Weaning A Patient From Mechanical Ventilation

Question

Task: Your first attempt to wean a patient from mechanical ventilation in the CMV mode using a T-piece. After 30 minutes on the T-piece you observe the following

• Pulse 90
• Stable blood pressure 125/80
• Respiratory rate 18/min
• Physical appearance-no signs of distress
1. Discuss what would your next action include?
2. Discuss the parameters which will keep a patient from being able to wean from mechanical ventilation?
3. Your patient has the following parameters collected to determine if the patient is ready to wean from mechanical ventilation. This patient’s IBW is 80 kg. The patient has been on the SIMV with pressure support of 10 with a rate of 4 and VT of 700 with an Fio2 of 40%. You put him on CPAP for 2 minutes and obtain the following data: HR 110 RR 14 BP 130/90 VC 900 mL MIP 40 cm H2O VT 500 ml
4. A 45-year-old male with severe COPD is intubated and ventilated with pressure support ventilation. You note that he is making inspiratory efforts that do not trigger the ventilator. What is the most likely cause and what can you do to improve the patient-ventilator interaction?

Q.1) What are the actions to be undertaken after removing a patient from mechanical ventilation?

Answer1): The present paper will help in solving the four problems mentioned above along with a discussion on some of the terms related to the problems. The first problem deals with a scenario wherein a patient has been put under ventilation and I have been tasked to wean him from the ventilator. First, it is to be studied what exactly wean or weaned means. In a layman’s language wean can be termed as a situation wherein a person is dependent on something since long and he or she is offered something different in place of it for e.g. a child being offered chocolate milk shake in place of chocolates. Under medical terms weaning is the process through which a patient who is under mechanical support is gradually shifted or withdrawn from the ventilator. Mechanical ventilation is a technique to support people suffering from breathing problems. The machine helps a patient to breathe when the patient is unable to breathe by himself.

Source: ( Donohue, 2016)

Continuous Mandatory Ventilation (CMV) is a process through which the breathing is controlled based on different set variables (Keszler and Chatburn, 2017). T-piece or T-tube is a process through which spontaneous breathing can be generated helping in weaning from mechanical ventilation (Ladeira et al, 2014). In the first problem question, the patient’s vital parameters were checked after being put on T-piece for 30 min. It was seen that his pulse rate was 90 per minute, his blood pressure was 125/80 mm of Hg and his breathing rate was 18 per minute. As per the parameters it can be stated that all the three elements, blood pressure, breathing and pulse is normal. Adding to the parameters being normal, the patient did not show any sign of distress which is a positive part. It can be clearly seen basis the results that the patient can breathe normally and the weaning has been successfully made, therefore there is no more requirement for the patient to be put under continuous mechanical ventilation. If the patient would have shown an adverse effect then it would have been mandatory to put the patient back on the continuous mechanical ventilation.

The next action would be to monitor the condition of the patient when he has successfully managed to adjust with the spontaneous method of breathing. It is to be decided whether the artificial way of breathing through T-piece is to be removed or not. The patient has to be regularly tested basis his mental status, coughing abilities and the secretions made. If the patient becomes tolerant and there is no sign of unstable breathing, the t-piece should be at once removed (Alia and Esteban, 2000). The weaning methods must be chosen basis the patient’s condition and clinicians should try weaning from mechanical methods once a day. The recommendation to wean once a day is required so that the patient’s ability to breathe can be checked thoroughly and it will give enough rest to the patient so that the patient’s muscles can be effectively recovered. In order to reduce the mechanical support it is required that the patient who is on continuous mechanical ventilation should be screened daily.

Q. 2) Discussion of the parameters of weaning off mechanical ventilation Answer 2) There are four parameters which is needs to be taken into consideration when a patient is being weaned from the ventilator:

Answer 2) There are four parameters which is needs to be taken into consideration when a patient is being weaned from the ventilator:

1. Checking the settings of the ventilator and its modes: When the healthcare professional thinks of removing the patient from mechanical ventilation, he or she needs to check certain factors related to the health like pulse rate of the patient, checking the arterial blood gas which is checking the oxygen and carbon dioxide level in the blood of the patient, checking the auscultation of the chest, verifying the patient’s health in terms of comfort, pain, blood flow and distress (Williams and Sharma, 2019). Next step is checking the ventilator settings and its parameters. It is to be verified whether the there is a change in the settings or not and checking the breathing rate per min.
2. Patient education: When a patient is under continuous mechanical ventilation, he or she is able to hear and communicate with the healthcare professionals. A direct communication may not be possible but communication through signs or pen and paper may be used to update him or her about the weaning process. Healthcare professionals should avoid saying something negative directly or indirectly about the condition of the patient. The patient needs to be updated about the implications of the continuing usage of mechanical ventilation which may include weakening of respiratory muscles, cardiac failure or becoming intolerant (Merchan-Tahvanainen et al, 2017). The patient’s family can also help in communicating and educating the patient about the implications of mechanical ventilation.
3. Managing the way of air: Managing the passage of air between the ventilation apparatus and the lungs should be monitored time and again. It should be monitored that the carbon dioxide is removed from the body. High inspiration of air flow may damage or injure the lungs. Healthcare professionals should ensure that there is no acquisition of trapped air within the lungs of the patient and there should be spontaneous breathing (Silva and Rocco, 2018).
4. Suctioning of the patients on ventilation: All patients who are on continuous mechanical ventilation needs to be suctioned. The patients are unable to secrete themselves so it is necessary to artificially suction the patient. Suctioning helps to check the quality of the cough and the amount of secretions. While doing the suction, the patient’s chest needs to be heard, if the chest is clear then there is no need to suction but if it is congested then the process needs to be adopted. The process of suction depends upon the need of the patient and not basis a schedule. The suctioning process should not last for more than ten seconds and the pressure exerted during the process must be low as increased pressure may lead to damages (Williams and Sharma, 2019).

Q.3) Your patient has the following parameters collected to determine if the patient is ready to wean from mechanical ventilation. This patient’s IBW is 80 kg. The patient has been on the SIMV with pressure support of 10 with a rate of 4 and VT of 700 with an Fio2 of 40%. You put him on CPAP for 2 minutes and obtain the following data: HR 110 RR 14 BP 130/90 VC 900 mL MIP 40 cm H2O VT 500 ml

Answer 3) Synchronized Intermittent Mandatory Ventilation or SIMV refers to controlling the volume of the ventilation. In this process the patient is delivered with a set of breaths at a set volume which allows the patient to breathe spontaneously. Synchronized Intermittent Mandatory Ventilation is used to wean patients from continuous mechanical ventilation (Lazoff and Bird, 2019). The method helps the respiratory muscles to relax and lessen cardiac arrests. As per the case scenario the patient has been on pressure support of 10 at a rate of 4 and VT of 700 with Fio2 of 40%. The patient was shifted to continuous positive airway pressure also known as CPAP for 2 min. It was observed that his heart rate was 110, his respiratory rate was 14, his blood pressure was 130/90mm of hg, his vital capacity was 900ml, his maximal inspiratory pressure was 40cmh20 and his tidal volume was 500ml.

What is rapid shallow breathing index?
Rapid shallow breathing index (RSBI) is an assessment of breaths that a patient takes within a minute. The Rapid shallow breathing index is calculated by dividing the respiratory rate with tidal volume. Tidal volume refers to the air volume inhaled with each breath (Karthika et al, 2016). When the Rapid shallow breathing index is below 105mm it is considered as the best index for weaning from mechanical ventilation. As per the scenario the index is 0.028.

Will the patient be able to be weaned and why?
As per the Rapid shallow breathing index the patient is in a situation where he can be weaned from the mechanical ventilation. The index rate is below 105 so the patient can be weaned by using any of the appropriate methods.

Which is the appropriate weaning method and why?
As per the scenario the patient may be weaned from continuous mechanical ventilation by using T-piece, Synchronized Intermittent Mandatory Ventilation or SIMV and pressure support ventilation. Synchronized Intermittent Mandatory Ventilation or SIMV is the best method to be used for the treatment of the patient. The method will comprise of gradual decrease in the mandatory rate from 2 to 4bpm. The gradual decrease will lessen the side effects and the patient will be facilitated with normal breathing.

Q.4) What is Pressure support ventilation and Patient-ventilator interaction, how it is caused and how can it be improved?

Answer4) Pressure support ventilation is a technique which is used to decrease the breathing and set limitation on barotrauma which is the injuries caused due to the air pressure. It helps in improving the generation of oxygen and lowering the breathing rates. The method is used to manage muscular disorders in a patient. Patient-ventilator interaction is the functioning of physician’s brain along with the patient’s brain. Both the brain needs to work in harmony in order to promote synchronization between patient-ventilator. The physician should ensure that the patient is able to react during the assisted mechanical ventilation. The ventilator should have a response when the patient makes an inspiratory effort (Loring and Malhotra, 2007). Sensitivity is triggered by pressure, flow and time. As per the scenario, the parameters which are set are not helping the patient rather it exerting a pressure on his respiratory muscles. The patient and ventilator interaction needs to be improved by manipulating the pressure, flow and time for example setting a less time can minimize the efforts that the patient is using during inspiratory efforts.

Reference List
Alia, I and Esteban, A. (2000) Weaning from mechanical ventilation. Critical Care, 4(2), pp. 72-80.

Donohue, B. (2016) ICU ventilators overused with advanced-dementia patients. Retrieved from: https://newsroom.uw.edu/story/icu-ventilators-overused-advanced-dementia-patients

Karthika, M., Enezi, F.A.A., Pillai, L.V and Arabi, Y.M. (2016) Rapid shallow breathing index. AnnThorac Med, 11(3), pp. 167-176.

Keszler, M and Chatburn, R.L. (2017) 15 - Overview of Assisted Ventilation. Assisted

Ventilation of the Neonate(Sixth Edition), pp. 140-152. Retrieved from: https://www.sciencedirect.com/sdfe/pdf/download/eid/3-s2.0-B9780323390064000156/first-page-pdf

Ladeira, M.T., Ribeiro, V.F.M., Andriolo, R.B., Andriolo, B.N.G., Atallah, A.N and Peccin, M.S. (2014) Weaning from mechanical ventilation using pressure support or a T-tube for a spontaneous breathing trial. Cochrane. Retrieved from: https://www.cochrane.org/CD006056/EMERG_weaning-mechanical-ventilation-using-pressure-support-or-t-tube-spontaneous-breathing-trial

Lazoff, S.A and Bird, K. (2019) Synchronized Intermittent Mandatory Ventilation. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK549846/

Loring, S.H and Malhotra, A. (2007) Inspiratory Efforts During Mechanical Ventilation. Chest, 131(3), pp. 646-648.

Merchan-Tahvanainen, M.E., Romero-Belmonte, C., Cundin-Laguna, M., Basterra-Brun, P., Miguel-Aguirre, A.S and Regaira-Martinez, E. (2017) Patients’ experience during weaning of invasive mechanical ventilation: A review of the literature. Enfermeria Intensiva, 28(2), pp. 64-79.

Silva, P.L and Rocco, P.R.M. (2018) The basis of respiratory mechanics: ventilator-derived parameters. AnnTransl Med, 6(19), p. 376.

Williams, L.M and Sharma, S. (2019) Ventilator Safety. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK526044/