Transcript Readiness For Weaning From the Ventilator

Readiness For
Weaning From the
Ventilator
Terry P. Clemmer, MD
Director CCM LDS Hospital
Professor of Medicine
University of Utah School of Medicine
7/17/2015
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1. Frontline
Engagement
6. Clear
Communication
2. Scripted
Processes
Requisite for
Sustainable
Improvement
3. Reliable
Execution
5. Scientific
Change Process
Terry P. Clemmer, MD
LDS Hospital
4. Organizational
Learning
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Define Weaning
1. It Is: Removal from Assisted
Positive Pressure Ventilation to:
– CPAP
– T-tube or Trach Mask
– Face Mask, Face Tent or Nasal Oxygen
2. It Is Not: Extubation or Removal of
Tubes From the Trachea:
– ET Tube
– Tracheostomy Tube
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Keys to Early Weaning
1. Therapist Driven Ventilator Management
and Weaning Protocols
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Rules for Assessing Weaning Readiness
Rules for Selecting Weaning Mode
Rules for Failure to Wean
Rules to Reduce Support During Weaning
2. Removing Patient From Sedation ASAP
3. Mobilizing Patient
4. Separate Extubation Rules and Process
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Example of Rules that Trigger
a Weaning Assessment
• FiO2 <= 0.5
• PEEP <= 10
• 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 < 27 and Vt > 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 < 4 ml/kg wait 4-6
hours and 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 < 4 ml/kg PBW
• Change in Mental Status
• pH < 7.25
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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 < 90% of FiO2 >= 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
Terry P. Clemmer, MD
LDS Hospital
4. Organizational
Learning
15