Roberts described the “Wake up and breathe protocol,” developed by Vanderbilt University Medical Center (VUMC).^iv He explained how nurses and respiratory therapists collaborate during the weaning process, describing it step-by-step, including spontaneous awakening trials (SAT), sedation weaning, spontaneous breathing trials (SBT), and extubation with the ultimate goal of liberation from mechanical ventilation. 

He presented data showing how the combination of SAT and SBT resulted in 3.1 fewer days on mechanical ventilation, reduced necessity of tracheostomy and lower risk for delirium.^v

“We as respiratory therapists are working together in concert with our nursing colleagues to wean sedation and to get the patient off the ventilator as soon as possible. This profoundly decreases the risk of mortality and trauma that patients may experience from prolonged mechanical ventilation,” said Roberts.

Roberts provided a high-level overview of weaning guidelines from the American Thoracic Society (ATS) and American College of Chest Physicians (ACCP), along with clinical studies that support various weaning recommendations. He offered data - some in support, some against - various weaning strategies, including:

• SBTs conducted with/without inspiratory pressure augmentation
• Acute patient protocols to minimize sedation
• Extubation to preventative non-invasive ventilation (NIV)
• Early mobilization of acute patients ventilated for 24+ hours
• Mechanical ventilation liberation protocols
• Cuff leak tests for those with high extubation risks
• Administration of systemic steroids following extubation
• Vasopressor use during extubation and after discontinuation of mechanical ventilation
• Rapid shallow breathing index (RSBI) to gauge extubation success
• NIV versus high flow oxygen therapy use post extubation
• Standard RT assessment tool versus automated monitoring alert

Roberts urged RTs to use their own expertise and knowledge in accordance with the guidelines. He posed the example of assessing patients for liberation of mechanical ventilation, where standard criteria for a SBT readiness include oxygen saturation, positive end-expiratory pressure (PEEP) and fraction of inspired oxygen (FIO2), stating:

“I’ve seen documented in charts that the patient was not ready for a SBT because they were on 50% of oxygen concentration and on a PEEP of 7.5. So, what’s the problem? The guidelines we use in my institution say, “less than or equal to,” which means it can be equal to 50% and PEEP can be 7.5. Even in your morbidly obese patients you may see PEEP a little higher than that and the patient is still eligible for SBT. We shouldn’t let these things limit us too much in terms of when patients are ready for SBT.”

While Roberts stressed the importance of clinical guidelines in helping RTs take the best course of action when weaning patients off mechanical ventilation, he also acknowledged how every patient is different. He described how the process of weaning can differ widely from patient to patient based on their condition:

“In my opinion, we are seeing a more individualized approach to our mechanically ventilated patients. Not every patient is the same and not every time we liberate a patient from mechanical ventilation should it be the same.”

To view the recorded webinar and earn one contact hour Continuing Respiratory Care Education (CRCE) credit from the American Association for Respiratory Care, 9425 N. MacArthur Blvd., Suite 100, Irving, TX 75063 visit A Breath Ahead.

Dräger helps support ATS and ACCP ventilator liberation guidelines through technology and cost-efficiencies. To learn more, download our white paper.

Winnie Sywulak, BS, RRT-NPS, serves as Senior Marketing Manager for Respiratory Care Solutions for Dräger in North America, an international leader in the fields of medical and safety technology.