WEANING / PENYAPIHAN DARI

VENTILASI MEKANIS

CRITICAL CARE MEDICINE

Reviewed by Dis Bima Purwaamidjaja

Pendahuluan

- +/- 40% : pasien dengan ventilasi mekanis  proses weaning

- Target weaning : ekstubasi / dekanulasi dan melepaskan dari
ventilasi tekanan positif.
- Metode weaning  beberapa : tergantung yang biasa / protokol
ditetapkan.
- Tantangan nyata : PASIEN SULIT / GAGAL WEANING

TARGET PEMBELAJARAN

1. Mengetahui definisi “weaning” dan discontinuation dari ventilasi

mekanis
2. Mendiskusikan metode weaning
3. Mengetahui kriteria ekstubasi
4. Mengetahui dan mempelajari penyebab terjadinya kegagalan
weaning
Weaning (discontinuation) dari ventilasi mekanis

Tindakan meliputi 2 hal :

1. withdrawal / penyapihan dari ventilasi mekanis
2. Melepas tube endotrakea

Metoda yang digunakan melepaskan dari suport respirasi : ketahui

alasan kenapa pasien diintubasi? Untuk berapa lama diperkirakan
pasien dg suport? Berapa banyak dan jenis obat sedasi yang
diberikan?

Secara umum : metoda apapun bisa digunakan : yang familiar

Pasien dengan ventilasi mekanis : resiko :

Pnemoni nosokomial
Stretch injury dan barotrauma
Trauma jalan nafas
Prolonged Sedation
 Weaning (discontinuation) from mechanical ventilation. Cont…….

Ekstubasi terlalu dini : resiko :

Hilangnya proteksi jalan nafas (aspirasi).

Hypoksemi
Peningkatan tonus simpatis – stres kardiovaskular
Kelelahan otot dan asidosis
Reintubasi jalan nafas yang edema (resiko trauma otak dll)

Weaning : pendekatan multisistem – Paru – paru : sebagian hal saja

Indikasi dari ekstubasi :

Pasien mampu ventilasi

Pasien mampu oksigenasi
Pasien mampu memproteksi jalan nafasnya
 Kriteria pasien siap weaning
Criteria Description

Objective measurements •Adequate oxygenation (eg, PO2 >60 mm Hg on FIO2 > 0.4; PEEP <5–10 cm H2O;
PO2/FIO2 >150–300);

  •Stable cardiovascular system (eg, HR <140; stable BP; no (or minimal) pressors)

  •Afebrile (temperature < 38°C)

  •No significant respiratory acidosis

  •Adequate hemoglobin (eg, Hgb >8–10 g/dL)

  •Adequate mentation (eg, arousable, GCS >13, no continuous sedative infusions)

  •Stable metabolic status (eg, acceptable electrolytes)

Subjective clinical
assessments •Resolution of disease acute phase; physician believes discontinuation possible;
adequate cough
Hgb = hemoglobin; HR = heart rate; GCS = Glasgow coma score.
Source: MacIntyre NR, Cook DJ, Ely EW, Jr., Epstein SK, Fink JB, Heffner JE et al. Evidence-based guidelines for weaning and
discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American
Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120(6 Suppl):375S-395S
 Weaning / Discontinuation  Partial Ventilation Support

The objective of partial ventilator support (PVS) is to allow the patient to

interact with the ventilator as the neuro-mechanical cause of respiratory
failure resolves. Unless the patient is being ventilated for post-operative
care, in which case the lungs are usually normal, the disease process
and the intensive care interventions (sedation), do not allow for
immediate movement from full support to extubation.

 Although partial support modes are widely used, there is no evidence

that they are superior to multiple daily T-piece trials. The most effective
method of PVS is  targeted pressure support.
Patients are actively weaned from full to partial support, using an
algorithm such as that below.
 Weaning / Discontinuation  Partial Ventilation Support continued…

Prior to weaning, the patient will usually be on one of three modes of

support: pressure (assist) control (PC), synchronized intermittent
mandatory ventilation (SIMV) with pressure support (PS), or volume
(assist) control (VC). All of these modes allow for spontaneous patient
breathing, differing in the amount of control the patient has over the
spontaneous breath. In all three modes the first priority is to reduce FiO2
to less than 60%, and to ensure that the patient is hemodynamically
stable.

Weaning from  pressure control requires normalization of inspiratory times

and reversal of neuromuscular blockade if present. The driving pressure
is targeted to a tidal volume of 4 - 6ml/kg.

As oxygenation improves and lung compliance increases, in all modes of

ventilation, the tidal volumes for any airway pressure will increase. Thus
the peak airway pressure and the CPAP/PEEP level can be weaned.
Most physicians will wean PEEP to 10cmH2O or less at this point.
 Weaning / Discontinuation  Partial Ventilation Support continued…

Pre-extubation, the PEEP level is usually 3-5cmH2O (unless the patient is obese).
Remember, the mean airway pressure, the CPAP level and the FiO2 are the
interventions which are targeted at oxygenation; the minute ventilation and, in
particular, the rate, are targeted at ventilation. Thus as PaCO2 reduces, it is
possible to reduce the control rate in each mode, until the patient is breathing
spontaneously.
In SIMV + PS the control rate is reduced towards zero (the patient is on pressure
support alone). Pressure assist control is  weaned to pressure support, the control
rate is reduced towards zero (pressure assist) and then, if tolerated, the mode
switched.
When weaning from a full support to a partial support mode it is important that you
use a logical approach. For example, it makes no sense to wean from pressure
assist-control to SIMV volume control with pressure support. If you are using
pressure targeted ventilation, you should stay in pressure targeted ventilation.
The most popular partial support mode, worldwide, is SIMV (volume control) +
Pressure Support. It is known that gradual reduction in control breaths in SIMV
(without PS) is the poorest weaning method. It is my practice to use this mode only
in post-operative patients, and as soon as the patient is breathing to switch to
pressure support alone. The patient should have full ventilation assistance when
on the mixed mode (the pressure support is set as the same as the driving
pressure (plateau pressure minus PEEP) on the controlled breath.
 TEHNIK
WEANING

1. PRESSURE
CONTROL
2. SIMV+ PSV
3. VOLUME
CONTROL
Weaning / Discontinuation  Spontaneous Breathing Trials
The best way to determine suitability for discontinuation of mechanical ventilation
is to perform a spontaneous breathing trial. There are three ways to do this:
putting the patient  on a minimum pressure support and PEEP (for example 5-
7cmH2O PS/5cmH2O PEEP performing mechanics and extubating), using
CPAP alone, or using a T-piece.

A T-piece (or trach-collar) trial involves the  patient breathing through a T-piece
(essentially the endotracheal tube (ett) plus a flow of oxygen-air and no
ventilatory assistance) for a set period of time. The work of breathing is higher
than through a normal airway (although this simulates laryngeal edema/airway
narrowing). If tolerated, the chances of successful extubation are high. If not
reattachment to a ventilator is simple.

 An alternative variant to this is the use of a CPAP circuit, which overcomes
some of the work of breathing through the ett and prevents airway collapse.
 Many physicians extubate the patient directly from PS and PEEP (the PS
overcomes the tube resistance). The conventional wisdom is that 7cmH2O of
pressure support is required to overcome the resistance through a size 7.5mm
(internal diameter) endotracheal tube, and 3cmH2O through a tracheostomy. If a
smaller tube is in place, pressure support of 10cmH2O is required.
If the patient tolerates a spontaneous breathing trial with any of these modes,
then one should proceed to extubation.
 General measures:

Ensure the patient is suitable for weaning

Conduct wean to extubation (spontaneous breathing) trials early in the

morning, when the patient is fully rested and there is a full compliment of
staff available.

During these trials the patient should be awake and co-operative,

apyrexial and on minimal pressor support (vasopressors are not a
contraindication to extubation, although they are a sign that the patient
may still require pulmonary support).

Place the patient in the upright or semi-upright position and explain what
you are attempting to do.

Check for a cuff leak by deflating the cuff and occluding the ett. The
absence of a cuff leak is not a contraindication to extubation, as the tube
may be snug with the trachea, but should alert the physician to the
possibility of laryngeal edema.
Suction out the tube, airway and oropharynx.
How do I know if the patient is intolerant of a spontaneous breathing trial?

Source:
MacIntyre NR, Cook DJ, Ely EW, Jr., Epstein SK, Fink JB, Heffner JE et al.

Evidence-based guidelines for weaning and discontinuing ventilatory support:

a collective task force facilitated by the American College of Chest Physicians; the
American Association for Respiratory Care; and the American College of Critical
Care Medicine. Chest 2001; 120(6 Suppl):375S-395S
 HEMANT, CHACKO, SINGH :

WEANING Indian J. Anaesth. 2006; 50 (6)

SBT can be in the form of a low level

of pressure support (5-7 cm H2O) or
simply as a T-tube breathing. The
initial few minutes of the trial called
the screening phase should be
monitored closely as most of the
detrimental effects of weaning occur
during this period. Thereafter the
patient should continue the trial for at
least 30 minutes but not more than
120 minutes to assess for weanability.
 Weaning / Discontinuation of Mechanical Ventilator

I wish to evaluate the patient for discontinuation from the ventilator

Does the patient meet the criteria?

Place the patient on Spontaneous Breathing Trial

Watch for 5 to 10 minutes

How do I know if the patient is If acute distress does not occur, continue for
tolerant /intolerant of the trial? a maximum of 2 hours

Is the patient suitable for extubation ?

Yes No

Sit the patient up in the bed, suction out Rest the patient on the ventilator
The endotracheal tube, explain what Ensure optimal analgesia and sedation
You are going to do
And extubate the patient
Failure to Ventilate Reassess failure to wean / discontinue
Failure to Oxygenate
Others factors Attempt SBT ONCE every 24 hours

Reccurent failure

Consider Tracheostmy :
- Requiring excessive sedation to tolerate ETT
- Marginal mechanics
- Psychological dependence on ventilator
- Mobility
- Airway trauma
 Key Points: the least you need to know

- Removing a patient from a ventilator involves discontinuation of

mechanical ventilation and extubation.

- There are two parts to weaning: weaning to partial ventilator support

and weaning to discontinuation. There is little evidence that partial
modes are more effective than T-piece trails. Of these modes, pressure
support is the best.

- The single most traumatic event for the patient is conversion from
positive pressure to negative pressure ventilation.

- To extubated a patient, they need to be awake, able to cough and

protect their airway.

- If it is possible to wean a patient to extubation, but the patient cannot

protect his/her airway, it is best to perform tracheotomy.

- Although the ventilator only appears to support on organ system, the

lungs, this is not in fact the case.
 Key Points: the least you need to know……..

-For a patient to self ventilate, many body systems must be functioning: the
cardiopulmonary apparatus, the central nervous system, the nerves that supply
the diaphragm (including the neuromuscular junctions), the muscles
themselves.
- Moreover the patient must be willing to breath and maintain their own
functional residual capacity (not if there is diaphragmatic splinting due to pain).
- There must be room in the abdomen for the diaphragm and lungs to move
into.
- There must be adequate hemoglobin to deliver oxygen to the tissues.
- It may be difficult to wean a patient if ongoing inflammatory processes persist
in the lungs: consolidation, fibrosis, auto-PEEP, diffusion defects.
- To overcome these problems, a holistic approach must be adopted.
- Muscles must be trained and nourished, and patient-ventilator interaction
encouraged.
- There most effective method of weaning to discontinuation is spontaneous
breathing trials (SBT).
- One must determine suitability for SBTs before commiting to them.
If a patient fails an SBT, then it is important to look for the reason and reverse
it. SBTs should not be performed more than once daily.
A reintubation rate of 10% is acceptable. Patients deserve a trial of extubation,
and many will do well in spite of poor mechanics (you must use clinical
judgment).
Clinical Scenario

A 77 year old male is admitted to ICU following a bowel perforation with fecal peritonitis,
due to caecal carcinoma. His portoperative course is complicated by a perioperative
anteroseptal myocardial infarction, systemic sepsis requiring insertion of a pulmonary
artery catheter, volume loading and vasopressors, and moderate renal dysfunction, with
serum creatinine reaching a peak of 3.3.
He is now at 14 days postop.
Currently he is difficult to arouse, with a GCS of 7 on a sedation cocktail of fentanyl
50μg/hour and lorazepam at 1mg 8 hourly.
His temperature is 37.8.
Cardiovascularly, his pulse is 76 and regular, blood pressure is 130/70 and CVP is 12.
His lungs are reasonably clear to auscultation, chest x-ray reveals some patchy infiltrates
throughout, bibasal atelectasis and a left sided pleural effusion. He is on 35% oxygen,
SIMV rate 8, spontaneous rate 6, pressure support 16 and PEEP 5 cmH2O. His blood
gases are pH 7.52, PaO2 72, PaCO2 44, BE +8, SaO2 94%.
His abdomen remains tense, with a would closed with tension sutures and two drains,
currently draining very little. His is tolerating post pyeloric feeding.
Liver function tests: normal except for an albumin of 1.6 (zeneth was 0.8). He has lower
limb, sacral and scrotal edema.
His fluid balance is even over the past five days.
Hb 8.1, WCC 18.5, Plat 102, Na 148, K 3.1, Urea 37, Creat 1.2, MgSO4 3.2, PO4 1.5, Ca
2.0.
The patient is completing a 14 day course of ampicillin, gentamycin and metronidazole
today, for appropriately isolated bowel organisms.
Describe how you would evaluate this patient for weaning from mechanical ventilation?
 What about this particular patient?

Following this system it is possible to identify a number of reasons why there may be difficulty weaning this patient:
1.  CNS – he remains sedated with long acting agents – lorazepam and fentanyl (which tends to accumulate), these will both reduce levels of
consciousness and impair central respiratory drive. These agents must be aggressively weaned.
2.  PNS – although he has only been ventilated for two weeks, he is doing little work himself, and may have some muscular atrophy. Moreover,
the long duration of aminoglycoside therapy may cause some neuromuscular blocking effects. In addition, the combination of a low serum
potassium, magnesium and phosphate does not augur well for muscular function. These need to be supplemented.
3.  CVS – the patchy infiltrates on CXR and the history of myocardial ischemia are worrisome, this indicates that this patient will not easily
tolerate the autotransfusion associated with moving from positive to negative pressure ventilation. It is essential to image his heart with an
echocardiogram, assess cardiac performance and consider the use of an agent that remodels the ventricle and reduced preload and afterload –
an ACE inhibitor. I would be cautious in this circumstance with the history of renal failure. Alternative therapies would be the introduction of
either nitrates or dobutamine in the hours peri-extubation.
4.   Renal – renal function is reasonably good now, although the high urea to creatinine ratio suggests over enthusiastic diuresis, confirmed with
the metabolic alkalosis (which may also indicate sodium bicarbonate use – seen in the high serum sodium). This alkalosis can be corrected with
judicious use of sodium chloride (the chloride will correct the alkalosis by returning to electro-neutrality) or increasing enteral free water delivery.
5. Gastrointestinal/Abdomen – a tense tight abdomen will interfere with diaphragmatic excursion, and thus respiratory mechanics. We have
little control over this. It is worth asking, nonetheless, with a tense abdomen and nothing draining, if the drains are blocked. Does the patient
have ascites? If so, it may be worth draining this to reduce intra-abdominal pressure.
6.   Extremities – the combination of peripheral edema and a low serum albumin does not make me feel confident about an early extubation, as
the patient probably also has soggy lungs, from sepsis induced capillary leak (low oncotic pressure and fluid extravascation). There is little that
can be done about this edema, the fact that it is resistant to diuretics is interesting. Has the patient been given adequate prophylaxis against
deep venous thrombosis and pulmonary embolism?
7. Pulmonary function – the x-ray findings indicate a distinct mechanical disadvantage, patchy areas of consolidation (difficult to oxygenate)
and a pleural effusion (difficult to ventilate). The effusion can be drained if necessary. I am concerned about a possible nosocomial pneumonia –
I note a persistent leucocytosis, lung infiltrates and a low grade temperature. The patient has not been covered for pseudomonas or MRSA
pneumonia, and it is essential to out rule this possibility by performing a broncho-alveolar lavage at this time. Is there any indication of infection
on tracheal aspiration (mucopurulent sputum)? How long have the patient’s lines been in – is that the source?
This patient will probably tolerate a spontaneous mode of ventilation (such as pressure support) fairly well, although his electrolytes and acid
base status require correction. If there is no movement towards minimal ventilator settings within 48 hours, a prolonged wean is probably likely
(due to low physiological reserve) and the patient will require a tracheostomy.
Is the Patient able to Ventilate?
Alveolar ventilation is adequate to keep the PaCO2 < 50 mmHg. The production of CO2 can be controlled by reducing the carbon load in the diet (high fat), and
minimize agitation, pain, fever, shivering and muscle workload.

FACTORS THAT MAY INTERFERE WITH WEANING

 
Neurological
                                                                                                                       
Central: prolonged sedation, with opioids (morphine, fentanyl, and benzodiazepines (lorazepam, midazolam) reduces respiratory drive and prolongs ventilation.
The amount of sedatives used must be minimized and the patient wakened daily. Psychological dependence on the ventilator follows prolonged usage, and this
needs to be addressed both holistically and pharmacologically.
A number of factors will reduce central respiratory drive. As CO2 is the main stimulus for ventilation, the patient’s PaCO2 must be returned to a level normal for
them. Metabolic or respiratory alkylosis reduces hydrogen ion concentration in the brainstem, and thus the stimulus to breath.
For weaning the patient must be awake and co-operative and able to protect his/her airway.
                                                                                                                     
Peripheral: it is essential to rule out the possibility of a persistent neurological injury such a phrenic nerve palsy, due to surgery. Neuromuscular blocking (NMB)
agents will prevent weaning, and it is important to ensure that full reversal of blockade has taken place (by using a nerve stimulator). Some drugs such as
aminoglycosides can mimic NMBs.
Prolonged critical illness may lead to the development of a critical illness polyneuropathy, due to axonal degeneration.
Muscular
Muscular atrophy due to malnutrition, prolonged muscle relaxants or critical illness myopathy may limit weaning.

Anatomical Problems
Chest Wall – flail chest: is the pain under control?
Does the patient have a compliant chest wall?
•If the patient has to work hard just to lift the chest wall - for example extensive edema, large fat pads, tight dressings, increased abdominal pressure - due to
bowel swelling, packs, blood etc, then weaning will be very difficult.
                                                                                                                                                    
Pleura – pleural effusions – are they present, can they be drained? Does the patient have a chest drain in – is there much coming in.
Airways – Is there any form of reversible airway obstruction – mucus plugging, excessive secretions or bronchospasm? Is there laryngeal edema – check for a
cuff leak.
Abdomen: does the patient have a compliant (abdominal surface) chest wall. The presence of ascites, distended bowel, abdominal hypertension, packs or tight
surgical dressings may interfere with ventilation.
 Is the patient able to oxygenate?
It is essential to minimize  the amount of lost oxygenation due to diffusion abnormalities, ventilation-perfusion mismatch,
dead space and shunt. Certain factors may limit successful weaning – persistent lower respiratory tract infection,
alveolar edema, airway/lobar collapse, lung fibrosis. Good quality physical therapy is required to mobilize secretions -
the commonest cause of airway collapse is absorption atelectasis, distal to mucus plugs. As we have seen, re-
expansion of collapsed lung units requires considerable work, particularly in patients with depleted reserve.
If the patient is requiring moderate to high levels of PEEP to oxygenate (PEEP prevents derecruitment at end
expiration), then weaning is unlikely.
Persistent cardiogenic pulmonary edema makes the lungs stiff and boggy. This causes diffusion defects and shunt. The
hearts performance needs to be optimized, be it with cautious doses of diuretics, inotropes or ACE inhibitors.
                                                                                                 
What other factors will influence weaning?
                                                                                    
Cardiovascular – pulmonary edema due to left ventricular failure or volume overload decreases lung compliance and will make weaning more
difficult. When mechanical ventilation is discontinued, significant physiological changes occur which will influence cardiovascular performance:
change from positive pressure to negative pressure ventilation, reduced mean intrathoracic pressure, increased preload and afterload. This may
lead to critical loading of myocardial fibers and provoke ischemia – failure and edema.
Gastroinestinal – recurrent aspiration pneumonitis, ascites or abdominal wounds leading to diaphgramatic splinting. Abdominal distension or
hypertension, for any reason (massive fluid resuscitation, surgical packs etc), will reduce chest wall compliance and lead to failure to ventilate.
Nutrition -protein malnutrition leading to muscular atrophy, which affects the diaphragm and intercostals.
Acid base – metabolic alkalosis, particularly due to use of diuretics reduces respiratory drive. Conversely, muscles perform poorly in an acidic
environment. Metabolic acidosis is caused by excessive amounts of measured anions (chloride) or unmeasured anions (lactate - from
hypoperfusion), ketones and renal acids.
Electrolytes– hypophosphatemia, hypomagnesemia, hypokalemia, hypocalcemia: these all affect muscular function and protein metabolism.
Endocrine – muscle weakness due to hypothyroidism or steroid induced myopathy.
Oxygen delivery capacity – the circulating hemoglobin concentration: anemia increases respiratory drive and cardiac output in order to maintain
oxygen delivery.
Pain control – it is very difficult to wean patients who are in pain, particularly from upper abdominal or thoracic surgery or injuries. If a patient has
a flail chest, it may be necessary to insert a thoracic epidural prior to extubation
 Key Points: the least you need to know
Removing a patient from a ventilator involves discontinuation of mechanical ventilation and
extubation.
There are two parts to weaning: weaning to partial ventilator support and weaning to discontinuation.
There is little evidence that partial modes are more effective than T-piece trails. Of these modes,
pressure support is the best.
The single most traumatic event for the patient is conversion from positive pressure to negative
pressure ventilation.
To extubated a patient, they need to be awake, able to cough and protect their airway.
If it is possible to wean a patient to extubation, but the patient cannot protect his/her airway, it is best
to perform tracheotomy.
Although the ventilator only appears to support on organ system, the lungs, this is not in fact the
case.
For a patient to self ventilate, many body systems must be functioning: the cardiopulmonary
apparatus, the central nervous system, the nerves that supply the diaphragm (including the
neuromuscular junctions), the muscles themselves. Moreover the patient must be willing to breath
and maintain their own functional residual capacity (not if there is diaphragmatic splinting due to pain).
There must be room in the abdomen for the diaphragm and lungs to move into. There must be
adequate hemoglobin to deliver oxygen to the tissues.
It may be difficult to wean a patient if ongoing inflammatory processes persist in the lungs:
consolidation, fibrosis, auto-PEEP, diffusion defects.
To overcome these problems, a holistic approach must be adopted. Muscles must be trained and
nourished, and patient-ventilator interaction encouraged.
There most effective method of weaning to discontinuation is spontaneous breathing trials (SBT).
One must determine suitability for SBTs before commiting to them.
If a patient fails an SBT, then it is important to look for the reason and reverse it. SBTs should not be
performed more than once daily.
A reintubation rate of 10% is acceptable. Patients deserve a trial of extubation, and many will do well
in spite of poor mechanics (you must use clinical judgment).
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