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Chapter 16: Ventilator Liberation

Introduction

Objectives

  1. Identify patients ready for ventilator discontinuation.

  2. Discuss the important role of the spontaneous breathing trial (SBT) to determine extubation readiness.

  3. Contrast the approaches used to wean patients from ventilatory support.

  4. List causes of a failed SBT.

  5. Discuss the role of sedation in the ventilator discontinuation process.

  6. Discuss the use of ventilator discontinuation protocols.

  7. Discuss criteria used to indicate readiness for extubation.

  8. Discuss issues related to prolonged mechanical ventilation and chronic critical illness.

The ultimate goal of mechanical ventilation is ventilator discontinuation. Most patients can be liberated from the ventilator when the physiologic reason for ventilatory support is reversed. In others, this may be a more prolonged process and associated with chronic critical illness. Because of their underlying disease process, some patients may become chronically ventilator-dependent (eg, those with neuromuscular disease). This chapter addresses issues defining readiness for ventilator discontinuation, assessments that predict readiness for ventilator liberation, approaches to liberation from ventilator support, use of protocols, automated weaning, and assessment for extubation. The content of this chapter is written to be consistent with evidence-based clinical practice guidelines (Table 16-1).

Table 16-1ACCP-SCCM-AARC Evidence-Based Ventilator Weaning/Discontinuation Guidelinesa
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Table 16-1 ACCP-SCCM-AARC Evidence-Based Ventilator Weaning/Discontinuation Guidelinesa

  1. In patients requiring mechanical ventilation for more than 24 h, a search for all causes that may be contributing to ventilator dependence should be undertaken. Reversing all possible ventilatory and nonventilatory issues should be an integral part of the ventilator discontinuation process.

  2. Patients receiving mechanical ventilation for respiratory failure should undergo a formal assessment of discontinuation potential if the following criteria are satisfied: evidence for some reversal of the underlying cause for respiratory failure, adequate oxygenation and pH, hemodynamic stability, and capability to initiate an inspiratory effort.

  3. Formal discontinuation assessments for patients receiving mechanical ventilation for respiratory failure should be done during spontaneous breathing rather than while the patient is still receiving substantial ventilatory support.

  4. Removal of the artificial airway from a patient who has successfully been discontinued from ventilatory support should be based upon assessments of airway patency and the ability of the patient to protect the airway.

  5. Patients receiving mechanical ventilation for respiratory failure who fail an SBT should have the cause for the failed SBT determined. Once reversible causes for failure are corrected, subsequent SBTs should be performed every 24 h.

  6. Patients receiving mechanical ventilation for respiratory failure who fail an SBT should receive a stable, nonfatiguing, comfortable form of ventilatory support.

  7. Anesthesia/sedation strategies and ventilator management aimed at early extubation should be used in postsurgical patients.

  8. Weaning/discontinuation protocols designed for nonphysician health care professionals should be developed and implemented by ICUs. Protocols aimed at optimizing sedation should also be developed and implemented.

  9. Tracheostomy should be considered after an initial period of stabilization on the ventilator when it becomes apparent that the patient will require prolonged ventilator assistance.

  10. Unless there is evidence for clearly irreversible disease ...

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