WEANING FROM A VENTILATOR:MAJOR CHALLENGE

The purpose of this article is to assist loved ones, caregivers and ventilator patients themselves to understand the complexities of trying to wean off a ventilator. In order to accomplish this understanding we must first understand a few basic ideas.First let's start with the word ventilator. Many people refer to a ventilator as a respirator. In medicine we understand when people refer to the ventilator as a respirator. The difference is simply in the technical definition. A ventilator moves air from one place to another a respirator exchanges gases; such as the oxygen and carbon dioxide we exhale.People find themselves on ventilators for various reasons, but many utilize this intervention because of lung disease. In certain lung diseases the ability to exchange these gases is significantly altered. Because of this alteration the ventilator can assist the patients breathing but not reverse the lung disease process. Therefore gas exchange cannot be guaranteed; hence a ventilator and not a respirator.It is sometimes difficult to understand why when it seemed so easy to initiate the ventilator can it be so difficult to remove it. There are many components to returning a patient to their own spontaneous breathing and each individual is just that “an individual”, so weaning programs should be tailored for the individual need.We must understand in the recovery and rehabilitation of a ventilator dependent patient removal of the ventilator is often the last phase of the process. So lets start at the beginning and work through the understanding of this process.A ventilator patient is deemed ready to wean. This determination is usually made when the primary reason for the initiation of the ventilator has been reversed or stabilized. It is important to remember there are as many ways to wean a patient, as there are reasons to place them on the ventilator. This concept works in favor of the weaning patient because it allows for the individualization of each patients program.A key component that is often overlooked in a weaning program is the patient’s nutritional status. The patient may have been supported for days on intravenous fluids that provide hydration but little nutrition. Often when a patient is deemed ready to wean their serum albumin and total protein levels in the blood reveal malnutrition. It is this writer’s belief that until significant gain in correcting this malnutrition has been achieved no weaning should be initiated. It is like asking a marathon runner to not eat for a weak and then run a 26-mile race. I am sure they wouldn’t get very far or finish.A dietician will work closely with the physician to provide the caloric intake and nutritional values that the patient needs to support the weaning process. The dietician has many factors to consider when determining the correct nutritional recipe for the patient.Patients often have many diagnoses that have to be considered in the nutritional formula. A patient with kidney disease will have difficulty with protein, a diabetic with glucose, and the lung disease patient may have significant issues with volume, an obese patient needs nutrition in a reduced number of calories.Another factor that must be considered, especially for those patients who eat by mouth is food simply has little or no taste. The reason for this is the tracheostomy tube. When a patient has a tracheostomy tube breathing through the nose and mouth no longer occurs. It is the nose that helps us smell and taste food. The tracheostomy patient no longer or has little ability to smell and taste like most people. This may cause decreased appetite. Encouragement and utilization of devices referred to as speaking valves often help with this issue.Once the recipe or nutritional formula has been determined and the patient is tolerating it and nutrition is improving its time to look at the next area that can and often does complicate the weaning process.Medications are like a double-edged sword; they have significant benefit in treating disease and their symptoms but never without consequence. In medicine the physician weighs the “risk-benefit” of medications carefully. The need for certain medications such as pain and anti-anxiety medications can complicate the weaning process as well as enhance it.Lets start with pain medications. If a patient has pain they are unable to participate in their rehabilitation process to the maximum potential. Many pain medications such as those in the opiods family (morphine) can suppress a patients breathing. Many of the anti-anxiety medications can cause the patient to be sleepy again reducing the ability to participate. Some medications can even cause confusion making it even harder for the patient to participate. The physician must look to relieve the pain and anxiety without over sedating the patient. If the level of medication required to relieve these symptoms cause the undesired side effects it may be necessary to postpone weaning attempts until these issues have been resolved.Now that the patient has improved nutritional status and has pain and anxiety well controlled we can proceed to the active rehabilitation of the ventilator dependent patient.Occupational, Physical and Speech therapists may begin to work with the patient one by one or as a team. It is imperative to remember a patient must be able to follow simple commands and participate in order for active therapy to occur.The therapists are an integral part of the weaning process. The major component of breathing requires muscle use, the diaphragm as well as muscles in the neck and chest.Just like the marathon runner it takes time and training to reach the goal. No one decides to run a marathon and succeeds the same day. Daily participation in therapies is essential to achieving the ultimate goal of weaning off the ventilator.During the rehabilitation phase the Respiratory therapists will work closely with the physician to determine a weaning program that will best suit the individual patient. Remember no matter how much we want someone to wean it takes all or most of the components to be successful as well as time.It is sometimes difficult to understand why patients are hesitant to come off the ventilator but if we look carefully we can comprehend the fear and anxiety that is associated with this process for the patient. Imagine if you will that you couldn’t breath and now you have a machine that helped you, makes your work of breathing easier. Now suddenly everyone wants to take that away from you. Patients wonder, what if I get short of breath, what if I get tired, what if I go to sleep and these are just a few of the “what ifs” that weigh heavily on their mind.Together the medical team and families can help allay the patients fear. Families can give the medical team insight to the personality and coping skills the patient had prior to their illness. These valuable insights can help the medical team develop a successful plan towards weaning. As family members your support in the process is essential. If you are fearful of the process so will the patient.Asking questions of the medical team will help you understand the plan. Trust is the essential ingredient for the patient. They must have the trust and confidence in their medical team to keep them safe and breathing easy.Very often the medical team will see the patients and their families focusing on “numbers”. They hear questions such as what is my pulse oximetry? Yesterday the number on the machine was 10 now its 12, why? This phenomenon is very understandable; people want to make sense out of all this technical information. The numbers are familiar, they flash on the ventilator screen and across the pulse oximeter routinely. Yet the question begs to be asked, what do the numbers mean?The numbers are used by the medical team to assess and trend information and monitor the patient’s progress. People often forget to look at the patient. Is the patient comfortable, not sweating; has good pink color, able to perform their required therapies?These are all good indicators that the patient is doing well. The medical team will evaluate all the “numbers” and adjust the plan of care accordingly.It is important to remember that just like in the laws of physics the patient is the sum of all its parts. Many factors and chronic conditions must be considered when initiating a plan of care for weaning. Age, chronic conditions, anxiety, depression, previous level of function as well as setting realistic goals are part of the planning process. It is very important that every member of the team; which includes the patient and their family, agrees with and understands the plan. Together, as a team with dedication and hard work the reward of being free from mechanical ventilation awaits you.