Readiness For Weaning From the Ventilator

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Readiness For Weaning From the Ventilator

• Terry P. Clemmer, MD
• Director CCM LDS Hospital
• Professor of Medicine
• University of Utah School of Medicine

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1. Frontline Engagement
6. Clear Communication
2. Scripted Processes
Requisite for Sustainable Improvement
3. Reliable Execution
5. Scientific Change Process
4. Organizational Learning
Terry P. Clemmer, MD LDS Hospital
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Define Weaning

• It Is Removal from Assisted Positive Pressure
  Ventilation to
• CPAP
• T-tube or Trach Mask
• Face Mask, Face Tent or Nasal Oxygen
• It Is Not Extubation or Removal of Tubes From
  the Trachea
• ET Tube
• Tracheostomy Tube

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Keys to Early Weaning

• Therapist Driven Ventilator Management and
  Weaning Protocols
• Rules for Assessing Weaning Readiness
• Rules for Selecting Weaning Mode
• Rules for Failure to Wean
• Rules to Reduce Support During Weaning
• Removing Patient From Sedation ASAP
• Mobilizing Patient
• Separate Extubation Rules and Process

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Example of Rules that Trigger a Weaning Assessment

• FiO2
• PEEP
• Hemodynamically Stable (Off Vasopressors)
• Patient Not Paralyzed and Able to Trigger
  Ventilator
• Meets Agreed Upon Timing Rules

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NIH-ARDSnet Rules
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Example of Weaning Assessment

• During Spontaneous Breathing Record
• VR, Vt, f/Vt, MIP, VC
• If VR 5 ml/kg PBW Give a Trial of
  Spontaneous breathing
• If VR is 28-37 and Vt is 4 ml/kg go to PS
  Weaning
• If VR 37 or Vt is recheck

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Example of Weaning Failure Rules

• Need to Increase FiO2 to 0.6 to keep SpO2 90
• Need to Increase PEEP to 12 to keep SpO2 90
• VR 37 Breathing Spontaneously
• VR 37 on PS 20 cm H2O
• Vt
• Change in Mental Status
• pH

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Example of Rules to Reduce PS During Weaning

• Every 2 hours Reduce PS by 2 cm H2O
• If VR 30 Increase PS by 2 cm H20
• If SpO2 0.6, Increase PS by 5 cm
  H2O
• If PS is 20 return to A/C
• If PS is 5 Go to CPAP or T-tube

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NIH-ARDSnet Rules
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NIH-ARDSnet Rules
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NIH-ARDSnet Rules
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How to Do This Safely

• Script the Rules (they do not have to be perfect
  just acceptable for a starting point)
• Have Front Line Test the Rules on One Patient
  Under Supervision using Rapid Cycle Testing
• Find and Correct the Problems with Rules

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How to Do This Safely

• Retest on Another Patient and Repeat Until the
  Rules Are
• safe
• effective
• doable in the local environment
• acceptable to local clinicians
• Spread To Other Patients

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1. Frontline Engagement
6. Clear Communication
2. Scripted Processes
Requisite for Sustainable Improvement
3. Reliable Execution
5. Scientific Change Process
4. Organizational Learning
Terry P. Clemmer, MD LDS Hospital