better method for weaning either T-Piece or PS

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Permalink Reply by Muhammad Arshaad on October 25, 2009 at 4:43pm

more often we are using PS mode for weaning not T- piece. Occasional use of T-piece does not make it a good weaning method. Also data shows that PS is better than T-Piece.

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Permalink Reply by Chris on October 26, 2009 at 11:28pm

To T-piece the ETT patient is cruel and not nessesary with today's vents. If your vent has some sort of tube compensation this is the preferred method of weaning. When using tube compensation and appropriate PEEP for your patient this is termed "electronic extubation". The advantage of tube comp vent weaning is that on many vents you can have a breath to breath f/VT. I haven't done T-piece with an ETT is years. T-piece is like SIMV, it's a tool in the toolbox, but there is no reason to ever use it. An example would be having a typewriter, we may have one but we now use a computer.

The term wean is really no longer relevant. Wean should be replaced by liberate. Weaning is really a gradual decrease in support. Liberate is going from full support to tube compensation with PEEP to extubation.

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Permalink Reply by Jeff Whitnack on November 3, 2009 at 12:40pm

I don't like the use of the phrase "weaning" when describing our efforts to get patients off the ventilator. I also don't like the term "liberate", although it describes the end result it still seems to imply that our knob twirling is somehow involved in such "liberation".

It is not just the use of the phrase "weaning' that is the problem. It is actually we RT's incorporating the internal mindset that we are "weaning" patients in order to get them off the ventilator as soon as possible. Think of what true "weaning" is. A baby used to breast milk may benefit from weaning as their system gets used to taking in whole food. A cigarette smoker may benefit from weaning via nicotine patches as the nicotine dose is gradually reduced. If I stopped drinking coffee cold turkey I would probably get a whopping headache---better to go gradual and avoid the cerebral dilation rebound.

But patients on ventilators?

We should call what we do "fledging" as in a baby bird in a nest. Focus on a good nest, feeding, daily wing flapping, maybe a daily flight test when looks ready. If they can't fly out of the nest then put them back in. No need to "wean" ala making the baby bird run around the nest perimeter and flap the wings as much as possible. It's as if people think the ventilator has contaminated the patient and not that the disease process the patient still needs to recover from.

When the patient recovers, when challenge is met with rest and nutrition, they will be able to fly out of the vent nest, no matter what knob twirling or ridiculous "weaning modes" we throw at them. In fact most "weaning modes" end up instilling a sub clincial level of unnecessary fatigue.

At one end of the extreme we have a CABG or AVR patient who walked into the hospital and, providing all went well, just needs to be awake enough to be extubated. A brief spontaneous breathing trial (we go right from A/C to Spont Mode with TC on 840) and we pull the tube. That is not "weaning" in any sense of the word. They can either lift their head up off the pillow or they can't. No monkeying around with SIMV rate reductions (until they over breathe) and/or PS reductions will affect that time. In fact such "weaning rituals" usually end up with the patient staying on the vent longer.

At the other end of the spectrum is a patient who has had a very prolonged ICU course, is trached. They need to build up both their strength AND endurance reserves. Gradually increasing times on trache collar, being sure not to play "I wish I were an Olympic Coach" and pushing them unto utter fatigue before reluctantly putting them back on full support.

If a year from now I were to be running marathons it would be because I'd conditioned myself via both strength and endurance. Not because I'd weaned myself off the TV.

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