Weaning

patients from

DARCY FERALIO

mechanical

36

Nursing2006, Volume 36, Number 9

www.nursing2006.com

2.5

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CONTACT HOURS

ventilation
Learn to meet two common challenges: facilitating rapid weaning and
helping patients who are difficult to wean from mechanical ventilation.
BY BILL PRUITT, RRT, AE-C, CPFT, MBA

PATIENTS RECEIVE mechanical

ventilation for many reasons and
for varying lengths of time. Some
need ventilatory support for only a
few hours; others need it for
weeks, months, or even years.
In this article, Ill focus on your
role in caring for patients at two
extremes of the ventilatory support
weaning continuum: those who can
be considered for rapid weaning
and those who are difficult to wean.
But before considering these special
situations, lets review some basics
about mechanical ventilation.
Reviewing ventilatory support

Mechanical ventilation is indicated

when the body cant meet its oxygen demand through spontaneous
breathing or when the body cant
adequately remove carbon dioxide
(CO2). Various conditions can
increase the oxygen demand, such
as abnormalities in the respiratory
system, neuromuscular disease, or
cardiovascular system failure.
Mechanical ventilation aims to
provide adequate ventilatory support to meet the patients oxygen
demands without harming the
patient. Ventilation is delivered via
an artificial airway: an oral or nasal
endotracheal tube or a surgically
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placed tracheostomy tube.

Tidal volume and frequency,
supplemental oxygen (FIO2), mode
of ventilation, pressure support,
and positive end-expiratory pressure (PEEP) are set on the ventilator. The patient may need a sedative or analgesic to control anxiety
or pain and may also receive intravenous fluid and nutritional support. These interventions are
designed to let the body recover,
heal, and regenerate if possible. If
the patient recovers well enough to
resume spontaneous breathing,
weaning begins.
Some patients, such as those
with acute heart failure and chronic obstructive pulmonary disease
(COPD), may need just a few
hours of mechanical ventilation
while being treated for heart failure. For other patients, such as
premature babies or burn victims,
weaning may not occur until after
days or weeks of ventilatory support. A babys immature lungs need
time to develop well enough to
support spontaneous ventilation.
The burn victim may need time for
the airways to heal or require full
support while his body recovers
from the burn.
Some patients have trouble being

weaned from ventilatory support.

When weaning is attempted, these
patients cant maintain spontaneous
breathing and continue to need
some degree of ventilatory support.
For example, a patient with a neurologic injury and paralysis of the
diaphragm may make some progress at weaning, but not enough to
be totally free from mechanical support. This patient may require minimal ventilation (or perhaps nighttime only support).
For some patients, weaning isnt
an option because the injury, disease, or system failure is too great
to overcome. These patients
remain mechanically ventilated for
the rest of their lives.
When to use rapid weaning

The rapid-wean approach is generally reserved for patients without pulmonary disease who were
placed on mechanical ventilation
to treat an acute or postoperative
condition thats expected to
respond quickly to treatment. The
formal rapid-wean approach,
which has the patient off the ventilator in 6 to 8 hours, is typically
used for patients whove had
open-heart surgery for coronary
artery bypass graft surgery or a
Nursing2006, September

37

valve repair or replacement. Most

other postoperative patients are
weaned and extubated in the
operating room as soon as anesthesia wears off (or is reversed).
In essence, these patients undergo
a rapid-wean procedure under the
care of the anesthesia staff before
being moved to the postanesthesia care unit.
For this article, Ill discuss a
rapid-wean approach in the setting
of an intensive care unit (ICU)
with patients whove had openheart surgery. Keep in mind that
this approach relies on the use of a
protocol and must be initiated by
physician order.
For open-heart-surgery patients,
a rapid-wean strategy has several
benefits. Early extubation reduces
length of stay in the ICU and in
the hospital, reduces the risk of
ventilator-associated pneumonia
(VAP), and lowers the cost of care.
Cardiac surgery, an expensive procedure, is performed on more than
500,000 patients each year in the
United States. If rapid weaning
goes as planned, weaning and
extubation is accomplished with
few or no problems for most of
these patients. But if patients are
moved too quickly in being weaned
and extubated and have to be reintubated, or suffer from other complications related to early weaning
or extubation, they could require a
longer length of stay, incur added
health care costs, and face a higher
risk of VAP or even death.
These three considerations are
key to the success of rapid weaning.
1. Choosing appropriate
patients to wean quickly. The
rapid-weaning protocol should
detail which patients are candidates, based on hemodynamic,
neurologic, and respiratory parameters. (For details, see Sample
rapid-weaning protocol.)
A key feature to weaning is the
spontaneous breathing trial. A
patient whos met all the readiness
criteria is placed on a T-piece. A
38

Nursing2006, Volume 36, Number 9

Sample rapid-weaning protocol

1. Initiate postoperative mechanical ventilation using ventilator settings
ordered by the anesthesia provider.
2. Obtain arterial blood gas (ABG) analysis 20 minutes after initiation of
mechanical ventilation. Correlate ABG results with pulse oximeter and endtidal carbon dioxide (ETCO2) values.
3. Nurse or respiratory therapist assesses patient and documents his readiness to begin weaning. Criteria are:
appropriate level of consciousness (alert, oriented, follows commands)
hemoglobin level greater than 9 grams/dL, electrolyte levels within normal
limits, and temperature of 36 C to 38 C (96.8 F to 100.4 F)
key ABG values within normal limits (pH, 7.3 to 7.5; PaCO2, 30 to 50 mm Hg;
PaO2 greater than 70 mm Hg, SaO2 of 92% or greater)
ETCO2 less than 40 mm Hg
FIO2 less than 0.5 and total patient/ventilator respiratory rate (the sum of the
mechanical ventilator breaths and spontaneous breaths) less than 30 breaths/
minute.
4. Decrease intermittent mandatory ventilation (IMV) rate by 2 breaths/
minute when the patient is awake and alert, responding appropriately, and
assisting the ventilator and his SpO2 is greater than 92%, ETCO2 is less than
40 mm Hg, and hemodynamic values are acceptable. Acceptable hemodynamic values are: heart rate less than 120 beats/minute with no serious arrhythmias, BP greater than 100 mm Hg systolic, pulmonary capillary wedge pressure less than 18 mm Hg, cardiac index greater than 2 liters/minute/m2
without intra-aortic balloon pump therapy, and chest tube drainage less than
100 mL/hour.
5. If the patient is stable 15 to 30 minutes after the IMV rate is changed,
continue decreasing the IMV rate by 2 breaths/minute every 15 to 30 minutes
as long as the patients SpO2 stays above 92%, his ETCO2 is less than
40 mm Hg, and his hemodynamic values are acceptable. Stop when the IMV
rate equals 2 breaths/minute.
6. Titrate the FIO2 to 0.4 in increments of 0.05 to 0.1 as long as the patients
SpO2 is above 92%.
7. If the patient is receiving positive end-expiratory pressure (PEEP) of more
than 5 cm H2O, decrease PEEP by 5 cm H2O every 30 minutes until PEEP is
equal to 5 cm H2O, as long as the patients SpO2 is above 92%.
8. Obtain an ABG analysis as needed and notify the physician or anesthesia
provider if the patients SpO2 falls below 92% or ETCO2 rises above 40 mm Hg
or if he shows any signs of agitation or distress.
9. Discontinue weaning if the patient cant maintain acceptable hemodynamic, neurologic, or respiratory parameters. Return to previous ventilator
settings and notify the physician.
10. When the IMV rate equals 2 breaths/minute, obtain an ABG analysis
and correlate the results with the patients SpO2 and ETCO2 values. Obtain lung
function tests; the patients tidal volume should be greater than 5 cc/kg, spontaneous respiratory rate between 8 and 30 breaths/minute, vital capacity
greater than 15 cc/kg, minute ventilation less than 10 liters/minute, and maximal inspiratory pressure less than -20 cm H2O. If readiness to wean criteria,
hemodynamics, and lung mechanics criteria are met, place the patient on a Tpiece at the current FIO2 and perform a spontaneous breathing trial.
11. Obtain an ABG analysis if the patient tolerates the spontaneous breathing trial for 30 minutes (as evidenced by his ability to stay on the T-piece with
acceptable neurologic, hemodynamic, and respiratory parameters).
12. If the ABG results meet acceptable criteria, the patient will be extubated. Place him on supplemental oxygen at 5 to 6 liters/minute via nasal cannula. Maintain his Spo2 over 92%. While hes awake, have him use an incentive
spirometer every hour.

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low level of PEEP (for example,

5 cm H2O) and low levels of pressure support (5 to 7 cm H2O) may
be used during the spontaneous
breathing trial.
2. Careful use of analgesia
and anesthesia. Once standard,
high doses of opioids (for example, more than 20 mcg/kg of fentanyl) are now giving way to lowdose opioids (for example, 20
mcg/kg or less of fentanyl), shortacting opioids, and use of hypnotic agents for anesthesia during
cardiac surgery, without significantly increasing the rate of reintubation. Using lower doses and
short-acting agents results in
fewer problems with depressed
respiratory drive.
3. Effective, efficient use of a
well-designed protocol. Protocols
for patients whove had open-heart
surgery should be designed to safely reduce ventilatory support while
maintaining stable hemodynamic
values, adequate oxygenation and
elimination of CO2, and acceptable
or appropriate neurologic status. A
multidisciplinary approach involving physicians, nurses, and respiratory therapists is essential when
developing, testing, implementing,
and evaluating the protocol.
A protocol-based weaning
process directed by nurses and respiratory therapists has been found
more effective than physiciandirected weaning because the
nurse and respiratory therapist are
at the bedside and can make more
timely changes while weaning.
Why weaning can be difficult

Patients whove been receiving

mechanical ventilation for a prolonged time may have many barriers to overcome in order to wean.
When going into this process, the
health care team must take into
consideration the reason mechanical ventilation was initiated and
evaluate whether this has been corrected. Then they can address the
prolonged effects of mechanical
ventilation. Most patients who are
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difficult to wean have problems in

one or more of the following areas.
Neurologic problems. Ventilator
dependence may involve problems
in the brainstem from stroke, trauma, or brain tumors; damage from
excessive sedation or opioid use;
or malfunction in nervous system
conduction of impulses to the respiratory muscles due to nerve
damage from trauma or disease. In
rare cases, these obstacles can be
overcome or reversed by medical
treatment or by the bodys own
healing and reprogramming
process. Otherwise, these patients
will remain on mechanical ventilation for the rest of their lives. Even
so, caregivers can work to reduce
mechanical support and supplemental oxygen as much as possible while providing the best quality care.
Inability to carry the respiratory load. This may be related to
respiratory muscle fatigue from
excessive work of breathing
(which may be imposed by the
ventilator or by the artificial airway), muscle atrophy from inactivity, or muscle damage from trauma
or surgery. Bronchospasm or excessive secretions may also be factors.
Patients with hyperinflated lungs
due to air trapping, which often
occurs with COPD, have flattened
diaphragms that compromise the
effectiveness of inspiratory efforts.
How can the ventilator or artificial airway increase the work of
breathing? If the ventilator circuit
contains rain out (a collection of
water in the low points) or the heat
and moisture exchangers (HME)
are clogged, the ventilator is less
sensitive to the patients efforts to
breathe. If the patient tries to trigger a breath and the machine
doesnt respond, the patients work
of breathing increases. Some older
ventilators may not respond rapidly to a high respiratory rate, thus
missing delivery of a breath.
In addition, some ventilators
may not end the inspiratory flow at
an appropriate point, resulting in a

breath thats shorter or longer than

the patients desired inspiration.
This may cause the patient to
breathe out of synchronization
with the ventilator, increasing his
work of breathing. Other factors
that increase the work of breathing
include artificial airways that are
too small, too long (which tend to
kink), or in a position that allows
the patient to bite down and
occlude the lumen. Correcting
problems like these can relieve
muscle fatigue, reduce the work of
breathing, and improve the
patients ability to carry the respiratory load.
Metabolic factors, such as inadequate nutrition and electrolyte
imbalances. Patients who have
chronic CO2 retention from COPD
have respiratory acidosis compensated by bicarbonate retention.
Sometimes these patients are overventilated during mechanical ventilation, which causes excessive
bicarbonate excretion as the CO2
is blown off. The result is a metabolic imbalance that may interfere
with weaning. Kidney failure
also may contribute to metabolic
imbalances that interfere with
weaning.
Inadequate oxygenation.
Failure of the lung-to-cell oxygen
delivery process may result from
low blood oxygen content, inadequate cardiac output, or impaired
oxygen uptake in the cell because
of sepsis. Physical assessment, lab
values, or chest X-rays often reveal
causes for oxygenation problems
that delay or interfere with weaning. Examples include anemia,
ventilation-perfusion abnormalities
due to atelectasis, infections such
as pneumonia, shock, and pulmonary embolism.
Cardiovascular limitations.
Excessive fluid in the body and
ineffective cardiac emptying can
result in heart failure, which
impedes weaning. Conversely, positive pressures in the thorax generated by the ventilator may reduce
venous return to the heart and
Nursing2006, September

39

decrease cardiac output; this also

impedes weaning.
Psychological factors. Patients
whove been on prolonged mechanical ventilation are afraid of losing
this support. Because psychological
barriers can be significant, provide
careful, frequent communication
and reassurance for the patient and
family throughout weaning.
Making weaning work

Multidisciplinary teams play a key

role in helping patients who have
difficulty weaning succeed. Besides
the patient and his family, an effective team may include physicians,
nurses, respiratory therapists,
occupational and physical therapists, speech therapists, social
workers, nutritionists, wound care
specialists, and chaplains. This
group should interact daily at the
bedside, participate in plans for
care, and conduct formal weekly
discussions of the care plan and
the patients needs.
The patient can benefit from an
evidence-based approach to weaning. (See Guidelines for weaning.)
Recent studies have shown that a
daily sedation vacation can
reduce the duration of mechanical
ventilation, possibly because the
awake patient is more likely to
undergo daily assessment of his
readiness to wean and extubate. A
daily interruption in sedation also
reduces ICU stay. (For more
details on sedation vacations, see
Best-Practice Interventions: How
Can You Prevent VentilatorAssociated Pneumonia? in the
February issue of Nursing2006.)
To rest patients respiratory muscles, use assist/control mode with
appropriate trigger sensitivity.
The following interventions are
appropriate for patients using the
rapid-weaning approach and are
crucial to weaning success for
patients who have difficulty weaning. For patients whove been on
long-term ventilation, addressing
all aspects of mechanical ventilation and hindrances to sponta40

Nursing2006, Volume 36, Number 9

Guidelines for weaning

These guidelines, published in 2001, were developed by a collective task force
comprising physicians, nurses, and respiratory therapists.
1. Search for all causes for the patient being ventilator-dependent and correct or reverse them.
2. Perform a formal assessment about readiness to wean if the patient
meets the criteria listed below. Some patients may still be considered for
weaning even if one of the following criteria isnt met:
The cause of the respiratory failure has been partially or fully reversed.
The patients Pao2/FIO2 is 150 to 200, positive end-expiratory pressure is
between 0 and 8 cm H2O, his FIO2 is less than 0.5, and pH is 7.25 or greater.
The patients hemodynamic status is stable, with no ischemia and no clinically important hypotension.
The patient can initiate an inspiratory effort.
3. Perform a formal assessment of readiness to wean. If the patient can tolerate a 30- to 120-minute spontaneous breathing trial, hes ready. Tolerance is
based on respiratory pattern (no retractions or obvious signs of distress and
respiratory rate less than 30 breaths/minute), adequate gas exchange, hemodynamic stability, and subjective comfort level.
4. Once the patient is discontinued from mechanical ventilation, assess airway patency and his ability to clear secretions. If the airway isnt patent, or if
he cant clear secretions, leave the artificial airway in place.
5. If he failed the spontaneous breathing trial, determine and correct the
cause. Then evaluate him based on guideline 2. If criteria are met, perform a
spontaneous breathing trial every 24 hours.
6. Between breathing trials, use a ventilator mode that provides support
that is stable, nonfatiguing, and comfortable. Let the patient rest to avoid overloading the ventilatory muscles.
7. Use proper analgesics and sedatives at the lowest possible dose, to avoid
blunting the respiratory drive.
8. Employ properly designed weaning protocols performed by a nurse/
therapist team. Use sedation protocols.
9. If the patient will clearly need prolonged mechanical ventilation, he
should have a tracheostomy. Early in the course of treatment is better than
later.
10. A patient should be classified as permanently ventilator-dependent only
after 3 months of failed weaning attempts, unless he clearly has irreversible
disease or injury, such as amyotrophic lateral sclerosis or spinal cord injury.
11. If weaning attempts in the ICU have failed, transfer a medically stable
patient to a specialized facility that has a good safety and success record in
accomplishing ventilator discontinuation.
12. When a patient has been on prolonged mechanical ventilation, go slowly in weaning and gradually increase the time used for spontaneous breathing
trials. Respiratory muscles need to be retrained and strengthened for patients
whove been ventilator-dependent for prolonged periods.

neous breathing will maximize

weaning success. Try these interventions to help make weaning
easier:
Elevate the head of the bed at least
30 degrees unless contraindicated to
help relieve diaphragmatic pressure
from abdominal contents and
reduce the chance of aspiration
pneumonia. Also, you can more

easily manage excessive secretions

when the patients head is elevated.
Kinetic therapy (mechanical
rotation of patients with 40-degree
turns by a specialized bed)
reduces the incidence of VAP and
atelectasis.
Suctioning should be performed
as often as indicated to clear secretions. Consider using a closedwww.nursing2006.com

system suction catheter so you

dont have to open the patientventilator circuit.
Adequate humidification of
inspired air helps prevent mucus
plugs.
Prevent bronchospasm with bronchodilator therapy, either through a
nebulizer or the equally effective
metered-dose inhaler with a spacer
device.
Careful attention to proper infection control practices reduces the
risk of VAP and other infections.
Prophylactic antacids can help
reduce the patients risk of stress
ulcers, which occur in 25% of
patients receiving mechanical ventilation. Raising the pH of gastric
contents also may protect against a
greater pulmonary inflammatory
response to aspiration of gastrointestinal contents.
Sleep deprivation in the ICU can
impair efforts to wean, so try to
minimize noise and avoid unnecessary interruptions when the patient
is sleeping.
Fight depression and motivate the
patient to improve by making his
daytime environment stimulating.
Clocks, calendars, and an outside

view help link the patient to time

and season. Pictures, music, TV,
and visits from friends and family
also can help stimulate and motivate. Help him communicate using
devices such as writing tablets or
picture and alphabet boards. If he
has a tracheostomy, he may be able
to speak by using a one-way
speaking valve on a fenestrated
tube. Also include the patient and
the family in developing care
plans.
Unless contraindicated, a
patient receiving prolonged
mechanical ventilation should be
moved into a chair for daily periods of sitting up. Better yet, help
him stand and walk if he can. Use
an oxygen cylinder and bagvalvemask to ventilate him if a
portable mechanical ventilator
isnt available. Take him outside if
weather permits so he can experience sunshine and fresh air.
Consider a visit by a therapy pet.
A winning team

The rapid-wean patient and the

difficult-to-wean patient represent
the two opposite ends of the
mechanical ventilation spectrum.

But by working with the patient,

his family, and other members of
the health care team, you can help
your patient breathe independently
and leave the ventilator behind.
SELECTED REFERENCES
Ely E, et al. Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: Evidence-based clinical practice
guidelines. Chest. 120(6, Suppl.):454S-463S,
December 2001.
Grap M, et al. Collaborative practice: Development, implementation, and evaluation of a
weaning protocol for patients receiving mechanical ventilation. American Journal of Critical
Care. 12(5):454-460, September 2003.
MacIntyre NR. Evidence-based ventilator weaning and discontinuation. Respiratory Care.
49(7):830-836, July 2004.
MacIntyre NR, et al. Evidence-based guidelines
for weaning and discontinuing ventilatory support: A collective task force facilitated by the
American College of Chest Physicians, the
American Association for Respiratory Care, and
the American College of Critical Care Medicine. Chest. 120(6, Suppl.):375S-395S, December 2001.
Marelich G, et al. Protocol weaning of mechanical ventilation in medical and surgical patients
by respiratory care practitioners and nurses: Effect on weaning time and incidence of ventilatorassociated pneumonia. Chest. 118(2):459-467,
August 2000.
Sessler C. Wake up and breathe. Critical Care
Medicine. 32(6):1413-1414, June 2004.
Bill Pruitt is an instructor in the department of cardiorespiratory sciences at the University of South
Alabama in Mobile and a p.r.n. respiratory therapist
at Springhill Medical Center in Mobile.
The author has disclosed that he has no significant
relationship with or financial interest in any commercial companies that pertain to this educational activity.

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Weaning patients from mechanical ventilation

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2.5

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Weaning patients from mechanical ventilation

GENERAL PURPOSE To provide nurses with an overview of mechanical ventilation and weaning patients from it. LEARNING OBJECTIVES After
reading the preceding article and taking this test, you should be able to: 1. Describe mechanical ventilation and weaning protocols. 2. Discuss
problems that may occur during weaning and appropriate nursing interventions.
1. Mechanical ventilation is indicated
a. to provide adequate circulatory support.
b. when the body cant meet its oxygen demand
through spontaneous breathing.
c. whenever the patient has an SpO2 less than 92%.
d. when the patients oxygen demand drops.

6. Readiness to wean criteria include

a. PEEP between 10 and 15 cm H2O.
b. FIO2 greater than 0.5.
c. PaO2/FIO2 of 150 to 200.
d. pH less than 7.25.

11. A patient will need a tracheostomy

a. when he needs prolonged mechanical ventilation.
b. if he needs short-term mechanical ventilation.
c. if he needs humidification of inspired air.
d. during cardiovascular surgery.

7. A key feature to weaning is

a. a high level of PEEP.
b. a high level of pressure support.
c. respiratory acidosis.
d. a spontaneous breathing trial.

2. Which isnt used to deliver mechanical

ventilation?
a. oral ET tube
b. chest tube
c. nasal ET tube
d. tracheostomy tube

12. A patient is considered permanently

ventilator-dependent after failed weaning
attempts lasting
a. 3 weeks.
b. 6 weeks.
c. 10 weeks.
d. 3 months.

8. Difficulty weaning and ventilator dependence may be caused by any of the following except
a. brainstem stroke.
b. reversal of the cause of respiratory failure.
c. respiratory muscle fatigue.
d. brain tumor.

3. The FIO2 setting on the mechanical ventilator gives you information about
a. supplemental oxygen.
b. tidal volume.
c. mode of ventilation.
d. pressure support.

9. An inability to carry the respiratory load

with resulting ventilator dependence is least
likely to be caused by
a. excessive work of breathing.
b. bronchospasm.
c. excessive secretions.
d. oral ET intubation.

4. The rapid-wean approach typically has

patients off the ventilator in
a. the postanesthesia care unit.
b. 1 to 2 hours.
c. 6 to 8 hours.
d. 24 to 48 hours.
5. A patient whos ready to wean from
mechanical ventilation should be able to
tolerate spontaneous breathing of
a. 1 to 5 minutes.
c. 11 to 20 minutes.
b. 6 to 10 minutes.
d. 30 to 120 minutes.

10. Overventilation on a ventilator can

result in
a. respiratory acidosis.
b. excessive bicarbonate excretion.
c. CO2 retention.
d. metabolic alkalosis.

13. Which intervention is recommended for

patients on mechanical ventilation?
a. head of bed flat
b. decreased gastric pH
c. kinetic therapy
d. dehumidification of ventilated air
14. A daily sedation vacation may result in
a. resting the patients respiratory muscles.
b. a more accurate assessment of readiness to
wean.
c. a prolonged ICU stay.
d. lengthening the duration of mechanical ventilation.

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