Weaning from the ventilator

Todd Fraser on 29-12-2012

It seems that when it comes to weaning long-term patients from a ventilator, there are as many theories on how to do it as there are intensivists. And probably more.

Many methods have been put forward. Certainly, its important to address any reversible factors that contribute to weaning failure, the subject of our December vodcast. Issues with resistance, compliance, power, demand and sputum clearance, as well as unmasking borderling cardiac function, all appear important.

The best method though for successfully liberating patients from the ventilator is contentious. Progressive reduction in inspiratory pressure, utilising intermittant mandatory ventilation with decreasing mandatory frequency, and periods of "spontaneous ventilation" have been proposed, and all probably have their merits. Few studies exist, with conflicting results, though SIMV does not appear to be as good as other methods. Much of this is myred in definitional differences, with no consensus on the appropriate use of these methods.

An interesting paper has been released recently highlighting the impact of mechanical ventilation on diaphragmatic strength, and the results are frightening. Although small numbers, if the results are verified, the 6% loss of diaphragmatic thickness per day is likely to have major effects on weaning, and begins less than 48 hours after initiation of mechanical ventilation.

So what is the best method of "training" patients to come of ventilation?

5 Comments

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Nathan, WA from Australia wrote 12-31-2012 05:04:55 pm
I dunno about the evidence, but my approach is a daily period of respiratory exercise - I set common sense parameters such as 20% increase in heart rate, 20% change in blood pressure, respiratory distress, rising CO2 etc, and let them go for it. My preference is for a T-piece on a humidified circuit. If they show any signs of getting tired, they go back to the vent. Try to extend each day until they can breathe without the vent for 24 hours.

Pac Man from Australia wrote 12-31-2012 08:39:58 pm
Nice review of this topic - http://www.nexcob.nl/resources/ABC-weaning-failure.pdf

Reformed ED physician from Canada wrote 01-07-2013 08:00:42 am
My practice is similar to Nathan's

Patrik from Australia wrote 02-24-2013 02:03:52 pm
I think that weaning a long-term Pt off the ventilator, is not only challenging and I also think that somewhere in this discussion besides talking about the parameters and ventilation modes and settings, people have been missing the most important part- the Patient going through the weaning process, as well as their Families. I personally believe that no long-term ventilated Adult or Child with Tracheostomy should stay longer than 60 days in Intensive Care. Why do I say this? Other countries, mainly in Europe(Germany, Austria, Switzerland, Netherlands) have adopted a far more effective, efficient and most importantly a far more Patient and Family focused practice as long as 15 years ago. The alternative for those long-term ventilated Adults or Children with Tracheostomy is to go home, looked after by Critical Care nurses. It's a no brainer in those countries. Why is it a no brainer?
a) it's Patient and Family friendly compared to a long term stay in ICU
b) it provides a far better Quality of Life and in some instances a far better Quality of end of Life for long-term ventilated Adults or Children with Tracheostomy and their Families, with a focus on opportunites and possibilities
c) It is more cost effective. That's a no-brainer too. $ 3,000-$ 5,000 per bed day in ICU compared to a nursing service providing 24/7 care at home is of course more cost effective
d) My experience in the Intensive Home Care niche in Germany has shown me that results in weaning are usually as good if not better, because people are at home. Once again, this whole approach is far more holistic and really Patient and Family friendly
e) Families of long-term ventilated Adults or Children with Tracheostomy usually 'put' their lives on hold while their loved ones are in ICU. Neglecting their private and professional lives, often neglecting elderly parents or children and unable to produce an income during that time. Wouldn't it be better to not only save money for the health system, but also have Family members of the Patient being productive during their loved ones ordeal?

I have been working in critical care in Australia since 2005 and when I first started, I realised that the massive issues that come with long-term ventilation are not addressed properly in Intensive Care units and most importantly, Patients and their Families are not given a choice(any other industry creates choice for their consumers) and I therefore decided to start a nursing service INTENSIVE CARE AT HOME. The service is based and build on my experience working in the Intensive Home Care niche in Germany, where we took professional, holistic, Patient and Family friendly care of long-term ventilated Adults and Children with Tracheostomy with great success. Now 15 years later, nobody even questions that the only palce for a long-term ventilated Adult or Child with Tracheostomy is home. And why is it so successful? Because it's Patient and Familiy friendly, it provides Quality of Life and it saves money and resources for Hospitals. In order to make this vision for Australia a reality, INTENSIVE CARE AT HOME is now a fully accredited health service against Australian Health care standards and you can find more information on www.intensivecareathome.com.au

Kind Regards

Patrik Hutzel

Faraz from Saudi Arabia wrote 04-02-2013 11:16:31 pm
I agree with Hutzel. The intensive care physicians and nursing staff can provide the care out of the icu environment when it is feasible and practical. This not only saves money but certainly helps preventing the nosocomial infections.

I think, we have to be more customer oriented just like other industries in the World.

Regards
F.Mansoor