Wales Critical Care & Trauma Network (North)

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Scarlett Holland
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and the Weaning Guidelines for Spinal Cord Injured Patients CCN long

1 Wales Critical Care & Trauma Network (North) Guidelines for Long Term Weaning Patients See also the Guidelines for Weaning from Ventilation and the Weaning Guidelines for Spinal Cord Injured Patients CCN long term weaning / Mottart & Pugh V7 Page 1 of 9 Approved at CCSC September 2015

2 North Wales Critical Care & Trauma Network Weaning plans for longer term weaning patients on critical care units Prolonged weaning, i.e. failure to liberate from mechanical ventilation a week after its initiation, has been estimated to affect up to 15% of the mechanically ventilated critically ill (Perren and Brochard 2013). Recognition of prolonged weaning, if not before, should promote patient review on a multi-disciplinary basis, for example with respect to the domains listed in Table 1 below. Medical optimisation in the context of prolonged weaning A number of patho-physiological processes may be relevant to the patient experiencing prolonged weaning, including inadequate resolution of primary pathology, development of ICU-acquired pathology (e.g. pneumonia) and pre-existing chronic disease. Reversible factors may be considered under the following sub-headings: 1. Increased respiratory load, due to: Excess fluid (pulmonary oedema and/or pleural effusions or ascites) - which may be managed by restricting fluid intake and/or diuretics Increased airways resistance and intrinsic PEEP - managed by bronchodilator treatment and by applying sufficient extrinsic PEEP (which may otherwise inhibit ventilator triggering) and pressure support (which should be adequate to minimise tachypnoea and dynamic hyperinflation) Underlying lung disease - and where there is suspicion that the underlying aetiology is poorly understood may warrant further input and investigation (e.g. with high -resolution CT scan or bronchoscopy) 2. Increased cardiac load Increased metabolic demand during weaning may contribute to cardiac decompensation. Echocardiography will help to identify systolic and diastolic ventricular dysfunction. Left ventricular dysfunction may be improved with attention to fluid balance and if appropriate ACE-inhibitors. Evidence of myocardial ischaemia during weaning should usually prompt cardiology input, and possibly prescription of beta-blockers and nitrates 3. Neuromuscular disorders Global weakness among patients with prolonged weaning is often a result of critical illness myo-neuropathy Nerve conduction studies may be appropriate to confirm clinical suspicion 4. Metabolic/ endocrine Maintain normal potassium, phosphate, calcium, magnesium Avoid significant metabolic alkalosis (e.g. through adequate ventilation rest periods, with CO 2 normalisation) Minimise exogenous corticosteroid therapy where possible Consider thyroid or adrenal (e.g. Addisonian) abnormality CCN long term weaning / Mottart & Pugh V7 Page 2 of 9 Approved at CCSC September 2015

3 Appropriate nutrition, bearing in mind efficiency of CO2 clearance and protein requirements. Pending dietician input, Peptamen AF may generally be appropriate given omega-3, antioxidant and protein content; Oxepa (which has relatively high fat content and therefore lower respiratory quotient) may be appropriate where CO2 clearance is particularly problematic. Refer also to NWCCN Nutrition Bundle Respiratory weaning principles These principles are intended to apply in the following circumstances to the prolonged weaning patient: Resolution of initial insult Tracheostomy in situ Haemodynamically stable Able to open eyes and follow command Afebrile and ph >7.3 It should be remembered that weaning is a holistic process of which adjustment of ventilator settings represents only one facet. Weaning efforts should initially occur during daylight hours leaving the patient to rest (returning to levels of ventilator support required for normal CVS parameters, reasonable respiratory rate and gases normal for patient at night). Weaning may occur at night once the patient requires minimal support during the day e.g. comfortable on CPAP only. However, rest days and holidays from active weaning should occur routinely (e.g. once a week duvet day ) and if any episodes of physical upset e.g. bouts of diarrhoea occur. Practical aspects to prolonged respiratory weaning An individualised weaning plan should be agreed by the MDT, led by the ICU consultant. An example process is outlined below (Fig.1) Probably the most important consideration is to allow adequate rest between periods of weaning, e.g. resting overnight by increasing set rate or increasing pressure support depending on stage of weaning. Using an NIV ventilator via tracheostomy tube may make it easier to switch between CPAP and assisted ventilation modes (rather than CPAP circuit to SPONT or CPAP ASB on ventilator), a nd to allow for cuff leaks and/or fenestrated tracheostomy tube. CCN long term weaning / Mottart & Pugh V7 Page 3 of 9 Approved at CCSC September 2015

Fig. 1 An example process for prolonged weaning Agree parameters with consultant E.g. respiratory rate, SaO 2, PaO 2, ETCO 2, PaCO 2, ph Once Pinsp/ Pressure Control/ IPAP < 25 cm H 2O, wean rate

4 Fig. 1 An example process for prolonged weaning Agree parameters with consultant E.g. respiratory rate, SaO 2, PaO 2, ETCO 2, PaCO 2, ph Once Pinsp/ Pressure Control/ IPAP < 25 cm H 2O, wean rate until 12 Ensure not exhausted at end of CPAP period and rested prior to next CPAP period If needed, rest on BIPAP/ DUOPAP or CPAP ASB/ SPONT Trial of CPAP ASB/ SPONT for e.g. 1-4 hours Rest on BIPAP/ DUOPAP for 2-4 hours Increase duration and frequency of CPAP ASB/ SPONT trial until established throughout daytime Review parameters and continued need for arterial line Rest either on BIPAP/DUOPAP overnight Rate 8 pm and Pinsp/Pressure Control or CPAP ASB/SPONT overnight with ASB or Pressure Support increased by 2 cm H 2O to ensure adequate rest. Reduce ASB/ Pressure Support by 1-2 cm H 2O every 12 hours Trial of CPAP 1-4 hours, resting on CPAP ASB/SPONT Aim to deflate cuff and/or fenestrated trache tube/ speaking valve as appropriate Increase duration and frequency of CPAP until able to manage continuously Adapted from: Pettit R et al. Nottingham University NHS Trust 2013 CCN long term weaning / Mottart & Pugh V7 Page 4 of 9 Approved at CCSC September 2015

5 References Boles, J-M et al. Weaning from mechanical ventilation. European Respiratory Journal 2007; 29: Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from mechanical ventilation. Intensive Care Medicine 2013; 39: Pettit R, et al. Guideline for weaning an adult patient from invasive mechanical ventilation. Nottingham University Hospitals NHS Trust, White A. Long-term ventilation strategies. Respir Care 2012; 57; CCN long term weaning / Mottart & Pugh V7 Page 5 of 9 Approved at CCSC September 2015

6 Table 1a Facets to long term weaning Domain Communication Psychological Monitoring Muscle strength & endurance Respiratory Patient involvement / Independence Discharge planning Sleep pattern Diet Rehabilitation Considerations / actions Communication aids including electro-larynx Glasses / hearing aids Language / translators Passey-Muir valve Deflate cuff or uncuffed tracheostomy Treat pain / delirium / anxiety / depression Patient ownership of process Achievable goal setting Own clothes Active stimulation vs passive entertainment Visible clock and daily timetable Trips out of unit Remove monitoring as not needed Respiratory weaning clinically not number driven Leg bag or flick flow value for catheter Physio tailored programme Include trips to physio gym Agree programme to dovetail with respiratory weaning Build in adequate rest and holiday periods Slow and steady! Ensure not exhausted. Build in adequate rest and holiday periods Use guidelines in document (above) Always give adequate support to ensure proper rest at night Participates in goal setting Remove monitoring / leg bag Increase patient self caring (washing, dressing etc) Plan early MDT meeting with key people including SW, OT, etc and family/patient Projected EDD with reference to significant dates for patient Recognise patient normal home pattern including daytime naps Awake during day (allow short cat naps only) Trazodone 50mgs nocte. Refer also to NWCCN Sedation Guidelines: Adequate respiratory support to ensure rest SALT & dietician involvement Swallow test & pharyngeal muscle exercises if fails NG feed at night only when eating Aperitifs prior to meals Home food Assessment of current rehabilitation needs Establishment of short- and medium- term rehabilitation goals CCN long term weaning / Mottart & Pugh V7 Page 6 of 9 Approved at CCSC September 2015

7 Table 1b Facets to long term weaning Addressograph Personal weaning goals and timetable week commencing Communication Psychological Monitoring Muscle strength & endurance Respiratory Patient involvement / independence Discharge planning Sleep pattern Diet Rehabilitation CCN long term weaning / Mottart & Pugh V7 Page 7 of 9 Approved at CCSC September 2015

8 Table 2a Weekly PLAN for activity timetable commencing. Addressograph Morning PLAN Tuesday Wednesday Thursday Friday Saturday Sunday Monday Afternoon Evening Night Signatures Patient.. Nursing Physio Consultant.. CCN long term weaning / Mottart & Pugh V7 Page 8 of 9 Approved at CCSC September 2015

9 Table 2b Weekly RECORD of activity timetable commencing. Addressograph Morning RECORD of (ACTUAL) ACTIVITY Tuesday Wednesday Thursday Friday Saturday Sunday Monday Afternoon Evening Night NB: Variances to be recorded in patient s notes CCN long term weaning / Mottart & Pugh V7 Page 9 of 9 Approved at CCSC September 2015

Mechanical Ventilation of the Patient with Neuromuscular Disease

Mechanical Ventilation of the Patient with Neuromuscular Disease Dean Hess PhD RRT Associate Professor of Anesthesia, Harvard Medical School Assistant Director of Respiratory Care, Massachusetts General