PURPOSE:Spontaneous breathing trials (SBTs) have become the standard approach for assessing readiness for discontinuation of mechanical ventilation (MV). Debate continues about the details of SBTs including the method (PSV vs CPAP vs T-piece), SBT duration, and the use of BIPAP for post-extubation failure. We report our experience with a respiratory therapist-driven, rapid SBT using low PSV.
METHODS:Patients (Pts) on MV in our 15 bed med-surg ICU are assessed daily for extubation by Respiratory Therapists (RTs) using a standard protocol. SBTs are initiated after approval by the ICU team using low PSV with 5 cm H20 if the endotracheal tube (ETT) is ≥ 8, or 8 cm H20 if the ETT is smaller. Pts are observed for stability by the RT at the bedside for the initial 5 minutes of the trial and every 15 minutes thereafter. Monitored outcomes (MOs) include distress, vital signs, oxygen saturation, and respiratory rate/tidal volume ratio (RR/Vt). At 45 minutes arterial blood gases (ABG) are drawn. At 60 minutes the Pt is extubated if MOs and ABG are satisfactory and RR/Vt is < 110. Pts failing the SBT undergo repeat SBTs twice daily for 3 days and if not extubated go to a long wean trial. Pts who deteriorate post-extubation are managed with BIPAP after assessment by the ICU team.
RESULTS:Six month data (8/07–1/08) are shown below. The protocol correctly predicted successful extubation (≥48 hrs) in 95.9% of 98 Pts. Eight Pts (8.2%) required BIPAP post-extubation. Two Pts (25%) receiving BIPAP required re-intubation.
CONCLUSION:A one hour Respiratory Therapist-driven protocol using low PSV is effective and efficient for assessing extubation readiness. BIPAP is effective management for post-extubation failure.
CLINICAL IMPLICATIONS:This approach has broad applicability in the management of Pts requiring MV.
DISCLOSURE:Miwa Fujiwara, None.