the slrh ventilator weaning protocol workgroup
DESCRIPTION
Mechanical Ventilation Weaning Protocol Education for Nurses, Respiratory Therapists and Physicians. The SLRH Ventilator Weaning Protocol Workgroup. Objectives of this program. - PowerPoint PPT PresentationTRANSCRIPT
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Mechanical Ventilation Weaning Protocol
Education for Nurses, Respiratory Therapists and PhysiciansThe SLRH Ventilator Weaning Protocol Workgroup
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Objectives of this programProvide education about ventilator weaning in the Critical Care Units and Medical Progressive Care and Step down UnitsProvide rationale and benefits for using a ventilator weaning protocolReview the assessment tool for ventilator weaning in critically ill patientsReview SLRH vent weaning protocol:
◦Revised acute vent weaning protocol◦New chronic vent weaning protocol
Explain tracheostomy decisions and careDemonstrate how weaning is integrated into the total care of the patient
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A Weaning Protocol:Promotes a standardized assessment of each patient’s readiness to wean as part of the
daily assessment by the nurse and respiratory therapistEmpowers the nurse and respiratory therapist to initiate the process of early weaning from the ventilator by identifying patients who are readyFacilitates collaboration between the RN/RT and physician or nurse practitionerThe 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 ProtocolStudies 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 ventilationEarly 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 SLRHWork together – RN, RT, NP, PA,
MD/DOEarly identification – Early in the
day, early in the courseAssessment by RN and RT in
daily screen and protocolNotify 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 patient’s disease and course.
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Weaning protocols in different unitsOur 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 WeaningWhat 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 protocolsThe protocols are found on Forms
on DemandWe will go through the steps of
the protocols for acute and chronic weaning
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Step 1: Assessment for Weaning ReadinessInitial 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 weaningThe 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
flowsheetIf 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 readinessThe 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 H20ABG 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 heldSedation goal RASS of 0 achieved or hold
sedationExplain to the patient
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Physician Order for WeaningThe MD/NP needs to place the
order for weaning only onceThis 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 earlyBetween 5:30 and 7 am in the
ICUsBy 9 am for chronically-ventilated
patients in the stepdown units
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STEP 3: Method of weaningchosen by physician
PRESSURE SUPPORT VENTILATION METHOD (PSV)□ Set PS___ □ FiO2___ %□ Decrease PS by ___q ___h□ ABG ( ) Y ( ) NGOAL : PS ≤ 5 for ____ min
SICU METHOD □ CPAP = 5, PS=0 □ FI02 21% □ Tolerates 20 min □ Then ABG:GOAL: Pa02 >50mmHg PaC02 <50 mmHg RR < 35/min
SIMV METHOD□ Set IMV___ PS___□ FiO2___%□ Decrease IMV rate by __ q __ h □ Decrease PS by ___ q ___ h □ ABG needed ( ) Y ( ) N
GOAL: IMV ≤ 4 AND PS ≤ 8 for ___min
SPONTANEOUS BREATHINGTRIAL METHOD (SBT)□ PS=____□ CPAP = ___□ FI02 ___%□ T-piece □ Duration ___minutes□ ABG needed ( )Y( ) N GOAL : ____ min
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Acute weaning – Spontaneous Breathing Trial “SBT”The most common method is the SBT:
CPAP mode, pressure support 5-8 cm H20. Duration 30-120 minutes.
Other methods include:◦ SIMV with gradual reduction in respiratory
rate◦ Pressure support with gradual reduction in
amount of pressure supportFor SICU patients, CPAP trial for 20
minPhysician Order: must complete
method, settings, and duration
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STEP 4: Assessing patient tolerance of weaning
• Respiratory Rate <35 breaths per minute• Heart rate between 50 and 130 bpm and within ± 20% of
pre-trial HR• Systolic Blood Pressure (SBP) between 90-170 mmHg and
within ± 20% of pre-trial SBP• Exhaled TV ≥ 5 cc/ kg IBW ( ≈ 300 – 400 ml )• SpO2 ≥ 92 %• Patient showing no diaphoresis, paradoxical respiration,
retractions, nasal flaring, agitation, or complaining of SOB, or use of accessory muscles
• Serial assessments of tolerance are made 5,15,30,60,and 120 minutes after the INITIAL setting and following any subsequent ventilator changes.
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STEP 5: Tolerating weaning trial – success! Notify physician and teamArterial blood gas, if orderedPhysician informed about the
successful weaningRT - set up for extubationPhysician will be present for
extubationThe patient is monitored following
extubation:◦ In addition to vital signs including
Sp02 ,always check for stridor, breath sounds, secretions
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Not tolerating weaning today…If not tolerating weaning go to
pre-trial settingsDocument on Weaning Flow
record – in what way the patient did not tolerate weaning, duration of weaning, level of support used
This will improve our communication and plan for the next weaning trial so that we can move forward with weaning the patient
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DocumentationThe daily outcome will be written in
the weaning flow record which will be kept in the Respiratory Care book. The RN and RT document the progress
The medical, nursing and respiratory staff will view the flow record in making further decisions about weaning
Vital signs, ventilator settings, extubation are charted in the ICU flow record as usual
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Weaning Flow Sheet Documentation
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Chronic Vent WeaningThis protocol applies to patients
with tracheostomies who are undergoing weaning in the Critical Care Units, MPCU, stepdown vent units RH 10B, SL 10E
The early assessment is the same
Screening by nurse or respiratory therapist for readiness◦ Document in nursing/respiratory
notes or ICU flow record
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Only one order to wean is needed and will apply until the order is discontinued
Weaning will be started by 9 am daily
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Methods of Chronic Vent WeaningSome patients who have been on a
ventilator for a prolonged period or have a tracheostomy may need a more progressive program for weaning
The two general methods are:◦Pressure support PS– gradually
decrease the PS amount and prolong the time
◦Trach collar – use trach mask for progressively longer periods of time
◦Other methods such as volume support may also be used
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Chronic Weaning
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DocumentationThe duration of weaning is
documented on the flow record. This will be kept in the respiratory folder. The RN or RT may document the progress
The medical, nursing and respiratory staff will view the flow record for further decisions about weaning
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Tracheostomy: IndicationsProlonged ventilator requirement and
inability to wean due to ◦ Generalized weakness, such as critical illness
polyneuropathy◦ Multiple comorbid conditions that require
prolonged ventilation◦ Chronic critical illness
Inability to clear secretions Severe neurologic dysfunction Airway obstruction
◦ Tumor, upper airway injury, edema◦ Severe obstructive sleep apnea with
complications, not amenable to usual treatments
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Patients not expected to wean- Addressing goals of careSome patients are not expected
to be weaned from a ventilator so tracheostomy would be considered for indefinite ventilator-dependence
In these patients, this decision point for tracheostomy would be an appropriate time to readdress life support/end-of-life decisions
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Benefits of tracheostomyAbility to mobilize patients with
prolonged need for ventilator with a more secure airway
Potential for patient to require less sedatives and communicate
Allows transfer to a chronic ventilator facility
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Planning for TracheostomyClinician assesses the potential for liberation from ventilator based on the patient’s illness, prognosis, and patient preference
Tracheostomies can be performed early (within 7 days) or later (at 2-3 weeks)
If the patient is unlikely to be weaned due to neurological/chronic pulmonary process, a decision on tracheostomy can often be made within few days of intubation
Patients with reversible disease who are unable to wean in 10-14 days are usually considered for tracheostomy at that time
Tracheostomy is not performed in unstable or dying patients
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Timing of TracheostomiesBased on individual patient
situationBenefits of early tracheostomy
include: improved comfort and decreased sedation, improved mobility
In some patients, early tracheostomy may facillitate weaning, so may decrease duration of mechanical ventilation
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Patients with tracheostomiesAssess for speech and swallowing
– may be candidate for speech valve
MOBILITY – out of bed, sit, stand, walk
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Decannulation – removal of tracheostomyPatients are completely off ventilator for
sufficient number of days to assure that the primary process is resolved
Able to cough secretionsTolerate speech valveTolerate capping of the tracheostomyClinically assure there is no upper
airway obstructionPatient requires close monitoring in the
first 24 hrsIf patient develops distress – consider
secretions, airway obstruction
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Respiratory distress in patients with endotracheal tubes and tracheostomies
Secretions and mucous pluggingDislodgement of tracheostomy/ ETTPneumothoraxVentilator dyssynchrony due to vent
settingsBecause of underlying diseases, may be
at risk for pulmonary embolism, heart failure, volume overload
Granulation tissue formation in the trachea can lead to high peak pressures
**These causes must be considered before treatment with sedatives**
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Look at the overall plan of careMobility in patients with
endotracheal tube or tracheostomy
SpeechNutritionGoals of care discussion with
patient and family
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MobilityEarly mobility can
◦ Decrease intensive care unit and hospital length of stay in survivors
◦ Reduce the functional decline from the illness
◦ Decrease risk of pressure ulcers and improve wound care
Multidisciplinary team – collaboration to provide safe mobilization of patients in the intensive care unit, progressive care and stepdown units.
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Weaning and mobilityIn addition to the effects on
duration of ventilation, mortality and ICU complications, weaning and mobility can potentially:
Improve patient spiritImprove communicationReduce delirium Reduce depression
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DocumentationOrders will be placed by MD using
the pre-printed paper order:◦Weaning orders
Physician places order for weaning in Prism
ICU Flowsheet will reflect the readiness screen and the weaning
RN/RT will document in weaning flow record
Extubation – Physician documents in progress note
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So let’s 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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Thank you for completing this program!We believe that a comprehensive
and multidisciplinary approach will improve care and outcomes of our patients who require mechanical ventilation.
For questions, please contact:Manju Pillai MDRaymonde Jean MDMark Collazo RRTJanet Shapiro MD