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Mechanical Ventilation Weaning Protocol Education for Nurses, Respiratory Therapists and Physicians The SLRH Ventilator Weaning Protocol Workgroup

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Objectives of this program 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

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A Weaning Protocol: Promotes a standardized assessment of each patients 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 Studies have shown that weaning protocols lead to a DECREASE IN: 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

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Improving weaning from mechanical ventilation Early morning daily awakening and daily spontaneous breathing trial decrease duration of mechanical ventilation Both nurse-driven and respiratory therapist- driven weaning protocols lead to earlier weaning and extubation, compared to physician-driven protocols Wesley,E et al; N Engl J Med 1996; 335:1864-1869 Kollef,Marin et al;Crit Care Med 1997; 25:567-574

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Why do we need a weaning protocol in our critical care units? 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.

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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 patients disease and course.

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Weaning protocols in different units 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.

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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 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

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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 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 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

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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

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STEP 2: Criteria met, Notify Physician for initiation of protocol 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

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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 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: Pa0 2 >50mmHg PaC0 2