来自美国Dakota大学医学中心的呼吸治疗师主导的撤机准则

功夫熊猫

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RT DRIVEN WEANING PROTOCOL


•        Every patient on ventilator, in the ICU, is to be assessed every day by RT for ability to wean.
•        For a patient to be not on this protocol would require a specific order from the physician.
•        Weaning can still be done out of this protocol by any other method as specifically ordered by the physician.
•        Weaning process would involve RT assessing the patient every day, reviewing contraindications- if none exist, measuring weaning parameters and then putting the patient on spontaneous breathing trial, once daily. If the trial is successful, physician will be notified of patient’s readiness to be extubated, but extubation (or alternative) will be physician’s decision. If trial is unsuccessful, patient will be returned to prior ventilator settings.
•        First RT weaning assessment will be within 30 hours of intubation.
•        Mandatory documentation by RT every day regarding weaning, unless there is an irreversible contraindication to either weaning or to patient being on weaning protocol. That will be documented also in at least one RT note. Examples of such conditions are ENT surgery (pt will not be on weaning protocol at all in that case), permanent CNS damage, permanent neuromuscular weakness etc where physician determines that patient is not weanable.

1.        CONTRAINDICATIONS to weaning
a.        Less than 12 hours on a ventilator.
b.        Any surgery less than 12 hrs ago.
c.        Hemo-dynamically unstable: SBP <90 or HR > 110, or patient on inotropes/vasopressors.
d.        Temp > 38.5 &#61616;C or 101.3 &#61616;F when last measured.
e.        ABG ph < 7.3 or > 7.5 if available. Otherwise ABG measurement is not a part of this protocol.
f.        F1O2 > 50%.
g.        PEEP > 6cmH2O..
h.        RR > 30 per minute.
i.        Patient too drowsy or uncomfortable.
j.        No gag or cough reflex.
k.        Labs:  last K+ < 3 or > 6   or   last HGB < 8
l.        Any ENT surgery, excluding a tracheostomy, during this hospitalization.

2.        WEANING PARAMETERS will be measured if NONE of the contraindications noted above are present. Measured parameters include RSBI, NIF, and Minute ventilation. If this step is tolerated, next step of spontaneous breathing trial would be done regardless of the weaning parameters being very good or not.

3.        SPONTANEOUS BREATHING TRIAL
a.        RT will do spontaneous breathing trial if NONE of the contraindications are present, and measurement of weaning parameters is tolerated. Trial method:   Change to CPAP mode, PS of 5cm, PEEP 5cm.
b.         Trial duration:  30 minutes, can be lesser if not tolerated.

4.        ASESSMENT of  spontaneous breathing trial
a.        Unsuccessful trial is evidenced by.
i.        Patient appears uncomfortable or complains of dyspnea.
ii.        Hemodynamic instability SBP < 90. HR > 110.
iii.        Desaturations, with O2 Sao2 being < 80 for > 1 min, or < 89 for > 5 minutes.
iv.        Arrhythmia.
v.        Any other evidence of patient not able to tolerate trial well.
b.        Successful trial is evidenced by:
i.        Absence of any evidence of unsuccessful trial.
ii.        F/Vt ratio remaining below 100 and patient appearing comfortable.
5.        AFTER THE TRIAL
a.        If spontaneous breathing trial is unsuccessful, return to prior ventilator settings.
b.        If trial is successful, RT or RN is to notify responsible physician (for surgical patients – primary surgical team, for medical patients – primary team or Pulmonologist). Further action requires physician decision.
i.        Extubation:  If spontaneous breathing trial is successful and physician is agreeable, patient should be extubated.  Extubation will always require physician approval.
ii.        If the physician does not want extubation after successful trial they can order any alternative, which may be resuming prior vent settings, or continued spontaneous breathing trial for a longer duration, or an ABG, or totally different settings. If patient ends up continued on the ventilator, he/she will remain in the protocol, and weaning will resume the next day.