Clinical Application of
MECHANICAL VENTILATION
Fourth Edition
David W. Chang
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Chapter 16
Weaning from Mechanical Ventilation
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Definition of Weaning Success and Failure
• Weaning is a process of gradually reducing
mechanical ventilatory support until a patient
is able to assume sustainable spontaneous
breathing
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Definition of Weaning Success and Failure
• Weaning success
– Absence of ventilatory support for at least 48
hours following extubation
– Success rate is highly variable because of different
clinical and patient conditions
• Success rate is higher in uncomplicated postanesthesia
recovery
• Success rate is lower in medical conditions because of
the chronic nature of diseases and presence of
coexisting medical problems
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Definition of Weaning Success and Failure
• Weaning in progress
– An intermediate category between weaning
success and failure
– Weaning in progress describes patients who are
extubated but continue to receive ventilatory
support by noninvasive ventilation
• Noninvasive ventilation does not require an artificial
airway
• Noninvasive ventilation allows early weaning attempts
and reduces complications of mechanical ventilation
and artificial airway
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Definition of Weaning Success and Failure
• Weaning failure
– Failure of spontaneous breathing trial (SBT)
• Clinical signs of SBT failure
– Tachypnea
– Tachycardia
– Hypertension
– Hypotension
– Hypoxemia
– Acidosis
– Arrhythmias
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Definition of Weaning Success and Failure
• Weaning failure
– Failure of spontaneous breathing trial (SBT)
• Physical signs of SBT failure
– Agitation
– Distress
– Diminished mental status
– Diaphoresis
– Increased work of breathing
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Definition of Weaning Success and Failure
• Weaning failure
– Need for reintubation within 48 hours following
extubation
• Reasons for reintubation
– Hypoventilation and hypercapnia
– Respiratory acidosis
– Rapid shallow breathing
– Excessive secretions
– Respiratory muscle disuse atrophy due to prolonged
mechanical ventilation
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Patient Condition Prior to Weaning
• Before weaning, the patient should have
recovered from the acute phase of the disease
leading to mechanical ventilation
• Disease conditions that should return to
normal prior to weaning attempt
– Patient/pathophysiologic
– Cardiac/circulatory
– Dietary/acid-base/electrolyte
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Patient Condition Prior to Weaning
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Weaning Criteria
Continues
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Weaning Criteria
(Continued)
Continues
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Weaning Criteria
• Ventilatory criteria
– f/VT
• Rapid shallow breathing index (RSBI)
• Rapid shallow breathing increases deadspace
ventilation due to unchanged anatomic deadspace and
reduced VT
• RSBI = f/VT breaths/min/L (cycles/L)
• <100 breaths/min/L for weaning readiness
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Weaning Criteria
(Continued)
Continues
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Weaning Criteria
• Oxygenation criteria
– PaO2/FIO2 (P/F index)
• P/F index ≥150 mm Hg for weaning readiness
– Patient must also have acceptable vital signs and
hemodynamic status
• QS/QT
– <20% for weaning readiness
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Weaning Criteria
(Continued)
Continues
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Weaning Criteria
• Pulmonary reserve
– Vital capacity
• >10 mL/kg for weaning readiness
• Patient cooperation is required
– Maximal inspiratory pressure
• >−30 cm H2O in 20 sec for weaning readiness
• Effort-dependent
• Maximal breathing effort may not occur until
mechanical ventilation is discontinued for a period of
time (i.e., 20 to 30 sec)
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Weaning Criteria
(Continued)
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Weaning Criteria
• Pulmonary measurements
– Static compliance
• >30 mL/cm H2O for weaning readiness
– Deadspace/Tidal volume ratio
• <60% while intubated for weaning readiness
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Rapid Shallow Breathing Index (RSBI)
• f/VT
– Accuracy relies on a stable breathing pattern and
use of minimum pressure support
– <100 breaths/min/L for weaning readiness
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Weaning Procedure
• Spontaneous breathing trial (SBT)
– Via ventilator or Brigg’s adaptor (T-tube)
– Up to 30 min
– Oxygen and a low level of pressure support may
be used to augment spontaneous breathing
– Similar success with different SBT methods
• Stand-alone SBT
• SBT with a low level of pressure support
• SBT with CPAP
• SBT with automatic tube compensation
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Weaning Procedure
• Spontaneous breathing trial (SBT) and partial
ventilatory support
– SBT may use T-tube, CPAP, or automatic tube
compensation
– SIMV is not recommended as a stand-alone mode
for weaning
– PSV may be used in conjunction with spontaneous
breathing or SIMV
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Weaning Procedure
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Weaning Procedure
• Failure of SBT
– Occurs within the first 20 to 30 min
– Clinical signs and symptoms include
• Agitation
• Anxiety
• Diminished mental status
• Diaphoresis
• Cyanosis
• Increased work of breathing
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Weaning Procedure
• Failure of SBT
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Weaning Procedure
• Pressure support ventilation
– Similar to proportional pressure support, volume-
assured pressure support
– Weaning with PSV
• Start PSV at 5 to 15 cm H2O
• Adjust PSV gradually upward until a desirable VT (10 to 15
mL/kg) or a desirable spontaneous frequency (<25/min)
is achieved
• Monitor and evaluate patient for further weaning
• PSV may be decreased gradually by 3 to 6 cm H2O until
PSV reaches 6 cm H2O
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Weaning Procedure
• Automatic tube compensation
– Evita 4 (Dräger Medical)
– Reduces airflow resistance of artificial airway
– Allows spontaneous breathing without the effects
of an artificial airway
– Reduces work of breathing and may facilitate
weaning
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Weaning Procedure
• Other modes of partial ventilatory support
– Synchronized intermittent mandatory ventilation
(SIMV)
– Volume support (VS)
– Volume-assured pressure support (VAPS)
– Mandatory minute ventilation (MVV)
– Airway pressure-release ventilation (APRV)
(Refer to Chapter 4 for a detailed discussion on
modes of mechanical ventilation)
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Weaning Protocol
• Weaning protocols should be used as a guide
• Weaning protocols should not be used as an
absolute set of procedures
– When results of weaning parameters show
borderline values, clinical assessment should be
done to guide decision
• Patient monitoring and assessment are the
key components of a successful protocol
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Weaning Protocol
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Signs of Weaning Failure
• Weaning must be stopped if patient shows
signs of weaning failure
– Tachycardia, use of accessory muscles, paradoxical
abdominal movement, diaphoresis, rapid shallow
breathing, and hyperventilation
– Hyperventilation (↓PaCO2) may be due to hypoxia,
pain, anxiety, or inappropriate ventilator settings
• In this case, ventilatory support must not be reduced
because this action will lead to further increase in work
of breathing
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Signs of Weaning Failure
• Indicators of weaning failure
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Causes of Weaning Failure
• Weaning failure is generally related to
– Increase of airflow resistance
– Decrease of compliance
– Respiratory muscle fatigue
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Causes of Weaning Failure
• Increase of airflow resistance
– Small ET tube
– Secretions in ET tube
– Kinking or biting of ET tube
– Condensation in ventilator tubing
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Causes of Weaning Failure
• Decrease of compliance
– Sudden decrease
• Tension pneumothorax
• Pleural effusion
• Migration of ET tube into main-stem bronchus
– Gradual decrease
• Pneumonia
• ARDS
• Atelectasis
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Causes of Weaning Failure
• Decrease of static and dynamic compliance
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Causes of Weaning Failure
• Respiratory muscle fatigue
– Work of breathing is directly related to the
transpulmonary pressure (PTP) and tidal volume
(VT)
– Prolonged increase in work of breathing may lead
to respiratory muscle fatigue and ventilatory
failure
• ↓compliance or ↑resistance → ↑PTP
• ↑PTP or ↑VT → ↑work of breathing
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Causes of Weaning Failure
• Respiratory muscle fatigue
– Is related to prolonged muscle disuse due to full
ventilatory support
– May be a result of MV-induced proteolysis and
contractile dysfunction due to oxidative stress
– Retraining of atrophied muscles may be
accomplished by short periods of T-tube trials and
use of pressure support to promote early
spontaneous breathing
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Terminal Weaning
• Terminal weaning is withdrawal of mechanical
ventilation that results in the death of a
patient
– Withdrawal is a process that occurs after initiation
of mechanical ventilation
– Withholding is a decision not to place a patient on
the ventilator
• may also result in the death of a patient
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Terminal Weaning
• Four elements of terminal weaning must be
addressed
– Patient’s informed request
• Should be done over a period of time so that emotion,
pain, or other intangible factors do not interfere with
an informed and valid decision
– Medical futility
– Reduction of pain and suffering
– Fear and distress
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Terminal Weaning
• Four elements of terminal weaning must be
addressed
– Patient’s informed request
– Medical futility
• Interpretation of futility (hopelessness) is based on the
experience of primary physician or specialist, in that
treatments were useless in the past 100 similar cases
– Reduction of pain and suffering
– Fear and distress
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Terminal Weaning
• Four elements of terminal weaning must be
addressed
– Patient’s informed request
– Medical futility
– Reduction of pain and suffering
• Disease process (e.g., cancer)
• Medical treatments (e.g., radiation)
• Procedures (e.g., venous and arterial punctures)
• Psychological trauma (e.g., isolation in an unfamiliar
environment, unable to care for self, eat, or talk)
– Fear and distress
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Terminal Weaning
• Four elements of terminal weaning must be
addressed
– Patient’s informed request
– Medical futility
– Reduction of pain and suffering
– Fear and distress
• Physical clues (e.g., tears, sadness, uncooperative with
medical staff)
• Verbal clues (e.g., expression of fear, special requests)
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Terminal Weaning
• Prior to withdrawal
– Immediate caregivers should be offered an opportunity
to withdraw from the case
– Patient’s pastor or hospital-based chaplain should be
notified
– Room should be kept quiet
– Unlimited visitation should be allowed
– Non-essential monitors, lines, and tubes should be
discontinued
– Should provide vital sign monitor, oxygen, and IV access
(for administration of analgesics and sedatives)
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Terminal Weaning
• Withdrawal
– Family members should be offered an opportunity
to stay with the patient
– The attending physician and chaplain are
encouraged to be present
– Analgesics and sedatives should be provided in
sufficient quantity for patient comfort and relief of
anxiety
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Terminal Weaning
• Withdrawal
– When the patient is intubated, ventilator settings
should provide minimal support (spontaneous
breathing with oxygen and humidity)
– If the ventilator is turned off, the patient is
extubated and placed on an oxygen mask
– The airway should be suctioned to ease breathing
effort
– Documentation should follow hospital policies
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