Rapid shallow breathing indexT piecespontaneous breathing trial中文T-piece trialWeaning ventilator guidelines 2019Weaning ProtocolWeaning from mechanical ventilationPressure support ventilationImpaired spontaneous ventilationweaning ventilator中文Extubation criteria

Spontaneous Breathing Trial • LITFL • CCC Ventilation

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Spontaneous breathing trials (SBT) are used to identify patients who are likely to fail liberation from mechanical ventilation. Skiptocontent OVERVIEW Spontaneousbreathingtrials(SBT)areusedtoidentifypatientswhoarelikelytofailliberationfrommechanicalventilation SBTis“thedefactolitmustestfordeterminingreadinesstobreathewithoutaventilator”Ideally,duringanSBTwewanttoobservethepatientunderconditionsofrespiratoryloadthatwouldsimulatethosefollowingextubation PREDICTORSOFFAILURETOWEAN SeeIndicesthatpredictdifficultyweaning IDENTIFICATIONOFPATIENTSSUITABLEFORSBT Patientsthatpassthefollowingdaily‘weanscreen’shouldundergoSBT: lungdiseaseisstable/resolvinglowFiO2(<0.5)andPEEP(<5-8cmH2O)requirementhaemodynamicstability(littletolowinopressors)abletoinitiatespontaneousbreaths(goodneuromuscularfunction) Thisindicatespatientssuitableforaspontaneousbreathingtrial,thosewhopassalsotobeassessedforextubation. METHOD SBTinvolvesthefollowingsteps: Itbeconductedwhilethepatientisstillconnectedtotheventilatorcircuit,orthepatientcanberemovedfromthecircuittoanindependentsourceofoxygen(T-piece)WhenusingtheventilatoraPSof5–7cmH2Oand1-5cmH20PEEP(socalled‘minimalventilatorsettings’)willovercomeincreasedworkofbreathingthroughthecircuit(i.e.ETT)Ifstillontheventilatorthepatientshouldhave‘minimalventilatorsettings”Initialtrialshouldlast30–120minutesIfitisnotclearthatthepatienthaspassedat120minutestheSBTshouldbeconsideredafailureIngeneral,theshortertheintubationtimetheshortertheSBTrequired 80%ofpatientswhotoleratethistimecanbepermanentlyremovedfromtheventilator CRITERIATOSTOPSBT NosingleparametershouldbeusedtojudgeSBTsuccessorfailure,butacombinationofthefollowingareoftenused: RespiratoryrateRR>38bpmfor5minutesor<6bpmSpO2<92%Tidalvolume(TV)<325mLHeartrate:HR>140OR25%abovebaselineORHR<60Bloodpressure:SBP40mmHgabovebaselineWorseningagitation,anxietyordiscomfortdespitereassuranceRapidshallowbreathingindex(RSBI)=RR/TV MostconsistentandpowerfulpredictorRSBI>105min/Lpredictedfailurewell,butifusedrigidlymayslowtheweaningprocess REASONSFORREINTUBATIONFOLLOWINGSUCCESSFULSBT AsuccessfulSBTdoesnotguaranteethatthepatientwillavoidreintubation: Upperairwayresistance(supraglotticedema)poorcoughandexcessivesecretionspoorairwayreflexesleadingtoaspirationRespiratoryweaknessmaskedbypressuresupportIncreasedcardiacloadinducedbyremovalofCPAPOnsetofnewpathology MINIMALVENTILATORSETTINGS Theconceptof‘minimalventilatorsettings’iscontroversial: MartinTobinhasarguedthataddingeither5cmH2Oas“physiologic”PEEPorpressuresupportof7cmH2Otoovercometheresistanceinanendotrachealtube(orboth,asisusuallydone)mayactuallyreducethe“spontaneously”breathingpatient’sworkloadby>40%Ithasbeenshownexperimentallythattheworkofbreathingthroughanendotrachealtube,comparedtotheworkofbreathingfollowingextubation,isalmostidenticalduetoupperairwayedemaresultingfromanETTbeinginplaceforseveraldaysTobinarguesforwideruseoftrueT-piecespontaneousbreathingtrials,especiallyinthoseathighriskoffailedextubationandwhentheconsequencesoffailedextubationmaybecatastrophicAnalternativeistohavetheventilatorseton“flow-by,”withpressuresupportandPEEPsetatzeroThereisnostrongevidenceinfavourofanyoftheseapproaches ReferencesandLinks LITFL CCC—WeaningfrommechanicalventilationCCC—DifficultyweaningfrommechanicalventilationCCC—Weaningfrommechanicalventilation(HotCase)CCC—ExtubationassessmentintheICUCCC—ExtubationassessmentintheED Journalarticlesandtextbooks EstebanA,FrutosF,TobinMJ,AlíaI,SolsonaJF,ValverdúI,FernándezR,delaCalMA,BenitoS,TomásR,etal.Acomparisonoffourmethodsofweaningpatientsfrommechanicalventilation.SpanishLungFailureCollaborativeGroup.NEnglJMed.1995Feb9;332(6):345-50.PubMedPMID:7823995.[FreeFulltext] MacintyreNR.Evidence-basedassessmentsintheventilatordiscontinuationprocess.RespirCare.2012Oct;57(10):1611-8.Review.PubMedPMID:23013898.[FreeFulltext] SassoonCS,LightRW,LodiaR,SieckGC,MahutteCK.Pressure-timeproductduringcontinuouspositiveairwaypressure,pressuresupportventilation,andT-pieceduringweaningfrommechanicalventilation.AmRevRespirDis.1991Mar;143(3):469-75.PubMedPMID:2001053. TobinMJ.Extubationandthemythof“minimalventilatorsettings”.AmJRespirCritCareMed.2012Feb15;185(4):349-50.doi:10.1164/rccm.201201-0050ED.PubMedPMID:22336673.[ReplytoLetterstotheEditor] Socialmediaandwebresources PulmCCM.org—Tobin:“Minimal”PEEPandpressuresupportduringSBTkillssomepatients(AJRCCM) CriticalCareCompendium…moreCCC ChrisNickson ChrisisanIntensivistandECMOspecialistatthe AlfredICUinMelbourne.HeisalsotheInnovationLeadfortheAustralianCentreforHealthInnovationatAlfredHealthandClinicalAdjunctAssociateProfessoratMonashUniversity. Heisaco-founderofthe AustraliaandNewZealandClinicianEducatorNetwork (ANZCEN)andistheLeadforthe ANZCENClinicianEducatorIncubator programme.HeisontheBoardofDirectorsforthe IntensiveCareFoundation andisaFirstPartExaminerforthe CollegeofIntensiveCareMedicine.HeisaninternationallyrecognisedClinicianEducatorwithapassionforhelpingclinicianslearnandforimprovingtheclinicalperformanceofindividualsandcollectives. AfterfinishinghismedicaldegreeattheUniversityofAuckland,hecontinuedpost-graduatetraininginNewZealandaswellasAustralia’sNorthernTerritory,PerthandMelbourne.Hehascompletedfellowshiptraininginbothintensivecaremedicineandemergencymedicine,aswellaspost-graduatetraininginbiochemistry,clinicaltoxicology,clinicalepidemiology,andhealthprofessionaleducation. HeisactivelyinvolvedininusingtranslationalsimulationtoimprovepatientcareandthedesignofprocessesandsystemsatAlfredHealth.HecoordinatestheAlfredICU’seducationandsimulationprogrammesandrunstheunit’seducation website, INTENSIVE. Hecreatedthe‘CriticallyIllAirway’courseandteachesonnumerouscoursesaroundtheworld.Heisoneofthefoundersofthe FOAM movement(FreeOpen-AccessMedicaleducation)andisco-creatorof litfl.com, the RAGEpodcast,the Resuscitology course,andthe SMACC conference. Hisonegreatachievementisbeingthefatheroftwoamazingchildren. On Twitter,heis @precordialthump. |INTENSIVE|RAGE|Resuscitology|SMACC Related LeaveaReplyCancelreply ThissiteusesAkismettoreducespam.Learnhowyourcommentdataisprocessed. 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