By Sebastian Benavides PGY2

ObjectiveIdentifying patients who are ready to wean

from mechanical ventillationVia clinical criteria

Identifying patient who are not ready for weaning

Knowing the weaning parameters

Defining WeaningProgressive decrease in the amount of

support a patient recieves from the ventilator2 step process

Patients who are ready to wean are identified using a two step predictors of weaning outcome

Weaning is then initiated

Weaning Clinical Criteria:

Cause of respiratory failure improvedPatient is hemodynamic ally stablePatient oxygenating well (SpO2>90% on

FIO2<50%, PEEP< or = to 5)Mental status: Awake and alertAble to initiate inspiratory effort

Weaning Parameters:

RSBI (RR/Vt)<105Mintue Ventilation <15L/minSpontaneous Vt > or = 5ml/kgNegative inspiratory force< or = to -30mm

H2O

Initial WeaningSet pressure support ventillation 1 hr prior to

initiation of weaning:FiO2 at 50%PEEP: must be less than 8Pressure support should be weaned down to 5

WeaningPrior to Extubation:

Confirm minimal FIO2 (less than or equal to 50%) and PEEP equal to 5

Evaluate upper airway comlications Check audible cuff leak (if concern for edema, stridor) Check if cough and gag are present

Have equipment ready NC/face mask/bipap

Suction secreationsExtubate!

Case62 year old male who weighs 70kg was intubated

3 days ago for hypercapnic respiratory failure Patient is alert, cooperative on the ventilator over

the past 6 hoursHe is on poressure support ventilation with a

tidal volume of 700ml, PS of 10 and an FIO2 of 50%

Upon assessing his weaning parameters, his RSBI is 70, minute ventillation is 10ml/min, his spontaneous tidal volume is 490ml nad NIF is -30mmH2O

CaseWhat would be the following appropriate plan of

action?a) Extubate patient to NCb) Increase pressure support to 15 assess weaning

parameters and extubate after 1 hour c) Decrease pressure support to 5 assess weaning

parameters and extubate after 1 hourd) Increase FIO2 to 60% then extubate after

assessing weaning parameterse) Decrease FIO2 to 40% then extubate after

assessing weaning parameters

CaseC is the correct answer

CaseAnswer: reinitubate and resume mechanical

ventilation

SummaryWhen weaning, remember that patients must

meet clinical criteria. Use your judgment and ask yourself if this patient looks ready to be extubated

Know your weaning parametersRSBI, Minute ventilation, Spontaneous tidal

volume, NIFAlways have equipment ready once extubating

as patient may fail extubation regardless if they meet all the weaning parameters and clinical criteria

Special ThanksWhoever created slides prior to my

adjustmentsThe ICU Book 3rd edition by Paul L. MarinoAngelina Amian (Excellent ICU fellow)