Mechanical Ventilation Weaning Protocol Education for Nurses,
Respiratory Therapists and Physicians The SLRH Ventilator Weaning
Protocol Workgroup
Slide 2
Objectives of this program Provide education about ventilator
weaning in the Critical Care Units and Medical Progressive Care and
Step down Units Provide rationale and benefits for using a
ventilator weaning protocol Review the assessment tool for
ventilator weaning in critically ill patients Review SLRH vent
weaning protocol: Revised acute vent weaning protocol New chronic
vent weaning protocol Explain tracheostomy decisions and care
Demonstrate how weaning is integrated into the total care of the
patient
Slide 3
A Weaning Protocol: Promotes a standardized assessment of each
patients readiness to wean as part of the daily assessment by the
nurse and respiratory therapist Empowers the nurse and respiratory
therapist to initiate the process of early weaning from the
ventilator by identifying patients who are ready Facilitates
collaboration between the RN/RT and physician or nurse practitioner
The Physician can order the weaning protocol based on the
assessment by the RN/RT and MD/DO
Slide 4
Benefits of a Weaning Protocol Studies 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
Slide 5
Improving weaning from mechanical ventilation Early 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
Slide 6
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
Slide 7
We need to standardize our goals and management of mechanically
ventilated patients in order to provide the best care for our
patients.
Slide 8
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
Slide 9
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 patients disease and
course.
Slide 10
Weaning protocols in different units Our 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.
Slide 11
In addition to the early morning protocol, weaning assessment
can be done at any time during the day.
Slide 12
Acute and Chronic Weaning What 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
Slide 13
The weaning protocols The protocols are found on Forms on
Demand We will go through the steps of the protocols for acute and
chronic weaning
Slide 14
Step 1: Assessment for Weaning Readiness Initial 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
Slide 15
Early assessment for weaning The 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 flowsheet If 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
Slide 16
STEP 1: Assessment for weaning readiness The 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 H20 ABG PARAMETERS PaO2 75 mmHg pH >
7.25
Slide 17
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 held Sedation goal RASS of 0 achieved or hold sedation
Explain to the patient
Slide 18
Physician Order for Weaning The MD/NP needs to place the order
for weaning only once This order will remain active for daily
weaning unless cancelled due to change in patient condition
Slide 19
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.
Slide 20
Start weaning protocol early Between 5:30 and 7 am in the ICUs
By 9 am for chronically-ventilated patients in the stepdown
units
Slide 21
STEP 3: Method of weaning chosen by physician PRESSURE SUPPORT
VENTILATION METHOD (PSV) Set PS___ FiO2___ % Decrease PS by ___q
___h ABG ( ) Y ( ) N GOAL : PS 5 for ____ min SICU METHOD CPAP = 5,
PS=0 FI02 21% Tolerates 20 min Then ABG: GOAL: Pa0 2 >50mmHg
PaC0 2