Monaldi Arch Chest Dis

2003; 59: 4, 342-344 PROCEEDINGS OF ADVANCES IN PULMONARY REHABILITATION

Therapist driven protocols
M. Vitacca
About 80% of patients admitted to an ICU and
mechanically ventilated because of acute respira-
tory failure, resume spontaneous breathing quite
easily after few days of ventilation [1]. The wean-
ing success rate differs between the studies de-
pending on the case mix and referrals of any indi-
vidual Intensive Care Unit (ICU). In particular
Brochard et al. stated that the length of weaning
is first explained by the etiology of the diseases,
patients with Chronic Obstructive Pulmonary Dis-
ease (COPD) being the most difficult to separate
from the ventilator [2]. The 20% rate of unsuc-
cess is mainly concentrated in specific popula-
tions, where age, residual or premorbid compro-
mise of the cardiorespiratory or neuromuscular
systems render the discontinuation from mechani-
cal ventilation particularly difficult [1]. It was re-
ported that 41% of the total time of mechanical
ventilation was devoted to weaning, with large dif-
ferences between patients with different diseases
[1]. Endotracheal intubation per se, long-term se-
quelae after intubation, heavy sedation of curariza-
tion, myopathy, sepsis and multiple organ failure
(MOF), the use of continuous intravenous seda-
tion, diaphragmatic atrophy, malnutrition, infec-
tive complications, chronic airway obstruction,
feeding aspiration, bone demineralization, protein
wastage and a decrease in total body water are of-
ten associated with prolonged mechanical ventila-
tion [1]. Several studies have been performed in an
attempt to assess the best ventilatory methods to
discontinue ventilatory support at the earliest pos-
sible time. They were recently reviewed in an arti-
cle by Butler [3] and coworkers, that conluded that
since there are very few rigorous randomized trials
[2, 4], more work is required in this area, and in
particular that from the studies reviewed they
could not identify a superior weaning technique
among the three most popular modes, T-piece,
Pressure Support Ventilation (PSV), or synchro-
nized intermittent mandatory ventilation (SIMV).
Our recent data [5, 6] show that spontaneous
breathing trials and decreasing levels of inspiratory
pressure support are equally effective in weaning
COPD tracheostomized patients undergoing mechan-
ical ventilation for more than 15 days. Whatever the
explanation, it is important for us to stress the point
that in the weaning process, the method employed is
probably less important than the confidence and fa-
miliarity with the technique adopted, and that the
Respiratory Intensive Care Units, Salvatore Maugeri Foundation IRCCS, Scientific Institute of Gussago, Italy.
Corrispondence: Michele Vitacca MD Salvatore Maugeri Foundation IRCCS, Scientific Institute of Gussago, Via Pindolo 23,
25064 Gussago (BS) Italy; e-mail mvitacca@fsm.it
Monaldi Arch Chest Dis 2003; 59: 4, 342-344.
Table 1. - Recommendations for MV weaning proto-
cols (modified from Ref 1)
Driven protocols should be included during tentative
weaning.
ICU clinicians should utilize protocols for liberating
patients from MV in order to reduce its duration.
Clinicians should conduct a SBT at least once daily to
identify those patients ready for liberation from MV.
If the patient fails: remediable factors? change modal-
ity of ventilation; repeat every day SBT; in the case of
repeated failures a tracheostomy should be considered.
If SBT is OK consider extubation.
Use of protocols with a) daily tentative ventilatory
cessation and b) drastic reduction of sedation.
Evidence based approach protocol; team approach; in-
teractive education; opinion leaders; reminders.
same ventilatory mode may produce different out-
comes depending on the underlying pathologies [1,
3]. Indeed recent papers have stressed the concept of
using standardized protocol to wean the patient away
from mechanical ventilation [7, 8, 9].
Therapist driven protocols (TDP) are a con-
sensus of medical knowledge and opinion that is
summarized into a care plan or algorhytm with
changes in therapy directed by changes in objec-
tive measurable patient variables [1]. The TDP
team usually consists of the physician, the patient,
the family, the nurse and a respiratory therapist
(RT) [1]. The daily plan of a TDP consists of
recording functional activities early in the morn-
ing, followed by a rest period before initiating the
weaning process in the optimal position for in-
stance sitting upright in bed or sitting upright in a
chair [1]. The plan for a TDP also adressess pre-
vention and amelioration of the deleterious effects
of bed rest, communication, emotional support,
psychological well-being and function [1]. Initial
evaluation will include assessment of the patient
and ventilator status and patient-ventilator syn-
chrony. This evaluation is usually performed rou-
tinely every 2/4 hours and with each ventilator set-
ting change. Table 1 shows recommendations for
the use of Mechanical Ventilation (MV) weaning
protocols, while table 2 shows the tips for im-
plemetations of these TDP during weaning. Table
343
THERAPIST DRIVEN PROTOCOLS
3 propose an example of a weaning protocol used
in our unit [6]. Saura [9] studied 51 patients
weaned by a fixed protocol who were studied
prospectively and compared with 50 retrospective
controls. When the patients were clinically stable
reaching the following criteria: PaO
2
> 60 mmHg
with FiO
2
less than 0.4, Pimax > 20 cmH
2
O, RR <
35 act/min and VT > 5 ml/kg they underwent a
weaning trial of a 2 hour period of spontaneous
breathing. The implementation of this weaning
protocol decreased the duration of MV and ICU
stay by increasing the number of safe direct extu-
bations. Similar results were found by Ely [7] who
demonstrated that the daily screening of the respi-
ratory function of ventilated patients, performed
by nurses or respiratory therapists, followed by tri-
als of spontaneous breathing and notification to
their physicians when the trials were successful,
can reduce the duration of ventilation, the cost of
intensive care and was also associated with fewer
complications. Similar results were also obtained
later on by Koleff et al. [8], stressing the opinion
that objective scientific methods improve out-
comes in mechanically ventilated patients. By
means of historical comparison our experience [5,
6] also shows that the application of a well-defined
protocol (see table 3), independent of the mode
used, is associated to a greater weaning success
rate, shorter time under mechanical ventilation and
Table 2. - Tips for implementations of TDP during
weaning (modified from Ref 1)
Identify the patient care issue
Test your institutions lengths of stay and complica-
tions rates
Design protocols (evidence based methods, local ex-
perts, review of protocols)
Change of weaning culture
Create a team approach (hospital administrator, physi-
cians, nurses, respiratory therapist, ethicists)
Define local main goals, succesful and unsuccesful
Avoid changes in personel (dedicated personel)
Education, timely feedback, compliance monitoring,
appropriate outcomes, be pragmatic, improve your
protocol during time
Avoid rigid interpretation of the rules
Clinical judgement remains important
Periodic refresher implementation processes
Table 3. - Example of weaning protocol used in the weaning centre of Fondazione S. Maugeri of Gussago
(modified from Ref 6)
Patient presents:
Minute Ventilation 15 L/min;
FiO
2
60%; PEEP 10 cmH
2
O;
alertness daily re-evaluation
You can start weaning
Patient presents the following parameters:
Minute Ventilation < 15 L/min; FiO
2
40 %; PEEP 6 cmH
2
O; HR < 140 b/min; PaO
2
/FiO
2
200; f/VT 105; MIP 20
cmH
2
O; RR < 25/min; pH > 7.35; systolic pressure > 100 and <150 mm Hg; SatO
2
> 90 %; presence of cough, good
neurological status, no agitation; no sedatives; no vasopressors; no arithmias
Start spontaneous breathing trial (SBT)
Does the patient present signs of distress?
f > 35 a/min; SatO
2
< 90% with FiO
2
40%;
HR> 145 b/min or increase in HR > 20%; arhitmias
systolic pressure > 180 or < 70 mm Hg; agitation
start the weaning process:
A) Decrease level of PSV (2 cmH
2
O/ twice a day)
In case of distress back to previous steps
B) SBT: increase lenght of SBT (30 minutes; 1, 2, 4, 8 hours)
In case of distress go back to previous steps

extubation
yes
no
no
no
yes
yes
FiO
2
= Fraction of inspired O
2
;
PEEP = Positive end expiratory pressure; HR = heart rate; f/VT = Frequency on tidal volume ratio; MIP =
maximal inspiratory pressure; RR = Respiration rate; PSV = pressure support ventilation.
344
M. VITACCA
4. help to safely and efficiently liberate patients
from MV reducing unnecessary or harmful varia-
tions approach.
References
1. ACCP, AARC, ACCCM task force. Evidence based
guidelines for weaning and discontinuing ventilatory
support. Chest 2001; 120: 375s-395s
2. Brochard L, Rauss A, Benito S, Conti G, Mancebo J,
Rekik, Gasparetto A, Lemaire F. Comparison of three
methods of gradual withdrawal from ventilatory sup-
port during weaning from mechanical ventilation. Am J
Respir Crit Care Med 1994; 150: 896-903.
3. Butler R, Keenan SP, Inman KJ, Sibbald WJ, Block G.
Is there a preferred technique for weaning the difficult-
to-wean patient? A systematic review of the literature.
Crit Care Med 1999; 27: 2331-2336.
4. Esteban A, Frutos F, Tobin M, Alia I, Solsona J,
Valverdu I, Fernandez R, De La Cal MA, Benito S,
Tomas R, Carriedo D, Macias S, Blanco J. A compari-
son of four methods of weaning from mechanical ven-
tilation. N Engl J Med 1995; 332: 345-350.
5. Vitacca M, Vianello A, Colombo D, Clini E, Porta R,
Bianchi L, Arcaro G, Guffanti E, Lo Coco A, Ambrosi-
no N. Comparison of two methods for weaning COPD
patients requiring mechanical ventilation for more than
15 days. Am J Respir Crit Care Med 2001; 164: 225-230.
6. Vitacca M, Giarelli A, Paneroni M, Barbano L, Am-
brosino N. I protocolli guidati dal terapista respiratorio
durante le fasi di svezzamento dalla ventilazione mec-
canica. Rass Pat App Resp 2002; 17: 198-208.
7. Ely EW, Baker AM, Dunagan DP, Burke HR, Smith
AC, Kelly PT, Johnson MM, Browder RW, Bowton
DL, Haponik EF. Effect of the duration of mechanical
ventilation of identifying patients capable of breath-
ing spontaneously. N Engl J Med 1996; 335: 1864-
1869.
8. Kollef MH, Shapiro SD, Silver P, St John RE, Printice
D, Sauer S, Ahrens TS, Shannon W, Baker-Clinkscale
D. A randomized controlled trial of protocol-directed
versus physician directed weaning from mechanical
ventilation. Crit Care Med 1997; 25: 567-574.
9. Saura P, Blanch L, Mestre L, Valls J, Artigas A, Fer-
nandez R. Clinical consequences of the implementation
of a weaning protocol. Intensive Care Med 1996; 22:
1052-1056.
shorter LWU and hospital stay than uncontrolled
clinical practice. Table 4 summarizes criteria used
in literature for TDP both to start weaning tenta-
tive or to test weaning steps failure.
In conclusion therapist driven protocols
should: 1. be used routinarly during weaning 2. not
represent rigid rules but rather guides to patient
care. 3. moreover evolve and improve over time as
clinical and institutional experience increase.
Table 4. - Criteria used in literature to start weaning
or to test weaning steps failure (modified from Ref 1)
Objective measurements:
PaO
2
> 60-65 mmHg; SaT O
2
>88%- 90%, FIO
2
40%-
60%, PaO
2
/FiO
2
>/= 200; PEEP < 5-10 cmH
2
O
Haemodinamic stability: no vasopressors or inotrops,
dopamyn < 5mcg/Kg/min, no arhitmie; sistolic pressure
> 90 mmHg e < 180 mmHg; HR > 50 e < 140
Temperature: < 37-38C
No respiratory acidosis under MV; ph > 7.35, PaCO
2
< 50
mmHg
Haemoglobin > 8/10 g/dL
Good neurological level; no sedative; GCS >/= to 10-13
Effective cough
Normal serum electrolytes
No use of accessory muscles; MIP >/= 20-22 cmH
2
O
Subjective measurements:
Clinical evaluation of:
respiratory load;
possibility of withdraw from MV;
no distress signs;
possibility of cough
Parameters on ventilator:
FR </= 35 acts/min;
Minute ventilation </ = 10-15 L/min;
F/Vt =/< 105;
Vital Capacity: >10 mL/Kg or double of VTe;
VTe > 5 mL/Kg or > 0.3 L
PEEP = Positive end expiratory pressure; F/Vt = Frequency on
tidal volume ratio; GCS = Glasgow coma scale; MIP = maximal
inspiratory pressure; VTe = Tidal Volume; HR = Heart Rate.