Algorithm for Assessing Whether a Patient is Ready to be Liberated from Mechanical Ventilation and Extubated - Flowchart
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

Approach to Discontinuing Ventilation/extubation

Approach to Discontinuing Ventilation/extubation

Approach to Discontinuing Ventilation/extubation

Reinstitute ventilation


Stable, nonfatiguing, comfortable

Reinstitute ventilation


Stable, nonfatiguing, comfortable

Reinstitute ventilation


Stable, nonfatiguing, comfortable


Stable, nonfatiguing, comfortable

    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)

    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)

    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)


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 stable, continue

If patient physiologically stable, continue

If patient physiologically unstable

If patient physiologically unstable

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.


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

    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

    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

    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


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% O2 2
Hemodynamics: no vasopressors
Respiratory: PEEP 5-7 cm H2O 2

Yes

Yes

Yes


    Extubate

    Extubate

    Extubate

Extubate

    Continue SBT for 30-120 minutes: Discontinue if any of the following occurs:


    General: 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…)

    Continue SBT for 30-120 minutes: Discontinue if any of the following occurs:


    General: 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…)

    Continue SBT for 30-120 minutes: Discontinue if any of the following occurs:


    General: 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…)


Continue SBT for 30-120 minutes: Discontinue if any of the following occurs:


General: 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…)


General: anxiety or sweating
Gas exchange: SpO2 <88%; PaCO2 by >10 mm Hg O2 2 CO2 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

No failure criterion met

No failure criterion met

Failed criterion

Failed criterion

Failed criterion

    Monitor

    Monitor

    Monitor

Monitor

Failure

Failure

Failure

Reintubate

Reintubate

Reintubate