Weaning protocols and difficult weaning
AARC Clinical Practice Guideline (2010) Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respir Care, 55, 6, 758 764
www.rcjournal.com/contents/06.10/06.10.0758.pdf
AARC Clinical Practice Guideline (2002) Respir Care, 47, 1, 6990
www.rcjournal.com/cpgs/ebgwdvscpg.html
AARC Clinical Practice Guideline (2007) Removal of the endotracheal tube. Respir Care , 52, 1, 81-93
Acosta F (1988) Biofeedback and progressive relaxation in weaning the anxious patient. Heart Lung, 17, 299-301
Alvisi R (2000) Predictors of weaning outcome in COPD patients. Eur.Resp.J, 15, 656-62
threshold values of weaning indices are different in COPD
Bailey CR (1995) The role of CPAP during weaning in cardiac surgical patients. Anaesthesia, 50, 677-81.
CPAP is not indicated routinely during weaning
Bien M-Y et al (2004) Breathing pattern variability: a weaning predictor. Int Care Med, 30, 241 - 247
www.springerlink.com/app/home/contribution.asp?wasp=62f56d83b3534a79925ee91a017a8d9a&referrer=parent&backto=issue,11,33;journal,18,126;browsepublicationsresults,950,2444;
breathing pattern variability associated with weaning failure in postop patients recovering from SIRS, and this variability may serve as a weaning predictor
Blackwood B, Alderdice F, Burns K (2011) Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients. BMJ, 342, c7237
www.bmj.com/content/342/bmj.c7237.full
Cochrane review recommending use of protocols for weaning
Bouley GH (1992) The experience of dyspnea during weaning, Heart Lung, 21, 471-6
Bourdelles GL (1996) Comparison of the effects of heat-moisture exchangers and heated humidifiers on ventilation during weaning trials. Chest, 110, 1294-8
the inspiratory resistance caused by an HME may be significant
Brochard L (1994) Comparison of three methods of gradual withdrawal from ventilatory support. Am J Resp Crit Care Med, 150, 896-903
Brochard L (2001) Weaning from mechanical ventilation: when paediatric intensive care medicine profits from adult experience and vice-versa. Int Care Med, 27, 1564-66
Bruton A, Conway J, Holgate ST (1999) Weaning adults from mechanical ventilation. Physiotherapy, 85, 652-61
Bruton A, McPherson K (2004) Impact of the introduction of a multidisciplinary weaning team in a general intensive care unit. Internat J Ther Rehab, 11, 9, 435-40
www.ijtr.co.uk/cgi-bin/go.pl/library/article.cgi?uid=19591;article=IJTR_11_9_435_440
Burns KEA, Adhikari NKJ, Keenan SP, Meade MO (2010) Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database of Systematic Reviews, Issue 8
onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004127/frame.html
NIV shows a consistent, positive effect on mortality and ventilator associated pneumonia
Campbell RS (1999) Extubation and the consequences of reintubation. Respir.Care, 44, 799-803
criteria for extubation
Cason CL (1994) Changes in oxygen saturation during weaning. Heart Lung, 23, 368-75
SvO2 is a useful to guide weaning
Chen YH, Tsai YH, Wu YK (2004) Exercise reconditioning in the rehabilitation for prolonged ventilator dependent patients. Eur Respir J, 24: Suppl. 48, 662s
www.ersnet.org/ers/lr/browse/media.aspx?id_dossier=18513&id_fiche=124415
exercise training improves pulmonary function, exercise capacity and hospitalization outcomes
Chiang L-L, Wang L-Y, Wu C-P (2006) Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther, 86, 1271-81
ptjournal.apta.org/content/86/9/1271.full
a 6-week physical training program may increase ventilator-free time
Cook D (2003) Withdrawal of mechanical ventilation in anticipation of death in the ICU. New Eng J Med, 349, 1123-32
need for advance care plans - pt preference often undocumented and/or unavailable or may change, pts wishes often at odds with family members
Cowan T (2001) Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes. Respir Care, 46, 460-5
www.rcjournal.com/contents/05.01/05.01.0460.asp
in weaning a tracheostomized patient, increasing the internal diameter of the tube by removing the inner cannula may be beneficial
Ely EW, Meade MO (2001) Mechanical ventilator weaning protocols driven by non-physician health-care professionals. Chest, 120, 454-463
www.chestjournal.org/cgi/reprint/120/6_suppl/454S
Epstein SK (2002) Weaning from mechanical ventilation. Respir Care, 47, 4, 454-66
www.rcjournal.com/contents/04.02/04.02.0454.asp
the case for protocol-directed weaning
Epstein SK (2002) Extubation. Respir Care, 47, 483-92
causes and avoidance of extubation failure
Esteban A (1995) A comparison of 4 methods of weaning. New.Eng.J.Med, 332, 345-50
weaning by intermittent spontaneous breathing is 3 times quicker than IMV weaning, twice as quick as pressure support weaning
Esteban A (1999) Effect of a spontaneous breathing trial. Am.J.Respir.Crit.Care Med, 159, 512-18
Ferrer M, Esquinas A, Arancibia F et al (2003) Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med, 168, 706
ajrccm.atsjournals.org/cgi/content/full/168/1/70?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&volume=168&firstpage=70&resourcetype=HWCIT
in patients with persistent weaning failure, non-invasive ventilation led to earlier extubation, shorter IPPV and length of stay, less need for tracheotomy, lower incidence of complications, and improved survival
Ferrer M (2009) Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet, 374, 9695, 1082-9
early NIV after extubation reduces respiratory failure and mortality in hypercapnic weaning COPD patients, so should be routine.
Girault C (1999) Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure. Am.J.Respir.Crit.Care Med, 160, 86-92.
Goldhill DR (2000) Clinical guideline: weaning from a ventilator. Care Crit.Ill, 16, 48
Hernandez et al (2001) Proportional Assist ventilation may improve exercise performance in severe COPD. J Cardiopulm Rehab, 21, 3.
Holliday JE (1990) The reduction of weaning time from mechanical ventilation using tidal volume and relaxation biofeedback. Am Rev Respir Dis, 141, 1214-20
Howie A (1999) Rapid shallow breathing as a predictive indicator during weaning. Nurs Crit Care, 4, 4, 171-8
Irvine M (2008) A protocol mandating a daily interruption of sedatives and spontaneous breathing trial improves patient outcome. J Intens Care Soc, 9, 2, 184-5
journal.ics.ac.uk/pdf/0902184.pdf
in non-surgical patients, a protocol pairing daily sedation breaks with spontaneous breathing trials results in earlier extubation, shorter ICU stay, shorter hospital stay and lower mortality at one year
Jacavone J (1998) Use of pulmonary rehabilition strategies to wean a difficult-to-wean patient. Crit.Care Nurse, 18, 6, 29-37
biofeedback by tidal volume monitoring
Jaeger JM (2002) The role of tracheostomy in weaning from mechanical ventilation. Respir Care, 47, 469-80
www.rcjournal.com/contents/04.02/04.02.0469.asp
tracheostomy is recommended within 3 days of intubation
children sustain greater long-term damage from tracheostomy than adults
Koksal GM (2003) The effects of different weaning modes on the endocrine stress response. Crit.Care, 8, R31-R34
weaning by T-piece causes greater stress response than weaning by PS or CPAP
Kollef MH (1998) We should listen to the patient when it comes to timing extubation. Crit Care Med, 26, 1148-9
Kozu R (1999) A prospective study of exercise training versus ventilatory muscle training on weaning outcome in long-term mechanically ventilated patients. WCPT Proc. p.318
exercise programme leads to reduced time on IPPV, increased weaning success, improved ADL
MacIntyre N (2009) Discontinuing mechanical ventilatory support. Chest, 132, 3, 1049-1056
www.chestjournal.org/content/132/3/1049.abstract
early tracheostomy may facilitate weaning in patients requiring prolonged ventilatory support.
Merveille OC, Childers MK, Kreimid MM (1999) Weaning from mechanical ventilation in a general rehabilitation center. Am.J.Phys.Med.Rehab, 78, 85-6
Mokhlesi B (2007) Predicting extubation failure after successful completion of a spontaneous breathing trial. Resp Care, 52 (12):1710-7
protocol for extubation - include mental status, bronchial secretions, and pre-extubation PaCO2:
Modawal A et al (2002) Weaning success among ventilator-dependent patients in a rehabilitation facility. Arch Phys Med Rehab, 83, 2, 154-8
Nava S (1998) Noninvasive mechanical ventilation in the weaning of patients with respiratory failure. Ann Intern Med, 128, 721-8
Nevins ML, Epstein SK (2001) Weaning from prolonged mechanical ventilation. Clin Chest Med, 22, 1, 13-32
Patel RG, Petrini MF, Dwyer TM (1999) Work of breathing during weaning from ventilation. Respir.Care, 44, 421-7
www.rcjournal.com/contents/04.99/04.99.0421.asp
CPAP no better than pressure support for weaning
Pinsky MR (2000) Breathing as exercise: the cardiovascular response to weaning. Int Care Med, 26, 1164-6
editorial on CVS dysfunction being the missing piece in predicting weaning success
Pittock SJ (2001) Rapid weaning from mechanical ventilator in acute cervical cord multiple sclerosis lesion after steroids. Anesth.Analg, 93, 1550-1
Ramachandran V (2005) Protocol-directed weaning. Crit Care, 9,138-140
ccforum.com/content/9/2/138/abstract
a physiotherapist-led or nurse-led protocol shortens weaning time
Rosario ND, Sassoon CSH, Chetty KG, Gruer SE (1997) Breathing pattern during acute respiratory failure and recovery. Eur Resp J, 10, 2560-5
failure to wean is presaged by a breathing pattern similar to acute respiratory failure
Scott K, Epstein MD (2002) Weaning from mechanical ventilation. Respir Care, 47, 4, 454-66
www.rcjournal.com/contents/04.02/04.02.0454.cfm
Shehabi Y (2010) The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients. Anaesth Int Care, 38, 82-90
xa.yimg.com/kq/groups/16749867/2013815741/name/The+effect+of+dexmedetomidine+on+agitation+during+weaning+of+mechanical+ventilation+in+critically+ill+patients-+Anesth+Intensiv
anxiety, fear and agitation are common non-pulmonary causes of failure to wean.
Siegel MD (2009) Technique and the rapid shallow breathing index. Respir Care, 54, 11, 1462-6
Smyrnios NA (2002) Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning. Crit Care Med, 30, 1224-30
Sprague SS, Hopkins PD (2003) Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther, 83, 171-81.
inspiratory strength training improves weaning
Sundaram RK, Nikolic G (1996) Successful treatment of post-extubation stridor by CPAP. Anaesth.Intens.Care, 24, 392-3
Twibell R et al (2003) Subjective perceptions and physiological variables during weaning from mechanical ventilation. Am J Crit Care, 12, 2
patients perceptions of dyspnea, fatigue, and self-efficacy
Wunderlich RJ (1999) Patients perceptions of uncertainty and stress during weaning from mechanical ventilation. Dim Crit Care Nurs, 18, 1, 2-8
AARC = American Association for Respiratory Care
CPAP = continuous positive airways pressure