Weaning From

Mechanical Ventilator
Juni Kurniawaty
 Objective
• Identify patients who are ready to wean from
mechanical ventilation
• Understand weaning parameters
• Identify when patients are ready for
extubation
 Introduction
• 75% of mechanically ventilated patients are
easy to be weaned off the ventilator with
simple process
• 10-15% of patients require a use of a weaning
protocol over a 24-72 hours
• 5-10% require a gradual weaning over longer
time
• 1% of patients become chronically dependent
on MV
Arnaud W. Thillea,b, Irene Corte ́s-Pucha, and Andre ́s Estebana
Discontinuing Mechanical Ventilation

• Two step process:

– 1. Readiness testing:
• Purpose is to identify patients who should start
weaning
– 2. Weaning:
• Process of decreasing the amount of support a patient
receives from the ventilator
 Readiness Testing
• Required Clinical Criteria:
– Cause of the respiratory failure has improved
– Adequate oxygenation
– Arterial pH > 7.25
– Hemodynamic stability
– Able to initiate respiratory effort
 Readiness Testing
• Optional Criteria:
– Hb: ≥7 to10 mg/dL
– Core temperature: ≤38 to 38.5°C
– Mental status: awake and alert or easily arousable

• Patients should be screened daily whether

they meet criteria to start weaning
Readiness Testing
 A+B
• Adequate oxygenation and gas exchange
• PaO2 >60mmHg on FiO2 <40%
• PEEP 5–8cmH2O
• CXR stable or improving
 C
• Absent or only low dose
vasopressors/inotropes
• With SBP>90mmHg or MAP>60mmHg
• Stable cardiac rhythm
• No tacycardia
• No evidence of myocardial ischaemia
 D
• Adequate mentation
• Rousable (this is controversial: some advise
GCS>8 equivalent, some able to follow
commands, some neither!)
• No continuous sedative infusion or
neuromuscular blockade
• No significant weakness (e.g. can lift head off
pillow, raise arms in air for 15 seconds, clap
hands)
• Pain controlled
E F
• No signicant acidosis • adequate fluid status (not
• No electrolytes disturbance overloaded)
(e.g. normal K, PO4 >0.4)
 G H
• abdominal pain/ distention • Adequate hemoglobin
controlled
• tolerating feeds

I
• Afebril/ sepsis controlled
Weaning
 Methods of Weaning
• Spontaneous Breathing Trial (SBT)
– When patient spontaneously breaths through ETT
for a set period of time (30-120 min)

• Pressure Support Ventilation (PSV)

– Progressive decrease in pressure support (2 to 4
mmH2O daily)
– Ventilator set to PSV 5 cmH2O and PEEP 5 cmH2O
– Alternative to patients who do not tolerate SBTs
 Methods of Weaning
• Continuous positive airway pressure (CPAP) trial
– using a CPAP level equal to the previous positive end-
expiratory pressure (PEEP) level.

A recent Cochrane systematic review concluded

that there is no difference between T-piece trials
and pressure support trials regarding extubation
failure and mortality with low quality of evidence
 Weaning Trial Failure
• If patient develops the following during SBT:
– Respiratory rate <6 or >35
– Heart rate <50 or >120
– Systolic BP >180 or <90
– Hypoxia not corrected by raising FIO2 (max FIO2
50%)
– Marked diaphoresis or agitation
– Deterioration in mental status

• End SBT and put patient back on prior vent

mode
 Diaphoresis
And nasal flaring

Heightened
sternomastoid Cyanosis
activity
Tachypnea

Abdominal
paradox
Suprasternal
and supraclavicular
recession

Intercostal
recession Tanda-tanda
kegagalan
Tachycardia
weaning
 Weaning Parameters
• Predictors:
– Rapid Shallow Breathing Index (RSBI):
• RR/Vt < 105
– Negative Inspiratory Force (NIF):
• ≤ -30mmHg H20
– Minute ventilation:
• RR x Vt <10 to 15L/min
– Spontaneous volume:
• ≥ 5 ml/kg
 Extubation
• Prior to extubation:
– Confirm minimal FIO2 and PEEP
– Evaluate upper airway complications
• Check cuff leak
• Check that cough and gag are present
– Have equipment ready
• NC/facemask/bipap
– Suction secretions
– Extubate!
 Mechanical Ventilation
Rest 24 hrs

PaO2/FiO2 ≥ 200 mm Hg
PEEP ≤ 5 cm H2O
Intact airway reflexes
No need for continuous infusions of vasopressors or inotrops

> 100
RSBI

<100
Low level CPAP (5 cm H2O),
24 hours Low levels of pressure support (5 to 7 cm H2O)
Stable Support Strategy
Assisted/PSV
Daily SBT “T-piece” breathing

30-120 min

RR > 35/min
Spo2 < 90%
HR > 140/min No
Yes
Sustained 20% increase in HR Extubation
SBP > 180 mm Hg, DBP > 90 mm Hg
Anxiety
Diaphoresis
 Case
• 59 year old male is admitted to the ICU and
intubated for respiratory failure secondary to
aspiration pneumonia
• Five days later he is hemodynamically stable, no
longer on vasopressors, and has O2 sat of 94%
on FIO2 of 35%
• He tolerates PEEP of 5 and PSV of 5 for 90
minutes
• Weaning parameters shows NIF of -50, RR of 34,
and Vt of 200cc
 Case
• What would be the appropriate plan of
action?
– A) Extubate patient
– B) Place patient back on volume control AC and
reassess with next SBT
– C) Increase sedation to decrease respiratory rate
– D) Continue the patient on PSV of 5 and PEEP of 5
until he can no longer tolerate it
 Case
• Answer: B
– Given high respiratory rate and low tidal volume,
patient is not ready for extubation. RSBI in this
case is 170 which predicts extubation failure. Even
though patient is not in marked respiratory
distress during the SBT and is able to complete the
trial, he should be placed back on an assist-control
mode in order to rest his respiratory muscles until
the next SBT, which in general is the next day.
 Summary
• Remember that patients must meet clinical
criteria in order to start weaning
• Know your weaning parameters
– RSBI, NIF, minute ventilation, spontaneous tidal
volume
• Use your judgment and ask yourself if the patient
looks ready to be extubated
• Even in planned extubations, 12-14% of patients
fail and require reintubation. Make sure to
frequently reassess patients after extubation.
Terimakasih