Weaning trial

Patients who are on ECMO should have daily discussions regarding their potential for possible weaning trials. All members of the interprofessional healthcare team clinicians, mid-level practitioners, nurses, respiratory therapists caring for the patient must be aware of attempted trials and be ready for any possible trial, whether it is successful or not.

Incorrect or improper communication between the team members could lead to morbidity or mortality when weaning patients from ECMO. When teams are in constant communication, this will enhance patient care and provide better outcomes.

Having a detailed plan for weaning and alternative plans if the patient fails the wean or emergently needs to go back on ECMO should have been discussed in depth with all team members with open communication lines to provide the best care. Being prepare for the weaning trials will provide the patient with the best possibility for weaning and decrease morbidity and mortality. An interprofessional team is needed to care for patients on ECMO. Once the patient has undergone cannulation with the initiation of ECMO, a multi-facet team must step in.

Surgical or medical intensivists monitor the progression of the patient on ECMO and also monitor the ventilator. The intensivists must decide along with other team members when the patient is ready for weaning trials or if they need more time to heal their damaged organs.

ICU nurses and ECMO technicians are crucial in their role with the management of the patient as they are at the bedside every day. Weaning patients from ECMO is not an easy task.

Every member of the team is crucial to the success of weaning the patients from the ECMO circuit. Interprofessional interventions and communication are vital to the success and outcome of the patient.

Interprofessional team monitoring is critical to the outcomes of the patient. While a patient is on ECMO, they should be monitored continuously by an ECMO technician who constantly monitors the circuit and looks at the vital signs. They can make small changes to help facilitate better hemodynamic stability for the patient.

All team members must be able to monitor the patient from the perspective of their field and be able to communicate to provide the patient with the best possible outcomes. The patient could have a complication arise at any time. Therefore all team members must be ready to do their part to help with the care of the patient. When all team members are prepared, the patients have better outcomes with less morbidity and mortality. This book is distributed under the terms of the Creative Commons Attribution 4.

Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Author Information Authors Michael A.

Affiliations 1 Mercy St. Vincent Medical Center. Continuing Education Activity Venovenous and venoarterial extracorporeal membrane oxygenation has become a more popular topic and treatment over the last several years. Introduction Extracorporeal life support ECLS , which is also known as extracorporeal membrane oxygenation ECMO , is essentially a functioning heart and lung machine for a patient in whom their own anatomy or physiology is impaired.

Physiology Every life form on Earth needs oxygen for survival except a few forms of bacteria. Indications Indications for Weaning VV ECMO The patient has recovered from their pulmonary disease process, and the lungs are ready to be tested for adequate performance of oxygenation and ventilation. The patient has recovered from their cardio-pulmonary disease process.

The heart and lungs are ready to be tested for the adequate performance of ejection and perfusion throughout the body. Contraindications The patient continues to have signs and symptoms of cardiopulmonary failure; therefore, the patient is not ready to be weaned. Equipment ECMO machine with an oxygenator and artificial lung cardiopulmonary bypass machine with all tubing, cannulas, and monitoring devices.

Personnel Critical care physicians. When preparing for weaning trials, you must have all necessary personnel to go directly back on full ECMO support if needed. If the patient shows signs of continued cardiac or respiratory failure requiring full support, weaning attempts should be avoided.

Patients who are deemed not good candidates for weaning should be discussed for transplant candidacy or assist device placement. Cardiac markers require monitoring for normalization.

Echocardiography plays a large role in monitoring for recovery of cardiac function along with any new problem that may arise. Echocardiographic findings when preparing for weaning that may indicate the patient will be difficult to wean: cardiac abnormalities with systolic or diastolic dysfunction, right or left heart ventricular failure, wall motion abnormalities, pericardial effusions or tamponade, hypovolemia, pulmonary artery hypertension.

Depending on the initial cause of VA ECMO initiation, the weaning process will start at different times for different disease processes. Every patient will have a different weaning strategy and an individual plan. The patient will need to have inotropic drugs at reasonable levels for support. The patient may also have an aortic balloon pump or a left ventricular device in place for added support. Some centers recommend weaning ECMO before removing the left ventricular support device.

When the pump is slowly titrated down, the patient will start to develop more pre-load, and the heart can be monitored for how well the left ventricle can eject. Each time the ECMO flow level is decreased, the cardiac function should be continuously monitored using echocardiography. Noninvasive cardiac function monitoring can be used, or a pulmonary artery catheter can be placed to monitor second to second cardiac function changes. Strict attention to the ventilator settings and respiratory support must always be accounted for.

Pulmonary blood flow will significantly increase, thus changing your PEEP and tidal volume settings. The maximum flow rate on the majority of ECMO machines is around 6 liters per minute. Flow rates should not drop below 2. Each time a decrease in flow rate is made, this rate should be maintained for at least 60 minutes to monitor the patient's decompensation. If the patient shows any signs of failure to have adequate cardiac output, signs of inadequate tissue perfusion, increasing blood lactate levels, or any echocardiographic findings of ventricular demise should prompt the physician to place the patient back on full support and monitor the patient for recovery of their cardiac function on full ECMO support.

These are good signs for ECMO weaning. If the patient shows signs of hemodynamic instability or signs of distress at any time, the patient should be changed to full ECMO support. When monitoring with a transesophageal echo or transthoracic echo when weaning, we need to look for signs of rising left or right-sided filling pressures, progressive ventricular dilation, worsening or new signs of mitral or tricuspid regurgitation, any sign of hypoxia or hypercarbia on arterial blood gas, any sign of ventilator changes with elevated peak pressures or plateau pressures.

Also, look for signs of increasing vasopressors support when the patient has signs of hypotension with a map less than Once the patient has completed weaning from the ECMO circuit, the heparin infusion can be stopped, and the pump flow on the ECMO machine will be raised.

This is performed to avoid any clot accumulation. Some institutions will administer a positive inotrope at this time to help facilitate cardiac output after the cannulas have been clamped. This could be performed at the bedside if the percutaneous placement of the cannulas was performed. If central cannulation or surgical cutdown were performed, the cannulas would need to be removed in the operating room.

Once the patient has been completely weaned from ECMO, the patient will need continuous monitoring of their cardiac output, oxygen saturation levels, lactic acid levels, pH, urine output, and vent settings to confirm the patient can maintain perfusion of their organs.

After liberating the patient from ECMO support, patients sometimes have signs of an inflammatory response requiring an increase in their inotropic support. This is not uncommon when weaning from ECMO. The patient's respiratory mechanics must demonstrate significant improvement. The prognostic significance of passing a daily screen of weaning parameters. Intensive care medicine. Weaning from mechanical ventilation. The European respiratory journal.

Application of heart-rate variability in patients undergoing weaning from mechanical ventilation. Critical care London, England ; 18 1 :R Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Critical care London, England ; 18 2 :R Heart rate variability as a predictor of cardiac dysrhythmias during weaning from mechanical ventilation. American journal of critical care : an official publication, American Association of Critical-Care Nurses.

Classification of patients undergoing weaning from mechanical ventilation using the coherence between heart rate variability and respiratory flow signal. Physiological measurement. Predictors of sleep quality and successful weaning from mechanical ventilation among patients in respiratory care centers.

The journal of nursing research : JNR. Clinical review: Critical illness polyneuropathy and myopathy. Critical care London, England ; 12 6 Increased duration of mechanical ventilation is associated with decreased diaphragmatic force: a prospective observational study. Critical care London, England ; 14 4 :R Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation.

Blood markers of oxidative stress predict weaning failure from mechanical ventilation. Journal of cellular and molecular medicine. Discontinuation of ventilatory support: new solutions to old dilemmas. Current opinion in critical care. European Respiratory Journal. The role of continuous positive airway pressure during weaning from mechanical ventilation in cardiac surgical patients. Positive end-expiratory pressure vs T-piece. Extubation after mechanical ventilation.

Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database of Systematic Reviews [Internet] A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation.

Evaluation of a knowledge-based system providing ventilatory management and decision for extubation. Neuroventilatory efficiency and extubation readiness in critically ill patients. Critical care London, England ; 16 4 :R Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU.

Clinical relevance of classification according to weaning difficulty. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Incidence and outcome of weaning from mechanical ventilation according to new categories.

Differences in clinical outcomes according to weaning classifications in medical intensive care units.

PloS one. Patient-ventilator interactions: optimizing conventional ventilation modes. Weaning Patients from the Ventilator. New England Journal of Medicine. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients.

The Cochrane database of systematic reviews. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis.

Critical care London, England ; 19 1 Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Outcomes of extubation failure in medical intensive care unit patients. Critical care medicine.

The 'cuff-leak' test for extubation. Association between reduced cuff leak volume and postextubation stridor. Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials. Critical care London, England ; 13 2 :R An analysis of potential physiological predictors of respiratory adequacy following cardiac surgery.

The Journal of thoracic and cardiovascular surgery. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure A different approach to weaning. Neurologic status, cough, secretions and extubation outcomes. Should patients be able to follow commands prior to extubation? Role of noninvasive positive-pressure ventilation in postextubation respiratory failure: a meta-analysis.

Nasal high-flow versus Venturi mask oxygen therapy after extubation Effects on oxygenation, comfort, and clinical outcome. Comparison of the effectiveness of high flow nasal oxygen cannula vs. Support Center Support Center. External link. Please review our privacy policy. Adequate cough. No neuromuscular blocking agents. Absence of excessive trachea-bronchial secretion. Reversal of the underlying cause for respiratory failure.

No continuous sedation infusion or adequate mentation on sedation. Stable cardiovascular status. No active myocardial ischemia. I personally think that its a wrong concept. A pressure support or CPAP by definition is an assisted mode and not a spontaneous mode. Only T-piece and to a certain extent tube compensation are the only spontaneous modes. Most common reasons for failure to wean are :. Decreased compliance with increased elastic workload : due to ARDS, atelectasis, chest wall restriction like kyphosis, pleural effusion, pneumothorax, massive ascites.

Decreased diffusion with abnormal gas exchange : alveolar edema, pneumonia , pulmonary fibrosis, diffuse alveolar hemorrhage. Cardiac : severe systolic dysfunction, arrythmias, high vasopressor use. Neurological : stroke, delirium, anxiety, sleep deprivation, sedatives , impaired respiratory drive. Musculoskeletal : diaphragm weakness from prolonged mechanical ventilation, critical illness myopathy, GBS. Work of breathing increase if patient has to overcome any of the above mentioned lung or cardiac issues.

For example, transition from mechanical ventilation to spontaneous breathing imposes an additional load on the cardiovascular system because of intrathoracic pressure changes, which increases ventricular afterload and increased oxygen consumption by the respiratory muscles. If the heart can't cope up with this increased load, patient may go into pulmonary edema with resultant weaning failure.

A methodical approach as mentioned above will provide an opportunity to address the underlying issues for weaning failure much faster.

For example, one of the most common causes of failure to wean is agitation with tachypnea, tachycardia and hypertenion during an SBT. Some of us sense this as failed attempt at weaning and put the patient back on full ventilator support with sedation. If other underlying causes like lungs and cardiac issues are ruled out, then anxiety could be the biggest reason for those signs and symptoms.

If we don't follow a methodical approach, instead of addressing the underlying anxiety, we are just putting the patient back on the ventilator due to wrong assessment, resulting in more sedation with prolonged stay on the ventilator with development of new complications and an ongoing vicious cycle.

Reference: Crit Care. Reasons for Reintubation following successful SBT and extubation :. Upper airway resistance supraglottic edema — A good marker for severe upper airway obstruction is the absence of air leakage when the endotracheal tube cuff is deflated. Intensive Care Med. The cuff-leak test is extremely useful because methylprednisolone therapy at least 12 hours before extubation might reduce the incidence of stridor and the rate of reintubation due to upper airway obstruction.

Poor cough and excessive secretions. Poor airway reflexes leading to aspiration. Respiratory weakness masked by pressure support. Increased cardiac load induced by removal of CPAP , especially with severe systolic heart failure.

Neurological impairment. Higher positive fluid balance Chest. Onset of new pathology. Criteria for initiating SBT:. Methods of weaning:. Different techniques have been used for weaning which include gradual reduction in mandatory rate as in SIMV, gradual reduction in pressure support, spontaneous breathing through a T-piece, proportional assist ventilation, NAVA and adaptive support ventilation.

Duration of weaning:. However, in patients with prolonged weaning, some recommended that mins of SBT is much safer. Also, Conventional weaning parameters did not predict extubation outcome in intubated subjects requiring prolonged mechanical ventilation.

Absent cough was the best predictor of extubation failure. Respir Care. Signs and symptoms of failed weaning trial:. Several criteria has been used with variable sensitivity and specificity. Refer to Table 3 : Respir Care. However, when tobin devised this index, it was designed to measure the patient readiness for weaning trial and was done before a SBT, not after SBT. If its less than , it indicates their readiness of weaning trial and hence, they were placed on SBT.

If its more than , they were placed back on full support. N Engl J Med ; J Bras Pneumol. RSBI rate :. The resulting number is then multiplied by RSBI rate, which is a dynamic measure of lung mechanics, is an accurate predictor of weaning outcome and even more reliable than other weaning parameters such as lung static and dynamic compliance and single RSBI determination.

It is a measure of how quickly the patient is trying to inspire. It is a very efficient way of predicting patient effort as well as evaluating the respiratory drive. It not only depends on respiratory drive but also on inspiratory muscle capacity. If it is too high i. When on weaning trial, the P 0.

If it is increasing becoming more negative , it predicts that patient had to generate that much negative inspiratory force for the same tidal volumes and it predicts weaning failure.

Please note that in this case the tidal volumes and RR may be the same but P 0. Threshold P 0. Since P 0. However, a normal P 0. This is patient effort dependant, and hence, a low value value doesn't indicate respiratory muscle weakness.