Weaning from Mechanical Ventilation
Mechanical ventilation plays a crucial role in the management of critically ill patients. Prolonged ventilatory support is associated with an increase in clinical complications, ICU length of stay and mortality. Liberation from the mechanical ventilator,
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Ayodeji Adegunsoye and John P. Kress
Case Presentation A 68 year old woman with a history of hypertension, diabetes, asthma, congestive heart failure (CHF) and end stage renal disease was intubated and admitted to the ICU for respiratory failure and hypotension following a one week history of fever, dyspnea, anorexia and cough productive of yellowish-green sputum. At initial presentation to the ICU, she received a bolus of intravenous crystalloid, and was commenced on vasoactive support with norepinephrine, vasopressin and phenylephrine infusions. White blood cell count was 15K and she was commenced on broad- spectrum IV antibiotics. Respiratory and blood cultures subsequently grew Pseudomonas aeruginosa and antibiotics were narrowed to IV cefepime. Over the next 72 h she became afebrile, her white blood cell count dropped to 8.5K and her vasoactive support was weaned off. Her
A. Adegunsoye (*) Section of Pulmonary & Critical Care, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA e-mail: [email protected] J.P. Kress Medical Intensive Care Unit, Section of Pulmonary & Critical Care, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
most recent CXR, vital signs and mechanical ventilator settings are shown in Fig. 31.1. Question What approach would best determine her readiness for liberation from the mechanical ventilator? Answer Spontaneous breathing trial (SBT) All intubated patients should be assessed with a SBT to determine their readiness for liberation from the mechanical ventilator after the underlying cause for intubation has been addressed and is improving. The patient had been ventilated on small tidal volumes (6 ml/kg ideal body weight) and her plateau airway pressures ranged between 20 and 24 cmH2O. Her PaO2/FiO2 ratio remained >200 with a PEEP of 5cmH2O and FiO2 of 40 %. Her hemodynamic status remained stable with no requirement for vasopressor support. She received an analgesic infusion of fentanyl, which was interrupted on a daily basis to assess her mental function. Physical and occupational therapy were commenced within 24 h of her ICU admission and she was maintained on a daily negative fluid balance of 1–2 L per day. Her most recent arterial blood gas was 7.32/42/75/98 and she had minimal airway secretions. Continuous sedation was discontinued and while she was awake, a 30-min spontaneous-breathing trial was performed with CPAP of 5 cm of water and her observed vital signs afterwards are depicted in Fig. 31.2.
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_31
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A. Adegunsoye and J.P. Kress
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Fig. 31.1 (a) Chest x-ray of index patient on admission day 3. (b) Telemetry monitor showing the patient’s vital signs on admission day 3. (c) Mechanical ventilator parameters of the index patient on admission day 3
ventilation for respiratory support. In patients with sepsis, the need for mechanical ventilation may be prevented by instituting early aggre
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