Algorithm for Assessing Whether a Patient is Ready to Be Liberated from Mechanical Ventilation and Extubated

Algorithm for Assessing Whether a Patient is Ready to Be Liberated from Mechanical Ventilation and Extubated - Flowchart Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome

«Flowchart»

Approach to Discontinuing Ventilation/Extubation

1. Daily assessment: Is patient ready for a spontaneous breathing trial?

General: resolving process, patient alert, no continuous sedation
Gas exchange: P/F >200; FIO₂ ≤50%
Hemodynamics: no vasopressors
Respiratory: PEEP ≤5-7 cm H₂O

1. Daily assessment: Is patient ready for a spontaneous breathing trial?

General: resolving process, patient alert, no continuous sedation
Gas exchange: P/F >200; FIO₂ ≤50%
Hemodynamics: no vasopressors
Respiratory: PEEP ≤5-7 cm H₂O

1. Daily assessment: Is patient ready for a spontaneous breathing trial?

General: resolving process, patient alert, no continuous sedation
Gas exchange: P/F >200; FIO₂ ≤50%
Hemodynamics: no vasopressors
Respiratory: PEEP ≤5-7 cm H₂O

General: resolving process, patient alert, no continuous sedation
Gas exchange: P/F >200; FIO₂ ≤50% IO₂ ₂ ≤
Hemodynamics: no vasopressors
Respiratory: PEEP ≤5-7 cm H₂O ≤ ₂

Yes

Reinstitute ventilation

Stable, nonfatiguing, comfortable

Reinstitute ventilation

Stable, nonfatiguing, comfortable

Reinstitute ventilation

Stable, nonfatiguing, comfortable

2. Initiate screening for spontaneous breathing trial (SBT):

Monitor patient with ECG, oximetry
Patient breathes spontaneously on PSV of 5-7 cm H₂O or on T-piece
Monitor physiological variables (RR, gas exchange, hemodynamics, subjective comfort)

2. Initiate screening for spontaneous breathing trial (SBT):

Monitor patient with ECG, oximetry
Patient breathes spontaneously on PSV of 5-7 cm H₂O or on T-piece
Monitor physiological variables (RR, gas exchange, hemodynamics, subjective comfort)

2. Initiate screening for spontaneous breathing trial (SBT):

Monitor patient with ECG, oximetry
Patient breathes spontaneously on PSV of 5-7 cm H₂O or on T-piece
Monitor physiological variables (RR, gas exchange, hemodynamics, subjective comfort)

Monitor patient with ECG, oximetry
Patient breathes spontaneously on PSV of 5-7 cm H₂O or on T-piece ₂
Monitor physiological variables (RR, gas exchange, hemodynamics, subjective comfort)

If patient physiologically stable, continue

If patient physiologically unstable

Evaluate and treat reversible causes of failure

Sedation, fluid status, myocardial ischemia, pain control, bronchodilator need, etc

Evaluate and treat reversible causes of failure

Sedation, fluid status, myocardial ischemia, pain control, bronchodilator need, etc

Evaluate and treat reversible causes of failure

Sedation, fluid status, myocardial ischemia, pain control, bronchodilator need, etc

4. Extubate

3. Continue SBT for 30-120 minutes:

Discontinue if any of the following occurs:

General: !UpArrow!! anxiety or sweating
Gas exchange: SpO₂ <88%; PaCO₂ ↑ by >10 mm Hg
Hemodynamics: sustained HR changes of >± 20% OR HR >140/min; SBP <90 OR >180 mm Hg
Respiratory: RR >35/min for >5 min; signs of ↑ WOB (paradoxical breathing, accessory muscles…)

3. Continue SBT for 30-120 minutes:

Discontinue if any of the following occurs:

3. Continue SBT for 30-120 minutes:

Discontinue if any of the following occurs:

General: !UpArrow!! anxiety or sweating
Gas exchange: SpO₂ <88%; PaCO₂ ↑ by >10 mm Hg ₂ ₂ ↑
Hemodynamics: sustained HR changes of >± 20% OR HR >140/min; SBP <90 OR >180 mm Hg
Respiratory: RR >35/min for >5 min; signs of ↑ WOB (paradoxical breathing, accessory muscles…) ↑

No failure criterion met

Failed criterion

5. Monitor

Failure

Reintubate