Weaning your patient from mechanical ventilation

Nursing,  Oct 2000  by Tasota, Frederick J,  Dobbin, Kathleen

• E-mail
• Print
• Link

More patients are being weaned outside the Intensive care unit. Here's what you need to know to make the process go smoothly.

Although most patients requiring mechanical ventilation remain on a ventilator for 7 days or less, some require support for several weeks or more. To control costs, institutions are increasingly inclined to move stable ventilator-dependent patients out of the intensive care unit (ICU) to other units or facilities for weaning from ventilator dependence.

The trend makes sense clinically as well as financially. Recent studies suggest that most patients on long-term mechanical ventilation don't need ICU care. In fact, continued placement in the ICU may increase infection risks and interfere with recovery.

Successful weaning is most likely when:

the patient is highly motivated, medically stable, and able to participate in activities of daily living

the patient and family fully understand available treatment options

the family actively participates in care

a multidisciplinary team, including experienced nurses, is available to provide support and direction. The last criterion explains why, as a rule, weaning is best undertaken in an acute or intermediate care setting with consistent caregivers.

In this article, we'll follow a ventilator-dependent patient transferred from the ICU to your four-bed medical respiratory care unit for weaning and discuss how you'd prepare for and manage his care.

Getting organized

Douglas Cox, 52, was transferred 2 weeks ago from a community hospital to your hospital's medical intensive care unit (MICU). He's made some progress with weaning, is hemodynamically stable, and no longer requires intensive care. He'll be transferred to your unit tomorrow and you'll be his primary nurse.

Preparing for his arrival, you call the MICU to obtain an advance report and arrange to stop by to introduce yourself to Mr. Cox and his family before the transfer. To help coordinate care, you decide to organize the data you collect into a daily weaning log for the benefit of other caregivers who'll play important roles in Mr. Cox's weaning. This log should include Mr. Cox's ventilator settings, breathing treatments, weaning mode and settings, time off the ventilator each day, reason for weaning termination, recent lab results, and the results of any procedures and diagnostic tests.

Next, call respiratory therapy to set up the ventilator for Mr. Cox's arrival. Then, prepare his room. Gather all the equipment you'll need, including:

suction supplies (in-wall suction for tracheal and possibly gastric suctioning, a manual resuscitation bag, and high-flow oxygen setup). A closed-suctioning system is preferred, but also have single-use suction catheters and sterile water available for emergencies. Have a tonsil suction device at the bedside for oral secretions.

pulse oximeter

blood pressure (BP) equipment

spare tracheostomy tube (same size and type the patient has in place).

History lessons

During report, you learn the following about Mr. Cox:

Medical history. Mr. Cox was admitted for exacerbation of his chronic obstructive pulmonary disease (COPD) complicated by a left lower lobe pneumonia. He required intubation and mechanical ventilator support soon after hospital admission. His medical history includes a 25-year smoking history and COPD, which was diagnosed 5 years ago. Before this hospitalization, he'd been treated with betaagonists and ipratropium inhalers. He's been receiving daily physical therapy and can transfer with a walker and assistance from bed to chair twice daily.

Weaning history. Despite several attempts at extubation, he hasn't been able to remain extubated longer than 24 hours. Consequently, he received a tracheotomy 8 days ago. His physician has chosen pressure support ventilation (PSV) as the mode of weaning. Mr. Cox is receiving PSV of +8 cm H^sub 2^O pressure and +5 cm H^sub 2^O continuous positive airway pressure (CPAP) during his weaning trials. Yesterday, he spent 10 hours and 50 minutes on this mode-his longest period off full support. His "resting mode" is assist/control. He continues to receive beta-agonists and anticholinergic nebulizer treatments every 4 hours to maintain airway patency.

Secretions suctioned from his airway have been clear and not excessive. His breath sounds are distant with intermittent expiratory wheezes bilaterally.

Mr. Cox's weaning trials have been terminated in the past because of tachypnea (respiratory rates greater than 35), tachycardia (heart rate greater than 120) and oxygen desaturation to the 91%-to-93% range from his range of 96% to 98% on assist/control. He's receiving lorazepam, a benzodiazepine, 2 mg every 8 hours, p.r.n., for anxiety and agitation.

Nutritional status. Mr. Cox has lost 10 pounds (4.5 kg) since his initial hospital admission. He's 10% under his ideal body weight, with low serum protein and albumin levels. Since his tracheotomy was performed, he's been on a regular diet. A calorie count has revealed that his caloric intake is below his estimated needs. After a swallowing evaluation, the speech therapist believes that Mr. Cox is at high risk for aspiration because of physical deconditioning and a weak cough, so he's receiving a percutaneous endoscopically placed gastrostomy (PEG) feeding tube today. He'll start enteral feedings in the near future.