Optimize vent weaning and SBT outcomes. Identify underlying causes for SBT failures. Role SBT and weaning protocol have in respiratory care

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2 Optimize vent weaning and SBT outcomes Identify underlying causes for SBT failures Role SBT and weaning protocol have in respiratory care

3 Lower risk of developing complications Lower risk of VAP, other hospital acquired infections Shorter length of stay Cost savings to patient and hospital

4 Ventilator Spontaneous mode Pressure support 8cmH20 Peep 5 100% tube compliance, Peep 5 Pressure support 0, Peep 0 to get RSBI reading T-Piece With oxygen

5 Large randomized trial compared routine SBTs to two other weaning strategies that did not include SBT s. Compelling evidence that protocol driven ventilator discontinuation strategies more successful Clear evidence RN/RT can reduces costs for patients utilizing protocols

6 Ely published results of 2-step protocol driven by RN/RT using daily screening procedure followed by SBT in those who met screening criteria and extubation was recommended.

7 151 patients managed with the protocol had a higher severity of illness than the 149 control subjects, they were removed from the ventilator 1.5 days earlier (with 2 days less weaning), had 50% fewer complications related to the ventilator and had mean ICU costs of care that were lower by >$5,000 per patient.

8 Another study showed the mean duration of mechanical ventilation could be reduced by 30 hours. Marelich showed duration of ventilatory support could be reduced almost 50% using nurse-driven and therapist-driven protocols

9 Patient assessment Can patient protect their airway Patient hemodynamically stable How long patient on ventilator Underlying cause for intubation resolved

10 Order for SBT Complete patient assessment for potential weaning PaO2/Fi02 ratio > than 150 or Sp02 > 90% on fi02 <.50 Peep < 8cmh20 Intact airway reflexes

11 Not on continuous infusion of vasopressors (Dopamine < 5mcg/kg/min allowed) Respiratory rate < 35 Any contraindication of this guideline requires call to physician prior to proceeding RT to consult with RN about patient sedation status. Perform RSBI if above criteria met

12 Spontaneous Mode PEEP 5cmH20 and Pressure Support 5cmH minutes Observe RSBI RSBI <100, initiate Spontaneous Breathing Trial (SBT) Head of Bed 30 degrees or greater Suction patient if necessary Alarms set and active during trial

13 Discontinue SBT If any of the following sustained longer than 5 minutes despite minor interventions such as suctioning or reassurance Blood pressure < 90 or greater than 200mmhg Respiratory rate is > than 35 and 50% reduction in minute volume Pulse greater than 120 or sustained 20% increase Severe anxiety

14 Significant decrease in level of consciousness from baseline EtC02 increase of 20 mmhg from baseline (only if EtCo2 monitoring in place) New onset or increased frequency of arrhythmias Sp02 is less than 90% on Fi02 less than or equal 50% RSBI greater than 100

15 If patient tolerates SBT after 30 minutes, call ordering physician or mid-level provider for further orders. If RSBI determination is greater than 100, begin Augmented Pressure Support in SIMV with Pressure Support Start with Pressure Support of 15cmH20 SIMV rate minus two of initial prescribed rate

16 Titrate pressure support for Spontaneous tidal volume of 6ml/kg of Ideal body weight When SIMV rate reaches 2, change ventilator mode to spontaneous If respiratory rate is less than 30 and RSBI is less than 100, begin SBT. If not, continue pressure support settings and notify physician or mid-level provider

17 Underlying cause for intubation not corrected Sepsis, ARDS, Lung injury Heart failure - BUN Stress Anxiety Drug use

18 Sedation/narcotic use Central apnea Nutritional support Phosphate/magnesium deficiency Cause muscle weakness

19 Studies are conflicting as to placing patient on weaning type mode of ventilation/simv as opposed to assist control ventilation. Patient dependent, some need more or full support between SBT trials, suggest a gradual change to weaning modes.

20 CABG < 6 hrs. CABG and valve repair <24 hrs. Ventilator checks q1 hr.. Q30 minute checks 4-6 hr.. Charting HR, RR, BP, Chest tube output Sedation, vasopressor ABG done 30 min hour upon arrival 8ml/kg VT, titrate FIO2 aggressively as tolerated

21 Starting hour 4 Sedation off, Fi , PEEP 5cmH20 Assess patient for SBT Patient has to follow commands Hand grip for 5 seconds Move feet/toes If patient meets criteria, place on SBT RT to remain at bedside for 5-10 minutes If patient not ready, place back on vent settings and try again in minutes.

22 Criteria for extubation Pt clinical stable Pt awakening from anesthesia Normal body temperature Pain under control Chest tube drainage <50ml hour or decreasing/stable PEEP 5cmH20, Fi02 <60% Sp02 > 92%

23 If patient does well on SBT ABG drawn ph pco P/F ratio > 150 on Fi02 < 50% Or Pre-Op baseline for patients with COPD If ABG outside these parameters call physician

24 If Patient not extubated in 6 hr. window Vent check every hour Adjust vent settings Bipap orders PRN IPAP 15, EPAP 5, Rate of 12 keep Sp02 >92% Continue ETC02 monitoring 12 hr. after extubation, or continuous if sleep apnea while on IV opioids

25 Female patient, mid 50 s GI Bleed Intubated to protect airway only Bedside procedure x 2 Extubate after 2 nd procedure Goal intubation <24 hr. No Respiratory history

26 Failed first SBT in the morning Pt sedated for comfort High anxiety Family very concerned Dr. wanted patient extubated

27 Explained SBT process to Patient and Family Sedation was weaned off Pt anxiety addressed Pt on Spontaneous mode for about 5 hours Successfully extubated patient in 6 hrs.

28 Adult average ventilator days per month Goal is 4.2 days July 4.71 days mostly below TOTAL VENTILATOR PATIENTS per month CVICU goal < 6hrs 60% of time. missed goal 4 times July 2015 Society of Thoracic Surgeons (STS) 3 star rating

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32 Advocate for Patients Be proactive in SBT Protocol for Vent Weaning/SBT

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