Weaning and Discontinuing

Ventilatory Support
Hanaa A. El Gendy
Assistant Professor of Anesthesia
(and ICU (ASUH
:Learning Objectives
The epidemiology of weaning( 1

Evidence-based weaning guidelines( 2

The pathophysiology of weaning failure( 3

? Is there a role for different ventilator modes in weaning ( 4

 Definition Of Weaning

ᵜProcess of gradual withdrawal of mechanical

ventilatory support that transfers the work of breathing
from ventilator to the patient

ᵜThis period may take many forms ranging from abrupt

to gradual withdrawal from ventilatory support
ᵜ75% of mechanically ventilated patients are easy to be
weaned off the ventilator with simple process

ᵜ10-15% patients require use of a weaning protocol over a

period of 24-72 hours

ᵜ5-10% require a gradual weaning over longer time

ᵜ1% of patients become chronically dependent on ventilator

ᵜOut of the total time that a patient spends on ventilator,

40% of the time is spent on weaning process
 Decreases the
availability of ICU
Increased cost beds

Increased hospital
Increased length of stay
risk of VAP
Why Wean
??? early
Increased ICU
Increased morbidity length of stay
& mortality

Can adversely
affect the
patient outcome

Re-intubation is not required in 50% of self-extubations

REINTUBATION VAP WEANING
FAILURE

6-8 FOLD
INCREASED RISK
HOW DOES LATENT MYOCARDIAL DYSFUNCTION
?BECOME MANIFEST DURING WEANING

PPV  SPONTANEOUS - VE INTRATHORACIC PRESS. 

VENOUS RETURN

 MYOCARDIAL O2 CONSUMPTION  LV AFTERLOAD

 Latent Manifest  LV
ischaemia ischaemia Compliance
SBT

 WOB – Weaning Decreased lung Pulmonary

failure compliance edema
 CRITICAL ILLNESS OXIDATIVE STRESS

Loss of diaphragm force-generating capacity that is specifically

related to use of controlled mechanical ventilation

Mitochondrial swelling, myofibril damage and increased lipid vacuoles.

Oxidative modifications noted within 6 h

Muscle atrophy Structural injury Fibre remodeling

 Schematic Representation of the Different Stages Occurring in a
Mechanically Ventilated Patient

Martin J. Tobin
2001

Definition of the different stages, from initiation to mechanical ventilation to weaning

Stages Definitions
Treatment of ARF Period of care and resolution of the disorder that caused respiratory failure and
prompted mechanical ventilation
Suspicion The point at which the clinician suspects the patient may be ready to begin the
weaning process
Assessing readiness to wean Daily testing of physiological measures of readiness for weaning (NIF, fR/VT)
to determine probability of weaning success
Spontaneous breathing trial Assessment of the patient’s ability to breathe spontaneously
Extubation Removal of the endotracheal tube
Reintubation Replacement of the endotracheal tube for patients who are unable to sustain
spontaneous ventilation
The Pathophysiology of Weaning Failure
 Cardiac load Neuromuscular
Respiratory load
causes

Neuropsychological Metabolic
causes
DIFFICULT WEANING

Nutrition Thorough & Anaemia

Systematic search for
these
potentially
reversible
pathologies
 Definitions of Weaning
Success and Failure
Weaning success is defined as
Extubation and the absence of ventilatory support 48 hs following
.the extubation

Weaning in progress: Requirement of NIV after extubation

: Weaning failure is defined as one of the following

Failed SBT(1
Reintubation and/or resumption of ventilatory support 48 hs( 2
following successful extubation; or
.Death within 48 hs following extubation( 3
 Classification of Patients According to the Weaning Process

ICU Hospital
Group Definition Frequency
mortality mortality

Patients who proceed from

initiation of weaning to
Simple(1( successful extubation on the
first attempt without 69% 5% 12%
weaning
difficulty

Patients who fail initial

weaning and require up to
Difficult (2( three SBT or as long as 7
days from the first SBT to 16%
weaning
achieve successful weaning
25%
Patients who fail at least
three weaning attempts or
Prolonged (3(
require > 7 days of weaning 15%
weaning after the first SBT

Boles, et al. Eur Respir J 2007

Evidence-based weaning guidelines
 Evidence-based weaning
guidelines

Recommendations from the ACCP/ AARC/ ACCM

1) Pathology of ventilator dependence
2) Assessment of readiness using evaluation
criteria.
3) Assessment during spontaneous breathing.
4) Removal of the artificial airway.
5) SBT failure.
 Evidence-based weaning
guidelines

6) Maintaining ventilation with SBT failure.

7) Anesthesia and sedation strategies.
8) Weaning protocols.
9) Role of tracheostomy in weaning.
10) Long-term care facilities for patients requiring
prolonged ventilation.
11) Clinician familiarity with long-term care facilities
 Evidence-based weaning
guidelines
Recommendation 1: Pathology of
ventilator dependence
– If mechanical ventilation >24 hours, search
for all causes that may be contributing to
ventilator dependence.
Recommendation 2:
– Assessment of readiness using evaluation
criteria:
 Evidence-based weaning
guidelines
Physiological parameters for weaning & extubation

A-Ventilatory performance and muscle strength

– VE ˂10 to 15 L/min
– VT > 4 to 6 mL/kg (IBW)
– F < 35 breaths/ min
– f/VT RSBI < 105 breaths/ min/ L(spontaneously breathing pt)
– Ventilatory pattern synchronous and stable
– Maximal inspiratory pressure (MIP)(NIF) (the maximum
pressure that can be generated against an occluded airway
beginning at functional residual capacity (FRC). up to 20
second ) < -20 to -30 cm H2O Total PEEP-max Paw drop

B- Measurement of drive to breathe P0.1> -2cm H2O

 )RSBI ( Rapid shallow breathing index

 Index of rapid and shallow breathing f/Vt

 RSBI<105 predicts successful weaning attempts

 The RSBI measurement is performed with minimal

ventilatory support with the patient still intubated and
spontaneously breathing for 1 min

 More accurate predictor of weaning success than any

other parameter studied
 RSBI > 105: 95% extubations failed

 Evidence-based weaning
guidelines

Measurements of drive to Breath

 Airway occlusion pressure (P0.1 [or P100]).
 P100 is the pressure generated during the first 100
milliseconds of inspiratory effort against an occluded
airway.
 A measurement of the neural output from the
medullary centers, it is effort independent.
 The normal range is 0 to -2 cm H2O.
 The minimum of 4 repeat measurements were required
to obtain valid results
 Evidence-based weaning
guidelines

C-Estimation of WOB
– Dynamic compliance>25 mL/cm H2O
– VD/VT<0.6 VD/VT = (PaCO2 – PECO2)/PaCO2
D-Measurement of adequacy of oxygenation
– PaO2>60 mmHg (FiO2 <0.5)
– PEEP<5 to 8 cm H2O
– PaO2/FiO2>150 - 250 mmHg.
– PaO2/PAO2>0.35
– P(A-a)O2<350mmHg (FiO2=1)
– Oxygen index = FIO2 x MAP x 100/ PaO2
very good < 5 medium 10 – 20 poor > 25

)PAO2 = ( FiO2 * (Patm – PH2O)) – (PaCO2 / RQ

.)MAP = (PIP * %IT) + (PEEP * %ET
 Evidence-based weaning guidelines

Recommendation 3:
Assessment during spontaneous breathing
1) Rspiratory pattern.
2) Adequacy of gas exchange.
3) Hemodynamic stability.
4) Subjective comfort. SBT of 30 to 120 minutes.
N.B. Unnecessary prolongation of a failed SBT can result in muscle
fatigue, hemodynamic instability, discomfort or worsening gas
exchange.
 Respiratory pattern

Passing Gas exchange

Haemodynamic stability

SBT Subject comfort

Tobin. Principles and Practice of Mechanical Ventilation, McGraw-
Hill, 1994, s1192
 Evidence-based weaning guidelines

Recommendation 4:
Removal of the artificial airway:
 In most cases, discontinuation of venilatory support
and extubation are a single process.
 This decision is based on assessment of:
- Airway patency.
- Ability to protect the airway.
Ex;upper airway burns or copious secretions & weak
cough)
 Evidence-based weaning
guidelines
Postextubation difficulties:
 Hoarseness, sore throat, and cough.
 ↑ WOB: subglottic edema,,secretions, airway obstruction, laryngospasm.
Postextubation glottic edema can → partial airway obstruction,
causing stridor.
TTT; aerosol oxygen,nebulized epinephrine or budesonide .
The recommended dose is 0.5mL/kg of 1:1,000 up to a maximum dose
of 5 mL
Prior to extubation dexamethasone 0.3- 0.5 mg/kg/dose
 The cuff leak

The expired tidal volume is measured with the cuff inflated on

Assist Control mode, The cuff is then deflated , four to six
consecutive breaths are used to compute the average value for the
expiratory tidal volume.
The difference in the tidal volumes with the cuff inflated and
deflated is the leak.
A value of < 110 ml (10 -12 % of expiratory tidal volume) gave a
sensitivity of 85% and a specificity of 95% to identify patients with an
increased risk of post extubation stridor.
A low value for cuff leak can also be caused by encrusted
secretions around the tube rather than by a narrowed upper airway
 Evidence-based weaning
guidelines

Noninvasive positive pressure ventilation

after extubation:
 Transition from invasive ventilation to
spontaneous breathing.
Benefits:
Lowers the mortality rate
Reduces the risk of nosocomial pneumonia.
 : NIPPV
Selected patients, esp. hypercapnic respiratory failure -
(( COPD

Should NOT be routinely used as in the event of-

extubation failure

Its use CANNOT be recommended for all patients failing-

a SBT Keenan et al, 2002 & Esteban et al, 2004

Group 2 & 3: NO firm recommendations-

 Evidence-based weaning
guidelines

Recommendation 5: SBT failure

Any ventilation mode without machine-triggered
breaths

30 minutes is as good as 2 hour

A failed SBT often reflects……….persistent

mechanical abnormalities of the respiratory
system…….a problem not likely to reverse
quickly.
 Termination of SBT

RR > 30 for 5 min-

SpO2 < 90% for 30 sec-
change in HR for > 5 min 20%-
P SYS > 180 or < 90 for 1 min-
Anxiety, agitation or diaphoresis-
for 5 min
 Criteria for extubation failure

fR >25 breaths/min for 2 h-

HR >140 beats/min or sustained increase or decrease of > -

20%

Clinical signs of respiratory muscle fatigue or increased -

work of breathing

SpO2 < 90%; PaO2 <80 mmHg on FiO2 ≥0.50-

Hypercapnia (PaCO2 > 45 mmHg or ≥ 20% from pre--

extubation), pH < 7.33
 Evidence-based weaning
guidelines

Recommendation 6: Maintaining ventilation with

SBT failure
 Patients who fail in SBT should receive a stable,
nonfatiguing, comfortable form of ventilatory support.
Recommendation 7: Anesthesia and sedation
strategies and protocols
 Anesthesia and sedation strategies and ventilator
management should be aimed at early extubation for
surgical pts.
Recommendation 8: Weaning protocols:
 Protocols for weaning should be developed and
implemented by intensive care units.
 Weaning Protocol

Protocol-directed daily screening of resp. function & SBT

:Advantage
of patients who required weaning from 80 to 10% % ↓
time required for extubation↓
incidence of self-extubation↓
incidence of tracheostomy↓
ICU costs↓
(incidence of VAP and death (Dries et al, 2004↓
 Evidence-based weaning
guidelines
Recommendation 9: Role of tracheostomy in weaning
– Considered when it becomes apparent that pt. needs prolonged ventilation.
Timing: within 7 days or sooner in neurologically impaired patients
Indications:
– Pts.requiring high levels of sedation to tolerate ETs.
– Marginal respiratory mechanics.
– High Raw.
Benefits
– Reduce the risk of muscle fatigue.
– Gain psychological benefit from the ability to eat, talk, and have greater
mobility.
– Less WOB , Vd and better secretion removal.
The most important beneficial outcome of a tracheostomy is
facilitation of the discontinuation of mechanical ventilatory
support.
Percutaneous
PercutaneousTracheostomy
Tracheostomy::
Cost-effective
Cost-effective&&Fewer
Fewercomplication;
complication;NO
NOdiff.
diff.in
inoutcome
outcome
 Evidence-based weaning
guidelines

Recommendation 10: Long-term care facilities for

patients requiring prolonged ventilation:
 Unless evidence of irreversible disease is present (i.e.,
high spinal cord injury, advanced lateral sclerosis),
prolonged M.V. should not be considered permanently
ventilator dependent until 3 months of weaning attempts
have failed.
Recommendation 11: Clinician familiarity with long-
term care facilities
 Failure of weaning attempts in ICU → long-term ventilation
care facilities when Pts. are medically stable.
 Terminal care for
Ventilator-Dependent Patients
Poor Quality of Life & Low survival-
rates

Withdrawal of mechanical-
ventilation ?XXX

Full disclosure of prognostic data-

Routine palliative care or ethics-

consultation can improve the quality
of decision making in the acute ICU
. setting
Is there a role for different ventilator modes
? in weaning
DO NOT WEAN TO EXHAUSTION
 Weaning modes

Methods of weaning from M.V.:

 Synchronized intermittent mandatory
ventilation (SIMV)
 Pressure support ventilation.
 T-piece weaning.
 Closed loop ventilation.
 Synchronized Intermittent Mandatory
Ventilation
(SIMV)
Weaning procedure

• Reduce the mandatory rate progressively→1-2

breaths/min at a pace that matches the patient's
improvement.
• Pressure support (PS) ~ 5 to 10cm H2O.
• PEEP: 3 to 5 cm H2O

Has the worst weaning outcomes in clinical trials -

Its use is not recommended-
Pressure Support Ventilation

• Patient triggered, pressure limited, flow cycled.

• Pt. control rate, timing, depth of each breath.
Weaning procedure
A. PS INITIAL SETTING:
 1st.method
– Setting pressure level: → a reasonable ventilatory pattern for
the patient. ( 5 to 20 cm H2O)
 2nd. method
– Setting pressure level: → reestablish a patient's baseline
respiratory rate (15 to 25 breaths/min) and VT (300 to
600mL/min).
 Pressure Support Ventilation

B. WEANING OF PS.:
 PS level ▼ (2cmH2O/ 2-4Hrs.)as long as:
 an appropriate spontaneous respiratory rate and VT are evident
 distress is not evident.
 When PS ≈5 cm H2O, level of PS is sufficient to overcome the work
imposed by the ventilatory system.
 PSV: should be favoured

As a weaning mode after initial failed SBT (group 2) Brochard et al. CCM-
1995

May be helpful after several failed attempts at SBT (group 3) Vittaca et-
al. AJRCCM 2000
 T-tube weaning
 Patients less likely to tolerate T-piece weaning include:

Severe heart disease, severe muscle weakness,panic

because of psychological problems ,preexisting chronic
lung conditions.
 Goals of Advanced Modes of
Ventilation
Limit the duration of invasive ventilation -

Prevent patient ventilator asynchrony-

Be applicable to a wide variety of patients and -

automatically adapt to changes in lung and
respiratory mechanics
 Closed loop ventilation

Idea:
A set variable is compared with a
measured control variable.
The ventilator adjusts some parameters
based on the results of the compared
variables.
 (ADAPTIVE SUPPORT VENTILATION (ASV

• Patient-centered closed loop that increases or

decreases ventilatory support based on monitored
patient parameters.
• Pressure-limited breaths that target a volume and
rate.
• Monitors pressure, flow, inspiratory and expiratory
time, compliance, resistance to ensure delivery of an
acceptable VE based on practitioner settings.
• Settings: Ideal body weight,PEEP, FiO2, rise time,
flow cycle, and percentage of predicted VE desired.
 ASV vent settings
Height of the patient (based on this, the vent will automatically calculate -
(ideal body weight and dead space

Gender-

Min Vol: 25-350%-%

Normal 100%, Asthma 90%, ARDS 120%, Others 110%

Trigger: flow trigger of 2 L/min-

Expiratory trigger sensitivity: Start with 25% and 40% in COPD -

Tube resistance compensation: Set to 100%-

High pressure alarm limit-

PEEP-

FiO2-
 Automatic Tube Compensation

Compensates for the resistance of ETT

Facilitates “ electronic weaning “ i.e pt during ATC mimic
their breathing pattern as if extubated

P=RVE∆

P (P support( α (L / r4 ( α flow α WOB∆

As the flow ↑ / ETT dia ↓, the P support needs to be ↑to ↓WOB

AUTOMATIC TUBE COMPENSATION (ATC(

Higher circuit pressure

Lower carina pressure

Pressure drop due to ET tube resistance