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AssignologyNursingMechanical Ventilation in Adult Patients-Weaning Protocol

Mechanical Ventilation in
Adult Patients-Weaning
Protocol
Subject: Nursing

Pages: 9

Words: 2312

Reading time:10 min

Study level: College

Critically ill adult patients admitted in intensive care units (ICU) require
assistance in the form of mechanical ventilation to meet the body’s oxygen
demand. However, the discontinuity involved in mechanical ventilation, the
process known as weaning often contributes to clinical complications
leading to mortality in patients who are weak in breathing. Weaning
protocols have been devised and applied in various formats in units. But,
there is no concrete information on the advantage offered by the
protocolised and nonprotocolised weaning approaches in reducing the
patient’s ventilator days and length of stay. Therefore, the main objective of
the study is to carry out a literature review to find significant information on
the protocols. Databases were searched like Pubmed, Cochrane using the
key words like ‘mechanical ventilation, weaning protocol, non-weaning
protocol, adult patients in ICU’s, protocolised and non protocolised
weaning. Studies included, reviews, randomized control trials in patients
with conditions like respiratory, cardiovascular and pulmonary ailments.

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It was found that protocolised weaning had superiority over non
protocolised weaning.

Significantly, several factors have influenced the success of weaning

protocol like nurse/ health care professional’s roles, awareness,
confidence, assessment, psychology and the overall inter unit-interactions.
Nurse driven sedation practice has influenced the weaning protocol.
Computer technology has brought several modifications to weaning
protocol. It was revealed that the most of the protocols on weaning are
regularly in use and standardized in many units. This led to their gradual up
gradation and preference compared to non-protocolised weaning. Non-
protcolised weaning found to suffer a huge paucity in the significant
contribution to the reduction of ventilation and length of stay. It can be
concluded that literature review has furnished better insight on the
protocolised weaning in an evidence based practice approach.

Health care strategies aimed at the betterment of mankind involve a lot of

support from several corners. Regardless of age and sex, the service
executed for a given patient relies mostly on the utility of specific devices
that play an influential role. Very often, the severity of a medical ailment
determines the care to be provided to the patient. Especially, in intensive
care units multiple devices are equipped to render instant help to the
patient in emergency condition. This task appears complicated with the
aged adult patients who require certain assistance in the form of
mechanical ventilation. Patients need mechanical ventilation for several
reasons and for variations in time periods which may be hours, weeks,
months and years. In fact, mechanical ventilation is recommended when
the oxygen demand is not met by the body through natural breathing or
when the carbon dioxide (CO2) is not sufficiently eliminated by the body.
Several conditions can contribute to an increasing demand of oxygen.

Various conditions can increase the oxygen demand, like aberrations of

cardiovascular system, neuromuscular disease, and respiratory system. So
this procedure is meant to give sufficient ventillatory assistance to meet the
oxygen demand of patient in a harmless fashion. The delivery of ventilation
is carried out through airway of artificial nature like a surgically placed
tracheostomy tube or an oral or nasal endotracheal tube (Pruitt Bill, 2006).
Under some circumstances, the process of mechanical ventilation is
discontinued which is known as weaning. This process often leads to
adverse consequences like high rat of mortality. The recognition of a
patient who is ready to breathe independently without mechanical
ventilation is a determining factor in the care.

Therefore, the purpose of the description is to provide a review of

mechanical ventilation with and without weaning protocol in adult patients
and its effect on length of stay in intensive care units (ICU) (Blackwood et
al., 2011).

In detail, in the care of severely ill and injured patients, the use of
Mechanical ventilation (MV) is considered as a vital component. But
weaning from the process of MV induces a task in intensive care units
(ICUs). This is because a small hindrance in weaning can lead to rise in the
complication number at a high rate. Although, nursing oriented protocol has
made the concept of weaning famous, the process is not used properly.
Discrepancies were recognized between the available and utilized time for
weaning. They revealed a significant delay between the available and
utilized time for weaning. The factor contributing was the role of intensive
care nurses in making use of available time for weaning (Hansen et al.,
2008).This indicated the role of nurses awareness on weaning protocol and
understanding the patients critical conditions.

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So, weaning protocol may rely on more number of factors to be considered
for the efficient care of adult patients in ICU’[Link] a qualitative study
involving semi-structured interviews, six important themes were identified
that could impact nurses choice on weaning. These are education,
confidence, nurse’s experience, clinical reassessment and decision
making, and physiological influences. Patients on weaning from mechanical
ventilation require a complex nature of care and decisions of critical care
(Lavelle & Dowling,2011).

Thus, the dependence on weaning protocol has firm connection not only
with patients condition but also on the health care professionals and nurses
decision. There was a gradual attention on the utility of mechanical
ventilation in a protocol based and non protocol based standards. Efficacy
of mechanical ventilation and novel approaches designed without the
interference of mechanical could be better assessed through comparisons
and contrast studies from several perspectives.

Protocol driven management of ventilated patients in experimental trials

have not proven significant in reducing the mechanical ventilation and
length of stay in ICU’s when compared with non protocol based local
management. This was attributed to the responsibility of staff nurse in
several forms of ventilatory practice (Bucknall, Manias & Presneill,2008). It
may be inferred that the presence or absence of a given weaning protocol
may influence the duration of patients stay in the hospital which n turn is
largely dependant on the nurse’s role. However, it is important to note that
patients who face difficult situation with weaning protocols need a longer
duration of stay which s associated with higher morbidity and mortality.
Attempts are still underway to minimize the weaning time to lessen the
ventilation duration and the relevant complications. This could be due to the
fact that there is a huge variation in protocol composition and execution in
several settings by different healthcare professionals (Blackwood et al.,
2009 a).
To investigate further, a collaborative study was carried out in various
nations like America, Europe and Australia on 1971 severely ill patients.
The ICU’s indicated that the patients had head injuries, trauma and
following major surgery, breathing difficulties and heart ailments. The
investigation was split into 11 studies, where eight had adhere to protocol
standards to minimize the support of ventilator and three had depended on
programmed computers on a protocol without ventilator support.

The findings indicate that there was a 25 % reduction in time spent in ICU’s
and the weaning duration was also lessened by 78% with a length of stay
reduction by 10%.

It may again indicate that practice methodology adopted like protocol

changes, the eligibility conditions for beginning the weaning, types of
implementation like computers or professionals, patients medical conditions
and the general weaning practice have led to a minimized patient stay
duration in ICU’S(Blackwood et al., 2011b). So, a weaning protocol
compared to a non weaning protocol affects ventilator days during ICU
length of stay through various factors mentioned above.

The advent of computer technology has brought forward an improvement in

mechanical support adaptation to the patient requirements. This is because
from the automated weaning studies conducted earlier, it was revealed that
computers could assess the variations in ventilation, predict real time real-
time physiological changes and facilitate ventilation adaptation to the
corresponding changes (Stahl et al., 2009). In contrast, the efficacy of non-
protocolized weaning is still not proven completely in their potential to
reduce the mechanical ventilation duration. The use of protocolized
weaning has achieved a stage that it has become a common practice in
many hospitals.

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Moreover, a sort of variable practice was observed in ICU’s of
surgical/trauma and medical departments. Here, an absence of reliable
approach to weaning was observed in medical unit compared to surgical
unit that has ventilator management standardised approach (Marelich et
al., 2000).The lack of reduction in mechanical ventilation could be due to
ICU’s usual practice that involved weaning assessment by critical care
nurses who are professionals. Hence, an association clinical outcomes and
critical care nurses could play a role in the weaning practice and its
implementation as described previously. This may encompass 24 hour
medical staff with a 1:1 nurse to patient ratio and an intensivist led rounds
twice daily in the hospital (Rose et al., 2008)
Weaning protocol was found to be more influential in reducing the length of
stay when there was potential staffing of medical personnel, which also
influenced reduced mortality in ICU and hospital (Pronovost et al., 2002).

Similarly, increased patient to doctor ratios have been significantly

connected to increased proportions of success of weaning and discharge at
home in patients who were on continued mechanical ventilation on non-
protocol pattern (Polverino et al., 2010).The instances cited above indicate
a standardized high level approaches to weaning in units that having work
culture in an organized manner and context that assist trained hospital
staff. Under these circumstances, the utility of weaning protocols may get
much benefit. This may shed light on the success of already existing
weaning protocols currently in use in hospitals and their superiority over
non standardized or non protocol based approaches.

Nursing interventions applied for the modulation of weaning protocol and

looking for gradual adaption of patients in ICU’s to that approach may
reflect a theory known as Adaptation Theory. This theory describes
adaptation as the adjustment of living beings / things to environmental
conditions. It is a spontaneously occurring process which influences
variations, interactions and responses. According to this theory, human
adaptation may occur at the level of internal (self ) social (others) and the
physical ( biochemical reactions) (Nursing Theories, 2012). For example, a
weaning protocol is better influenced by sedation practice which in turn
effects the duration of ventilation and length of patients ‘stay nursing driven
protocols (Rivera et al., 2008). Here, adjusted experimentation was applied
for the use of sedatives and analgesics using an algorithm-based. In a
heterogeneous patient group on mechanical ventilation, this strategy may
likely to enhance the feasibility of extubation (Rivera et al., 2008).

Sedative agents used for this purpose has reflected their pharmacological
properties and importance. In the hospital and intensive care unit, small
time periods of ventilation and length of stay were related to administration
of sedative agents in moderate doses and analgesics rather than breaks in
sedation daily and subsequent weaning assessments (Kress et al.,
2000).In contrast, protocols that did not involve sedation led patients to
spend more number of days significantly without ventilation than those who
received sedation breaks on a daily schedule (Strom, Martinussen & Toft,
2010).

Therefore, it is reasonable to mention that nurse care of adult patients in

ICUs may have a firm link with the nursing theory of Adaptation. More
probably, the goal of nurses is to predict a change in the care environment
that has a patient and his or her health as the main components. The
standard weaning protocols that have become usual and common in units
have a mandatory change and adaptation oriented nurse care factor, as
observed in content described here and also in the literature reviews. So,
non-weaning protocols may have a poor significant outcome compared to
weaning protocol which is constantly being focused with changes and
updates for novel insights.

In view of the above mentioned information, it can be summarized that

adult patient’s ventilation duration and length of stay are largely influenced
by the use of weaning protocol in intensive care unit. Protocol based
weaning has superiority over non protocol based weaning due to the
regular standardized application of weaning protocol as an objective criteria
for determining weaning readiness and a monitored approach to lessen the
support. Likewise, decreased length of stay in ICU’s is due to lessened
mechanical ventilation. This could lead to low need for tracheostomy
requirements.

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Several factors have influenced the weaning protocol in ICU’s during care
delivery to adult patients. These may include educational awareness
confidence, expertise of nurses, assessment in clinical decision making
and psychology.

The staffing of doctors, nurses, nurse /or doctor to patient ratio, continuous
availability have also influenced the weaning protocol implementation and
duration of stay.

The complexity involved in weaning process is not easily understood which

is leading to heterogeneity accompanied by variations. Discrepancies in
results do exist and are attributed to adverse events, quality of life,
mortality, quality of life etc. (Blackwood et al., 2009). Attempts to evaluate
the influence of different patient population on mechanical ventilation
duration by focusing on ICU types have become essential. But not all
studies are providing the significant results due to the fact that certain units
are of mixed type and involve trauma, neurosurgical, surgical and medical
units (Blackwood et al., 2011a).

The weaning protocol and its effect on duration is also influenced by

population of patients. Non protocol based approaches receive poor
appreciation due to the paucity of studies and relevant significant
information in care implementation. This made it inferior and become less
reliable compared to protocol based approaches. Constant focus on the
standard protocol in use has become usual in many units. Hence, the
intervention of computer technology has brought forward many changes in
the existing weaning protocol in regular use compared to the non-protocol.
Well organized and structural formats in weaning protocol applied were
efficient in offering the care. Use of sedative agents by nurse driven
protocols has contributed to the reduced ventilation and length of stay. This
approach reflected adaptation theory of nurses which emphasizes on the
living being’s adaptation to changes in the environment.

Overall, database search has yielded significant information for the health
care professionals to implement novel changes in an evidence based
practice approach.

References
Blackwood, B, Alderdice, F. Burns, K., Cardwel, C., Lavery, G., & Halloran,
P. O.(2011a). Use of weaning protocols for reducing duration of mechanical
ventilation in critically ill adult patients: Cochrane systematic review and
[Link], 342,c7237.

Blackwood, B., Alderdice, F., Burns, K., Cardwel, C., Lavery, G. & Halloran,
P. O.(2011b). Protocolized versus non-protocolized weaning for reducing
the duration of mechanical ventilation in critically ill adult
patients. Cochrane Database Syst Rev,7,CD006904.

Blackwood, B., Alderdice, F., Burns, K.E., Cardwell, C.R., Lavery, G.G.,&
Halloran P.O.(2009). Protocolized vs. non-protocolized weaning for
reducing the duration of mechanical ventilation in critically ill adult patients:
Cochrane review protocol.J Adv Nurs,65(5), 957-64.

Bucknall, T.K., Manias, E., & Presneill, J.J. (2008). A randomized trial of
protocol-directed sedation management for mechanical ventilation in an
Australian intensive care unit. Crit Care Med,36(5),1444-50.

Hansen, B.S., Fjaelberg, W.T., Nilsen, O.B., Lossius, H.M., & Søreide, E.
(2008). Mechanical ventilation in the ICU–is there a gap between the time
available and time used for nurse-led weaning? Scand J Trauma Resusc
Emerg Med, 16(17).

Kress, J.P., Pohlman, A.S., Connor, M.F., Hall, J.B.(2000). Daily

interruption of sedative infusions in critically ill patients undergoing
mechanical ventilation. N Engl J Med, 342, 1471-7.

Lavelle, C.,& Dowling, M. (2011). The factors which influence nurses when
weaning patients from mechanical ventilation: findings from a qualitative
study. Intensive Crit Care Nurs,27(5),244-52.

Marelich, G.P., Murin, S., Battistella, F., Inciardi, J., Vierra, T., Roby, M.
(2000). Protocol weaning of mechanical ventilation in medical and surgical
patients by respiratory care practitioners and nurses: effect on weaning
time and incidence of ventilator-associated pneumonia. Chest,118,459-67.

Nursing Theories: An Overview.(2012). Web.

Polverino, E., Nava, S., Ferrer, M., Ceriana, P., Clini, E., Spada, E, et al.
(2010). Patients’ characterization, hospital course and clinical outcomes in
five Italian respiratory intensive care units. Intensive Care Med,36,137-42

Pronovost, P.J., Angus, D.C., Dorman, T., Robinson, K.A., Dremsizov, T.T.,
Young, T.L. (2002). Physician staffing patterns and clinical outcomes in
critically ill patients: a systematic review. JAMA, 288, 2151-62.

Pruitt, B. (2006). Weaning patients from mechanical ventilation. Nursing,

36 (9), 36-41.

Rose, L., Presneill, J.J., Johnston, L., Cade, J.F. (2008) A randomised,
controlled trial of conventional versus automated weaning from mechanical
ventilation using SmartCare TM/PS. Intensive Care Med,34,1788.

Stahl, C., Dahmen, G., Ziegler, A., & Muhl, E. (2009).Comparisonof

automated protocol-based versus non-protocol-based physician-directed
weaning from mechanical ventilation. Intensivmedizin und
Notfallmedizin,46(6), 441–6.

Strom,T., Martinussen,T., Toft,P.(2010). A protocol of no sedation for

critically ill patients receiving mechanical ventilation: a randomised
trial. Lancet, 375,475-80.
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