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The process of withdrawing the patient from
dependence on the ventilator.
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The patient is gradually removed from the
ventilator,
then from the tube Finally from the oxygen
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recovering from the acute stage of medical
and surgical problems and when the cause of
respiratory failure is sufficiently reversed.
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If the patient is stable and showing signs of
improvement or reversal of the disease or
condition that caused the need formechanical ventilation, weaning indices
should be assessed.
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Stable vital signs and arterial blood gases
are also important predictors of successful
weaning. Once readiness has been determined, the
nurse records baseline measurements of
weaning indices to monitor progress.
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Vital capacity: 10-15mL/kg
Maximum inspiratory pressure (MIP) at least -
20 cm H20 Tidal volume: 7-9 mL/kg
Minute ventilation: 6 L/min
Rapid/shallow breathing index: below 100
breaths/minute/L
PaO2 > 60 mmHg with FiO2 less than 40%
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the control rate is decreased,
R: so that the patient strengthens the
respiratory muscles by triggeringprogressively more breaths.
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The nurse assess the patient for signs of
distress:
rapid or shallow breathing, use of accessory muscles,
reduced level of consciousness,
increase in carbon dioxide levels,
decrease in oxygen saturation, andtachycardia.
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indicated if the patient satisfies all the
criteria for weaning but cannot sustain
adequate spontaneous ventilation for longperiods.
As the patients respiratory muscles becomestronger, the rate is decreased until the
patient is breathing spontaneously.
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allows the ventilator to generate pressure in
proportion to the patients efforts.
With every breath, the ventilatorsynchronizes with the patients ventilator
efforts.
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Nursing assessment includes careful
monitoring of the patients
respiratory rate, arterial blood gases,
tidal volume,
minute ventilation,
breathing pattern.
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allows the patient to breathe spontaneously
while applying positive pressure throughout
the respiratory cycle to keep the alveoli openand promote oxygenation.
Providing CPAP during spontaneousbreathing also offers the advantage of an
alarm system and may reduce patient anxietyif the patient has been taught that the
machine is keeping track of breathing.
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It alsomaintains lung volumes and
improves the patients oxygenation status.
CPAP is often used in conjunction with PSV.
Nurses should carefully assess for tachypnea,
tachycardia, reduced tidal volumes,decreasing oxygen saturations, and
increasing carbon dioxide levels.
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When the patient can breathe spontaneously,
weaning trials using a T-piece or
tracheostomy mask are normally conductedwith the patient disconnected from the
ventilator , receiving humidified oxygen onlyand performing all work of breathing.
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Because patients do not have to overcome
the resistance of the ventilator, they may find
this mode more comfortable, or tilator, theymay find this more comfortable, or they may
become anxious as they breathe with nosupport from the ventilator.
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During T-piece trials, the nurse monitors thepatient closely and provides encouragement.
This method of weaning is usually used whenthe patient is awake and alert, is breathingwithout difficulty, has good gag and coughreflexes, and is hemodynamically stable.
During the weaning process, the patient ismaintained on the same or higher oxygenconcentration than when receiving mechanicalventilation.
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While the patient is using the T-piece, he or
she is observed for signs and symptoms of
hypoxia, increasing respiratory musclefatigue, or systemic fatigue. These include:
Restlessness,
Increased respiratory rate (greater than 35
breaths per minute)
Use of accessory muscles
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Tachycardia with premature ventricular
contractions
Paradoxical chest movement (asynchronousbreathing, chest contraction during
inspiration and expansion during expiration)
Fatigue or exhaustion
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If patient appears to be tolerating the T-piece
trial, a second set of arterial blood gas
measurements is drawn 20 minutes after thepatient has been on spontaneous ventilation
of a constant FiO2, pressure supportventilation
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Weaning from the tube is considered when
the patient can breathe spontaneously,
maintain an adequate airway by effectivelycoughing up secretions, swallow and move
the jaw.
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If frequent suctioning is needed to clear
secretions, tube weaning maybe
unsuccessful.Secretion clearance andaspiration risks are assessed to determine
whether active pharyngeal and laryngealreflexes are intact.
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Once the patient can clear secretions
adequately, a trial period or mouth breathing
or nose breathing is conducted. This can beaccomplished by several methods.
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changing to a smaller size tube to increase
the resistance to airflow or plugging the
tracheotomy tube.
The smaller tube is sometimes replaced by acuffless tracheotomy tube, which allows the
tube to be plugged at lengthening intervals tomonitor patient progress.
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involves changing to a fenestrated tube (a
tube with an opening or window in its bend).
This permits air to flow around and through
the tube to the upper airway and enablestalking.
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switching to a smaller tracheotomy button
(stoma button).A tracheotomy button is a
plastic tube approximately 1 inch long thathelps keep the windpipe open after the larger
tracheotomy tube has been removed.
An occlusive dressing is placed over thestoma, which heals in several days to weeks.
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The FiO2 is gradually reduced until the PAO2
is in the range of 70 to 100 mmHg while the
patient breathing room air. If the PaO2 is less than 70 mm Hg on the
room air, supplemental oxygen isrecommended.
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To be eligible for financial reimbursement
from the Centers for Medicare and Medicaid
Services for in-home oxygen, the patientmust have a Pao2 of less than 60 mm Hg
while awake and at rest.
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Assess patient for weaning criteria
Monitor activity level, assess dietary intakeand monitor results of laboratory results of
nutritional status.
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Assess the patients and familys understandingof the weaning process and address anyconcerns about the process. Explain that the
patient may feel short of breath initially andprovide encouragement as needed. Reassure thepatient that he or she will be attended closelyand that if the weaning attempt is notsuccessful, it can tried again later.
Implement the weaning method prescribed:A/Cventilation,IMV,SIMV,PSV,PAV,CPAP, or T-piece
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Monitor vital signs, pulse oximetry, ECG, and
respiratory pattern constantly for the first 20
to 30 minutes and every five minutes afterthat until weaning is complete. Monitoring
the patient closely provides ongoingindications of success or failure.
Maintain a patent airway; monitor arterialblood gas levels and pulmonary function
tests.Suction the airway as needed.
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In collaboration with the physician, terminate
the weaning process if adverse reactions
occur. These include a heart rate increase of20 beats/min, systolic blood pressure increase
of 20 mmHg, a decrease in oxygen saturationto less than 90%, respiratory dysrhythmias,
fatigue, panic, cyanosis, erratic or laboredbreathing, paradoxical chest movement
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If weaning process continue, measure tidalvolume and minute ventilation every 20-30minutes; compare with the patients desired
values, which have been determined incollaboration with the physician. Assess for psychological dependence if the
physiologic parameters indicate weaning isfeasible and the patient still resists. Possiblecauses of psychological dependence include fearof dying and depression from chronic illness. It isimportant to address this issue before the nextweaning attempt.