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Author: Contact Name and Job Title Ruth Pettit, Deputy Sister
Explicit definition of patient group to which it applies (e.g. Adult critical care patients ventilated on invasive
inclusion and exclusion criteria, diagnosis) mechanical ventilation, through an endotracheal
tube or tracheostomy. Excluding, paediatric
patients, high cervical spine injury patients.
Version 2
Statement of the evidence base of the guideline has the Peer Reviewed by Consultant and senior
guideline been peer reviewed by colleagues? nursing staff within critical care. Guieline also
passed through critical care guidelines
process in March 2013.
Evidence base: (1-6)
1
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
Introduction
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weaning delay (>14 days in ICU where respiratory dependency is now the
primary problem and the patient requires invasive ventilatory support for >6
hours per day, NHS Modernisation Agency (2002)) or weaning failure (>21
days in ICU where respiratory dependency is now the primary problem and
the patient requires invasive ventilatory support for >6 hours per day, NHS
Modernisation Agency (2002)), an individualised weaning care plan approach
may be required.
Indications
PaO2 > 9.0 Kpa / SaO2 >90% unless underlying chronic lung condition
3
Exclusions
Contra-Indications (absolute)
Equipment
Ventilator (Evita 2 Dura, Evita 4 and Excel are the preferred choice for
weaning patients)
4
Principles of Care/Action/Responsibilities
PRINCIPLE RATIONALE
1. PATIENT ASSESSMENT
Physical
If weaning is predicted to be more than 7 Tracheostomy reduces dead space and may
days a tracheostomy may be required. result in reduced ventilator dependency time
(Griffiths et al. 2005).
Daily review of the patients readiness to A daily assessment will reduce any delay in
wean should be made. initiating the decision to wean (Norton,
2000). The assessment should address all
the indicators for weaning and include a
multidisciplinary approach.
Psychological
The patient is orientated to night and day. ICU delirium can delay weaning; efforts
should be made to reduce the onset of
delirium.
5
Delirium should be treated. Delirium may contribute to longer ventilation
times; national guidelines recommend the
management of delirium (Borthwick et al
2006). Refer to NUH critical care delirium
guidelines for management
Effective interpersonal skills are vital for successful weaning from mechanical
ventilation. Practitioners should inform and work collaboratively with patients
throughout the weaning process (Newmarch 2006).
PRINCIPLE RATIONALE
Respiratory
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Patient has an acceptable amount of Excessive secretions results in frequent
secretions. need for suctioning, causes coughing and is
exhausting (Grap et al 2003).
The need for a recent chest X-Ray has A chest X-Ray gives information about the
been considered and performed if patients likelihood of successful weaning
required. and eliminates pneumothorax or pleural
effusions as a cause of failure to wean.
The correct level of humidification for the Low humidification levels can lead to
patient is established utilising either a thickened sputum whilst over humidification
HME or heated wet circuit. can lead to excessive sputum.
Cardiovascular
Cardiovascularly stable (with or without A heart rate of above 140bpm may result in
inotropes/vasopressors). inadequate filling of the ventricles and
reduced cardiac output.
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pH > 7.25 Acidosis will result in a compensatory
increase in respiratory rate causing fatigue.
Nutrition
Trace elements (K+, PO4, Mg, Ca) are Normal values of trace elements are
checked and normalised. required for muscle function (MacIntyre
2001).
Neurological
Patient has sufficient respiratory drive. Excessive sedation will reduce respiratory
drive; the patient does not need to be
conscious but must have sufficient drive.
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Patients GCS is improving and will allow The patients GCS should be 8 or greater
for protection of airway upon extubation. prior to extubation of an oral ETT. (Those
patients with a tracheostomy have a
protected airway).
PRINCIPLE RATIONALE
High spontaneous respiratory rate A high respiratory rate will cause fatigue. It
is an early sign of fatigue, usually
compensating for a decreased tidal volume
or increased carbon dioxide (Tobin et al
1986).
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Small Tidal Volumes. A decrease in tidal volume is a sign of
fatigue, or maybe a sign of respiratory
failure (Fiastro et al 1988, Howie1999).
Arterial blood gases within prescribed ABGs should be checked if any sign of
limits. deterioration or 20 minutes after each
change in ventilation. Deterioration in
arterial blood gases may indicate fatigue or
respiratory failure and is a late sign.
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PRINCIPLE RATIONALE
4. PROCESS OF WEANING.
A protocol directed weaning method may Protocol directed weaning provides a safe
be utilised initially. Weaning protocols method of weaning for all levels of nurses
may be useful in certain circumstances. and reduces duration of mechanical
Refer to appendix one; flowcharts 1-4. ventilation (Tonnelier et al 2005)
The weaning plan should be written for a Different clinicians may utilise different
number of days at anyone time; this approaches to weaning. Consistency for the
allows a consistency in approach and patient is the important factor rather than the
ensure that weaning continues when less method of weaning employed. Junior staff
experienced staff are present. may not feel confident in planning weaning.
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The individualised weaning plan should The plan should be explicit to prevent
outline the mode of ventilation, settings confusion.
and period of time to be spent on each
setting. Parameters to determine patient
weaning failure should also be set.
Periods of rest should be incorporated.
The reason for any deviation from the To identify problems with weaning and allow
weaning plan should be documented. a new weaning plan to be created.
Any patient who has been ventilated for These provide a holistic plan of care for the
more than two weeks should be included patient which will assist in weaning.
in the long term patient ward rounds.
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The guidelines should be used with flowcharts 1-4 which are attached in
appendix one and can be found in the bedside folders.
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REFERENCES
Burns KEA, Meade MO, Premji A & Adhikari NKJ (2013) Noninvasive
positive-pressure ventilation as a weaning strategy for intubated adults with
respiratory failure (Review). The Cochrane Collaboration. Published online
09/12/13.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004127.pub3/pdf
Crocker, C (2002) Nurse led weaning from ventilatory and respiratory support.
Intensive and Critical Care Nursing. 18 272-9
14
Fiastro J, Habib M, Shon B, Campbell S (1988) Comparison of standard
weaning parameters and the mechanical work of breathing in mechanically
ventilated patients. Chest 94 (2) 232 238.
15
mechanical ventilation. A randomized Trial. JAMA
http://jama.jamanetwork.com. Accessed 29/01/2013.
Newmarch C (2006) Caring for the mechanically ventilated patient: part two.
Nursing Standard, 20:18, 55 64.
Norton L (2000) The role of the specialist nurse in weaning patients from
mechanical ventilation and the development of the nurse-led approach.
Nursing in Critical Care 5 (5) 220 227.
16
unsuccessful trials of weaning from mechanical ventilation. American Review
of Respiratory Disease. 135. 865 870.
Date: 19/03/13
Audit points.
17
Critical Care
Summary of the procedure for weaning an adult patient from invasive
mechanical ventilation
This guideline provides guidance on weaning the patient from ventilation up to the point
whereby the patient is ready to be extubated. The nurse should then refer to the separate
guideline for extubation. This is a summary of the whole guideline and should be used in
conjunction with it as required.
Indications for Weaning
If no medical staff decision to the contrary weaning should commence using the following
indicators:-
Resolving medical condition
FIO2 < 50%
PaO2 > 9.0 Kpa / SaO2 >90% unless underlying chronic lung condition
Acceptable level of PEEP/CPAP (<8 cmH2O or less)
Acceptable acid/base balance (relevant to that particular patient)
Hb > 7 g/dl and haemodynamically stable
Adequate pain control
Effective neurological function/stable ICP.
In patients whose physiological parameters are outside of those outlined above, weaning
should be discussed with the medical staff and initiated as soon as possible.
Exclusions
Patients with high cervical cord injuries these patients should be weaned according to
individualised plans in conjunction with spinal injury patient guidelines.
For patients who are primarily ventilated for airway protection, i.e.
post-operative elective surgery or reduced GCS.
Yes
No signs of fatigue
or distress
Trial of CPAP/ASB
Signs of fatigue or
distress
Signs of fatigue or
distress (this applies
Yes to all stages) No
Continue to
reduce frequency
Remain on
(bpm) by 2 until 8
current settings
Trial of CPAP/
ASB for
30 minutes
Patient not improving or
deteriorated, contact
Dr, consider increasing
support Refer to weaning from CPAP ASB flow
chart
Critical Care
Reduce ASB by 2
Signs of distress /
fatigue (this applies
to all stages)
No Yes
BIPAP top
pressure below
25 Yes
No
Set total ASB to
same as Pinsp.
Dr. to assess
patient.
Set Pinsp
according to VT,
PO2, PCO2 Reduce frequency
by 2 bpm
No
Yes
Continue to
Return to reduce by 2bpm
previous settings until frequency is
and allow to rest 8bpm. If patient is
for 2 hours managing well
change mode to
CPAP / ASB
Wean using
Consider the need to create an CPAP ASB flow
individualised weaning plan chart
Critical Care
For use when an individualised weaning plan has not yet been
completed. An individualised weaning plan should be completed at the
earliest opportunity.
or
Increase duration and frequency
Rest at night on CPAP/ASB with
of CPAP trials until able to manage
ASB increased by 2
CPAP continuously.