Protocol for Liberation/Weaning From Mechanical Ventilation

By Paul Marik, MD

Step 1 Step 2 Step 3 Failure to wean Notes Disclaimer

Introduction

A number of different approaches to ventilator liberation have been reported (See note 1). The
most popular and efficient method is described. According to this approach:
All ICU patients are screened daily by the RT (See note 2)
Suitable patients undergo a 3 minute spontaneous breathing trial
This is followed by a 30 minute to 2 hour spontaneous breathing trial in those who pass the 3
minute test

Step 1. Screening of patients

Candidates for the 3 minute spontaneous breathing trial: (See note 3)
Adequate gas exchange
Non COPD: a PaO2 > 60mmHg with a FiO2 of 0.4 or less (PaO2/FiO2> 150)
COPD: pH > 7.30, PaO2 > 50mmHg with a FiO2 of 0.35 or less
PEEP < 6 cmH2O
Alert and cooperative patient.
Patient not on a continuous infusion of sedatives/narcotics
Temperature < 38C and > 36.5C
No requirement for vasopressor agents
dopamine > 10 ug/kg/min
norepinephrine
Minute ventilation < 15 L/min and RR < 30
Adequate cough during suctioning
Heart rate less 100 beats/min
Systolic blood pressure > 90 and < 180 mmHg

Step 2. Three minute spontaneous breathing trial

Patients who meet all the above criteria then undergo a 3 minute spontaneous breathing trial.
The patient will be placed on one of the following trial modes:

CPAP with auto-flow

CPAP with pressure support of 5cm/H20 (See note 4)

The FiO2 is set at the same level as that used during mechanical ventilation. Trial must be
monitored by pulse oximetry and electrocardiography. The trial must be stopped immediately
when the patient meets any of the following criteria:
Resp Rate/Tidal Volume (Liters) > 105
Respiratory rate < 8 or > 35
Spontaneous tidal volume < 4cc/kg
Arterial saturation < 90%
Heart rate > 140 or heart rate change (either direction ) > 20%; no arrhythmia

Step 3. Trial of Liberation

Patients continue to breath through the CPAP circuit. The FiO2 may be increased up to 50%.
Back-up apnea parameters must be set on the ventilator to activate at a 20 second apneic
interval.

Trial terminated when:

Respiratory rate > 35/min
Arterial saturation < 90
Heart rate > 140 or heart rate change (either direction ) > 20% or arrhythmias
SBP > 180 and < 90
Increased anxiety and diaphoresis

Should the patient tolerate the CPAP trial for 2 hours (some studies have used 30 minutes) then
the patient may be extubated.
The trial is repeated daily in those patients who fail to tolerate this spontaneous breathing trial.
The time to liberation is not shortened by repeating the spontaneous breathing trial multiple
times per day.
The ICU team must be notified should the patient pass this phase of the liberation process and
an order obtained to extubate the patient.
Orogastric tubes, if present should be removed to reduce the risk of aspiration. If gastric access
is required a naso-gastric tube should be placed. The tube feeds should be stopped at this point
in time. Intravenous glucose must be given to prevent hypoglycemia.

Treatable causes of "failure to wean"

Hypophosphatemia
Hypokalemia
Hypomagnesemia
Hypocalcemia (ionized)
Pulmonary edema
Angina
Anemia
Malnutrition
Overfeeding with excessive carbohydrate (increased CO2 production)
Notes:
Weaning/liberation is the process by which a patient is removed from the ventilator. In many
patients ventilatory assistance need not be decreased gradually, mechanical ventilation and
artificial airways can simply be removed (liberated). According to this thesis patients can simply
be removed from the ventilator once the disease process which led to intubation and
mechanical ventilation has improved or resolved; a prolonged "weaning process"is therefore
not required."

Several studies have been performed comparing the efficacy of SIMV, T-piece/CPAP, and PSV
weaning. No technique has proven superior to T-piece/CPAP weaning.
Cinical judgement alone does not accurately predict whether mechanical ventilation can be
discontinued successfully.It has recently been demonstrated that screening patients daily to
identify those who can breathe spontaneously will promote earlier weaning from mechanical
ventilation.(Return to text)

These are screening criteria; some patients who fail to meet these criteria may be candidates
for the "three minute trial" if approved by the ICU medical team.(Return to text)
Patient evaluations should begin early in the morning (around 5:00 am) and the patients who
meet the inclusion criteria will then immediately begin this protocol. Attending physicians will
be notified during morning rounds with an update of all evaluated patients.(Return to text)
Patients with cardiac disease are best weaned with CPAP and pressure support; this includes
patients with cardiac failure and patients with significant coronary artery disease. The level of
pressure support should initially be set at between 10-12 cmH20 and reduced by 2 cmH20 until
the patient is able to tolerate a PSV of 5 cm H20 for 2 or more hours. An electrocardiogram
should be obtained prior to extubation in patients with a history of coronary artery
disease.(Return to text)

Note to reader: The author of this protocol has checked with sources believed to be reliable
and up to date in an effort to provide information that is complete and generally in accord with
standards of practice at the time of publication. However, in view of the possibility of human
error or changes in medical science the author of this protocol cannot warrant that the
information contained herein is in every respect accurate or complete. Readers are encouraged
to confirm the information contained herein with other sources.
Disclaimer: Use at your own risk! Verify all information before initiating treatment.
Feedback: Please e-mail comments, corrections or suggestions to pmarik@zbzoom.net