Ventilatory weaning

[HLL04]

The Pulmonologist at my hospital has weaning trials for the ventilator for 24 hours with a patient on CPAP. This seems excessive and can exhaust the patient. Many times the patient ends up back on A/C and we have to start over. Some RTs who work at other hospitals say the patients there are usually on CPAP for a couple hours and then extubated. I understand each patient is different and may require CPAP for a shorter/longer amount of time, but 24 hours standard for every patient seems a bit much. Any thoughts?

[SL2014]

No, this doesn't seem like a bit much... since CPAP is less exhaustive than breathing without any pressure assistance I am not sure what you mean about it exhausting the patient... The problem with CPAP only for a short while then extubated is that they fatigue from breathing on their own then get tubed again. With 24 hours of CPAP the doc can see that the patient has the stamina to self-sustain breathing.

This is just my understanding...

[TraumaSurfer]

It all depends upon the type of unit you are in and your patient population. A medical ICU might lean more towards short SBTs of PSV if the patient has significant pulmonary disease or injury. A surgical unit may do a short trial and extubate. A neuro unit with patients which have no or little pulmonary disease may opt to leave the patient on a spontaneous mode at a comfortable level until there is significant resolution of the initial incident. Some believe "resting" a patient overnight is no longer useful and can set a patient's progress back with it comes to muscle retraining or retaining status especially in neuro patients. CT post op units will have their own weaning preferences which may be surgeon driven which will usually differ from a Pulmonologist. Intensivists without a Pulmonary Fellowship will also have their own ideal weaning theories. There will be a difference in East Coast and West Coast ventilator strategies as some Travelers will notice. Hospitalists and Internal med or GPs will have a different view on weaning which some bedside caregivers view as frustrating. There are also some old timers who swear by SIMV weaning and dropping the rate by one very slowly. This might be okay for some long term units which have lots of time. If a patient is in an acute ICU, a patient such as this will be determined after a few SBTs are attempts. After that they need a step down or LTAC hospital once the acute illness is stabilized.

It also was not that long ago when patients went from IMV to CPAP to T-piece for a day or two before extubation. Occasionally the T-Piece is still utilized although most modern ventilators now have a mode for "flow-by" or 0/0. Advocates for VAP protocols prefer to keep the circuit closed.