Download approach to assesment and weaning at the bed side

DR. ANKIT JAIN
APPROACH TO
ASSESSMENT AND
WEANING AT THE BED
SIDE
WHEN TO WEAN??
I
WHEN TO WEAN??
1.
2.
Why was he ventilated??
Resolution/Reversal of Primary Pathology for which patient
was ventilated.
1.
2.
Clinical Evidence.
Lab/Radiological Evidence.
WHEN TO WEAN?
Early
Late
WHEN TO WEAN?
1.
Search and treat other causes that may contribute to
ventilator dependence.
1.
Know the causes of Ventilator Dependence/Failure to wean.
FACTORS IN WEANING
FAILURE
CAUSES OF VENTILATOR DEPENDENCE AND
FAILURE TO WEAN
 Causes of Respiratory Failure
 Neurological Factors
 Central
 Stroke
 Drugs
 Electrolytes
 Peripheral
 Neuropathies/Myopathies
 Drugs
 Respiratory Factors
 Chest Wall
 Parenchymal Disease
 Airway Disease
CAUSES OF VENTILATOR DEPENDENCE AND
FAILURE TO WEAN
 Non Respirator y Factor s.
 Cardiac Factors
 Acute LVF
 Acid-Base Factors
 Respiratory Alkalosis
 Metabolic Acidosis
 Metabolic Factors
 Hypo PO4
 Hypo Mg
 Hypothyroid
 Pharmacological Agents
 Sedation
 NMBA
 Aminoglycosides
 Nutrition
 Malnutrition.
 Overfeeding
 Psychology
WHEN TO WEAN?
1.
Search and treat other causes that may contribute to
ventilator dependence.
1.
2.
Know the causes of Ventilator Dependence/Failure to wean.
Structured bed side approach to identify these causes. (In Exam
and in Clinical Practice.)
BEDSIDE APPROACH TO
IDENTIFY THESE CAUSES
IDENTIFY THESE CAUSES AT THE BEDSIDE
 Keep the Causes in Mind.
 Structured Patient Examination
 The Environment






Cubicle
Patient Monitor
Ventilator
Infusions
Equipment
Drains
 Trends (Ask for in the Exam)
 Investigations (Ask for in the Exam)
WHEN TO WEAN?
1.
Search and treat other causes that may contribute to
ventilator dependence.
1.
2.
3.
Know the causes of Ventilator Dependence/Failure to wean.
Structured bed side approach to identify these causes. (In Exam
and in Clinical Practice.)
Treat these causes!
CERTAIN MEASURABLE
CRITERIA TO BE
FULFILLED
CERTAIN MEASURABLE CRITERIA
1.
Adequate Oxygenation
1.
ABG
1.
2.
3.
4.
2.
PaO2>60 with FiO2<0.4
PaO2/FiO2 >150
PEEP < 8 cm H20
pH >7.25
Hemodynamic Stability
1.
2.
Clinically no Hypotension
No or Low dose Vasopressors
(EXCEPTIONS TO THE CRITERIA)
“SUPERVISED”
SPONTANEOUS
BREATHING TRIAL
III
“SUPERVISED” SPONTANEOUS BREATHING
TRIAL
 When??
 Everything okay uptill now. (Step I and II cleared)
 Screening for few minutes
 Extended SBT
 Duration
 30mins to 120 minutes
 Mode




CPAP/PS
T-Piece
SIMV
Complex Modes
 ATC, ASV, MMV
“SUPERVISED” SPONTANEOUS
BREATHING TRIAL
 Factors Assessed
 Respiratory Pattern
 Tidal Volume
 Respiratory Rate
 Rapid Shallow Breathing Index (RSBI)





Reliable
RR (breaths per minute) /T V (Liters)
1 minute after Disconnecting
RSBI should be < 105
Normal 60 to 105
 Complex Parameters (WOB, Dynamic Compliance, CROP index)
 Adequacy of Gas Exchange
 Monitor/SpO2
 ABG
 HD Stability
 Subjective Comfort.
SBT FAILED
WHAT
NOW??
FAILED SBT
 Back to the Drawing board
 Remember the Causes of Failure to Wean and How to identify them
clinically??
CAUSES OF VENTILATOR DEPENDENCE AND
FAILURE TO WEAN
 Causes of Respiratory Failure
 Neurological Factors
 Central
 Stroke
 Drugs
 Electrolytes
 Peripheral
 Neuropathies/Myopathies
 Drugs
 Respiratory Factors
 Chest Wall
 Parenchymal Disease
 Airway Disease
CAUSES OF VENTILATOR DEPENDENCE AND
FAILURE TO WEAN
 Non Respirator y Factor s.
 Cardiac Factors
 Acute LVF
 Acid-Base Factors
 Respiratory Acidosis
 Metabolic Acidosis
 Metabolic Factors
 Hypo PO4
 Hypo Mg
 Hypothyroid
 Pharmacological Agents
 Sedation
 NMBA
 Aminoglycosides
 Nutrition
 Malnutrition.
 Overfeeding
 Psychology
FAILED SBT
 Back to the Drawing board
 Remember the Causes of Failure to Wean and How to identify them
clinically??
 Identify and Treat these Cause.
FAILED SBT
 No trial of SBT for another 24 hours
 Even twice daily SBTs offer no advantage.
 Do not reduce ventilator Support aggressively during these 24 hours.
 No evidence that a gradual support reduction strategy is better than
providing full stable support between once daily SBTs.
SBT SUCCESSFUL
WHAT
NEXT??
SBT SUCCESFUL
 Patient can be Weaned but…..
 Can he be Extubated???