony due to vent settings
Because of underlying diseases, may be at risk for
pulmonary embolism, heart failure, volume
overload
Granulation tissue formation in the trachea can
lead to high peak pressures
**These causes must be considered before
treatment with sedatives**
Look at the overall plan of care
Mobility in patients with endotracheal
tube or tracheostomy
 Speech
 Nutrition
 Goals of care discussion with patient and
family
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Mobility
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Early mobility can
◦ Decrease intensive care unit and hospital length of
stay in survivors
◦ Reduce the functional decline from the illness
◦ Decrease risk of pressure ulcers and improve
wound care
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Multidisciplinary team – collaboration to
provide safe mobilization of patients in the
intensive care unit, progressive care and
stepdown units.
Weaning and mobility
In addition to the effects on duration of
ventilation, mortality and ICU
complications, weaning and mobility can
potentially:
 Improve patient spirit
 Improve communication
 Reduce delirium
 Reduce depression
Documentation
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Orders will be placed by MD using the preprinted paper order:
◦ Weaning orders
Physician places order for weaning in Prism
 ICU Flowsheet will reflect the readiness
screen and the weaning
 RN/RT will document in weaning flow record
 Extubation – Physician documents in progress
note
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So let’s W.E.A.N.! at SLRH
Work together – RN, RT, NP, PA, MD/DO
 Early identification – Early in the day, early in
the course
 Assessment by RN and RT in daily screen and
protocol
 Notify physician to start protocol and how
patient tolerates weaning
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Thank you for completing this
program!
We believe that a comprehensive and
multidisciplinary approach will improve
care and outcomes of our patients who
require mechanical ventilation.
For questions, please contact:
Manju Pillai MD
Raymonde Jean MD
Mark Collazo RRT
Janet Shapiro MD