Difficult To Wean Protocol

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Policy and Procedure:

1. Indications for the protocol
   • The patient must have the following indications for weaning:
     • SpO₂ >90%
     • FIO₂ <0.40
     • PEEP <5 cm H₂O
     • Compliance >30 mL/cm H₂O
     • NIF (Negative Inspiratory Force) <-20 cm H₂O, and
   • Patient failed two current and consecutive flow-by trials or spontaneous breathing parameter attempts.
2. Weaning Steps:
   • Once the above criteria are met, the patient can be placed on pressure support at the level of the plateau pressure, IMV of 2 with a VT of 6-8 mL/kg.
   • Reassess the patient on these settings. If the SpO₂ is >90% and the respiratory rate is <30, then decrease the pressure support by 2 cm H₂O every 3 hours. When the pressure support needed to sustain these parameters is ≥ 15the patient will be placed on an IMV rate of 8. If the SpO₂ decreases <90% or the respiratory rate increases >30, increase the pressure support to the previous setting and maintain at this level (baseline). Respiratory rates > 30 will be accepted in cases of centrally driven tachypnea. The Respiratory Care Practitioner will make this decision with the approval of the ICU Attending Physician. Centrally driven tachypnea is defined by a PaCO₂ < 35 and pH > 7.45.
   • Once baseline level is obtained, decrease the pressure support level daily, by 2 cm H₂O, unless the patient’s condition abruptly changes.
   • When the patient is stable on a pressure support of 5 cm H₂O, initiate a flow-by trial (refer to policy “TBE Standing Ventilator Orders,” Chapter 5, Section 3.1) Weaning parameters will be obtained each morning and a flow by will be attempted for patients on > 5 cm H₂O of pressure support.