Weaning From a Ventilator
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
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
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
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
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
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
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
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