My mother is in a LTACH in LA (known for vent weaning) after pneumonia and 6 weeks on vent. She had a trach 4 weeks ago and was on CPAP trials at the hospital prior to transfer. At the new hospital, they took her all the way in about 9 days to a 24 hour SBT. My mother is 84 and has COPD. They actually skipped her ahead on their protocol several hours. She started to become exhausted after the 18 and 20 hour trials. On the 24 hour trial, HR went up and O2 down (172 and 84) and they put her back at the beginning of the protocol (SIMV/PS). I question if they should have accelerated her like that. Is this normal to have her go through 20 hours off vent and then have to regress so far back? This is supposed to be the state of the art place but I'm beginning to wonder. They do not use CPAP at this facility.
please allow me to reassure you. There are various techniques and strategies that are used at different facilities that will all work and wind up at the same end point in about the same amount of time. The keys to expeditiously weaning a patient safely are generally considered to be: begin considering weaning attempts as soon as the underlying disease process that caused vent support to be needed is resolving. Give routine SBTs usually daily with either CPAP or T-piece. Advance the trials as tolerated by the patient, which is indicated by measurable parameters such as vital signs, level of consciousness, and pulse ox etc. The final key and probably as important as any is that a specific strategy, usually defined by the facilities weaning protocol, is chosen and used as the primary way to the goal of weaning from the ventilator. When the patient being weaned is 84 and has an underlying chronic lung condition, particularly an obstructive disease process then this adds much challenge to the process. As a therapist who is a veteran of many weans in the long term acute arena, I believe that in many cases there are windows of opportunity in weaning and when the patient is doing well in the SBT you continue until their physiology dictates stopping. At that point you return to prior resting settings and begin again after a rest, usually only a night or a day or two. If this cycle repeats too many times then perhaps a new strategy is worth considering that might be outside the protocol, but which all care givers are clear on and keep trying. This cycle of failed repeated attempts can be very frustrating for patient and family, but patience is my advice. What you describe really does sound pretty state of the art. The fact that the wean was advanced as descried tells me that your mother could have been off right now if her systems were ready and that they really gave her a good chance at reaching that goal early, something that is commendable. Usually when the approach I mentioned is used the wean may end with a marked change in the measured parameters. We strive to catch that before there are permanent negative effects, but occasional failed weans are the mark of a good facility aggressively attempting to wean the patients. I am responding to your post three days after you put it up. I hope your mother is well back on her way to being weaned. There may be professional debates among RTs and Pulmonary docs as to which specific strategy works the best, but don't let that confuse you, as long as they have a consistent approach that works along the general keys I described then AC to CPAP vs SIMV/PS to T-piece is not going to make as much difference as you might think. Thank you for your post. We wish your mother, yourself and your family the best of outcomes.
Gary Mefford RRT
Thanks Gary for your reply. My mother was again accelerated through some of the earlier steps so we didn't have to go through 19 steps again. She was off 4 hours today (step 11)but has some residual fluid on lungs from a few days ago and did not get sleep for 2 days so they are going to let her rest tomorrow (and adjust sleeping medication) and resume 4-6 hours off vent on Monday. I think when I read their protocol it looks like a linear progression of hours off vent but what we have found is that it is a lot of back and forth. I just am hoping that with her tolerance of the 20 hour mark that she can make it back to getting off the vent completely. It is very frustrating because we don't really understand everything and it is hard to watch my mother work so hard and some of her vitals go up. Her doctor did tell me that it is like training for a marathon - you have to work hard and try to go a little longer each day. Thanks again for the explanation. Michelle
I presently working at subcute hostpital. My boss has asked me help write weaning procotols for our pts. Do know where is good place find writen procotols for long term pts.
Let me interject some assistance in this arena.
The AARC has some excellent resources on protocols and evidenced based practice.
Check out aarc.org
My mother had heart surgery on April 30th. She is now in a LTAC in Louisiana trying to wean off vent. She is 77 years old. She has got pneumonia twice and septic. At present seems to be getting better. I am so scared she will never come home. The caseworker keeps trying to get her sent to skilled nursing idk why. I cry all the time I so scared. I came across this site in search for some success stories of hope. I am really trying to keep faith. She stayed off vent all day from about 6 am today so past 12 hours today. I have also noticed just about all the staff use hand sanitizer instead of washing hands with soap and water. Could some one tell me please how long is too long on vent before there is just no hope left, and how to avoid nursing home and her to come home. A family member has not left her alone more than a couple hours we have been there through it all it is very tiring and causing family feud. Any advice on getting mom home???
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