Readiness For Weaning From the Ventilator

1. Readiness For Weaning From the Ventilator Terry P. Clemmer, MD Director CCM LDS Hospital Professor of Medicine University of Utah School of Medicine

2. 1. Frontline Engagement 6. Clear Communication 2. Scripted Processes Requisite for Sustainable Improvement 3. Reliable Execution 5. Scientific Change Process 4. Organizational Learning Terry P. Clemmer, MD LDS Hospital

3. Define Weaning • It Is: Removal from Assisted Positive Pressure Ventilation to: • CPAP • T-tube or Trach Mask • Face Mask, Face Tent or Nasal Oxygen • It Is Not: Extubation or Removal of Tubes From the Trachea: • ET Tube • Tracheostomy Tube

4. Keys to Early Weaning • Therapist Driven Ventilator Management and Weaning Protocols • Rules for Assessing Weaning Readiness • Rules for Selecting Weaning Mode • Rules for Failure to Wean • Rules to Reduce Support During Weaning • Removing Patient From Sedation ASAP • Mobilizing Patient • Separate Extubation Rules and Process

5. Example of Rules that Trigger a Weaning Assessment • FiO2 <= 0.5 • PEEP <= 10 • Hemodynamically Stable (Off Vasopressors) • Patient Not Paralyzed and Able to Trigger Ventilator • Meets Agreed Upon Timing Rules

6. NIH-ARDSnet Rules

7. Example of Weaning Assessment • During Spontaneous Breathing Record • VR, Vt, f/Vt, MIP, VC • If VR < 27 and Vt > 5 ml/kg PBW Give a Trial of Spontaneous breathing • If VR is 28-37 and Vt is > 4 ml/kg go to PS Weaning • If VR >37 or Vt is < 4 ml/kg wait 4-6 hours and recheck

8. Example of Weaning Failure Rules • Need to Increase FiO2 to > 0.6 to keep SpO2 > 90% • Need to Increase PEEP to > 12 to keep SpO2 > 90% • VR > 37 Breathing Spontaneously • VR > 37 on PS > 20 cm H2O • Vt < 4 ml/kg PBW • Change in Mental Status • pH < 7.25

9. Example of Rules to Reduce PS During Weaning • Every 2 hours Reduce PS by 2 cm H2O • If VR > 30 Increase PS by 2 cm H20 • If SpO2 < 90% of FiO2 >= 0.6, Increase PS by 5 cm H2O • If PS is > 20 return to A/C • If PS is = 5 Go to CPAP or T-tube

10. NIH-ARDSnet Rules

11. NIH-ARDSnet Rules

12. NIH-ARDSnet Rules

13. How to Do This Safely • Script the Rules (they do not have to be perfect just acceptable for a starting point) • Have Front Line Test the Rules on One Patient Under Supervision using Rapid Cycle Testing • Find and Correct the Problems with Rules

14. How to Do This Safely • Retest on Another Patient and Repeat Until the Rules Are • safe • effective • doable in the local environment • acceptable to local clinicians • Spread To Other Patients

15. 1. Frontline Engagement 6. Clear Communication 2. Scripted Processes Requisite for Sustainable Improvement 3. Reliable Execution 5. Scientific Change Process 4. Organizational Learning Terry P. Clemmer, MD LDS Hospital