Weaning from ventilation: Hot Case

GENERAL APPROACH

  • Brain
  • Cough
  • Nerves
  • NMJ
  • Respiratory Muscles
  • Pleura
  • Airways (large and small)
  • Parenchymal
  • Chest wall
  • Ventilator asynchrony

Assess for:

  • Resolution of primary illness
  • Cardiac failure
  • Respiratory failure (primary disease; VAP; clearing secretions)
  • Abdominal distension/failure and nutrition
  • Neurological failure (GCS, weakness)

Cases:

  • chest trauma
  • neuromuscular disorders
  • prolonged critical illness

INTRODUCTION

CUBICLE

  • inhalers
  • ventilators
  • sputum
  • isolation (MDR Organisms)
  • evidence of being in ICU a long time

INFUSIONS

  • TPN
  • inotropes (active medical problems)
  • bronchodilators
  • antibiotics (MDRO)
  • IV IG (GBS, MG, vasculitis)
  • may be few or no infusions: weaning difficulty main reason for continued ICU stay

VENTILATOR

  • type of tracheostomy
  • type of ventilation (NIV, invasive, spontaneous breaths)
  • settings (FiO2, PEEP, RR, PS, IE ratio)
  • assess weaning strategy (T piece, flow by, gentle weaning of pressure support or RR)
  • RR <30 (good)
  • unassisted TV (>325 mL or 5mL/kg = good)
  • rapid shallow breathing index (f/VT <105 = good)
  • vital capacity (>15mL/kg = good)
  • MV (<15 L/min = good)
  • maximum inspiratory pressure (-15cmH2O = good; 90-120 cmH20 is normal)

MONITOR

  • oxygen saturation (A-a gradient)
  • tachycardia
  • fever (ongoing sepsis)

EQUIPMENT

  • intercostals drains (number, bubbling, drainage)
  • inhalers
  • nebulisers
  • steroids (corticosteroids, testosterone analogues)

QUESTION SPECIFIC EXAMINATION

  • tracheostomy
  • neurological -> consciousness
  • hands -> head -> chest -> abdo -> feet -> back

-> cardiovascular -> respiratory -> abdominal (tolerating feeds, distension, diarrhoea)

  • nutritional state

Questions

  • trends (e.g. fever, fluid balance)
  • last sedation or paralysis?
  • physiotherapy frequency
  • frequency of suctioning
  • nature of tracheal aspirates
  • tolerating feeds
  • diarrhoea

RELEVANT INVESTIGATIONS

  • CXR
  • ABG
  • microbiology

OPENING STATEMENT

  • = Multi-factorial and list headings of causes -> clinical signs associated with list

DISCUSSION

  • strategies used to wean from mechanical ventilation
  • objective indices to predict difficult weaning
  • role for early tracheostomy
  • automated weaning modes

References and Links

LITFL

Textbooks

  • Foote C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine (2nd Edition), Elsevier 2011

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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