The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

WEANING THE VENTILATOR DEPENDENT PATIENT USING TRANSTRACHEAL AUGMENTED VENTILATION

Wendy Woods Dedrick, RRT, Melanie Ziolkowski, BSN, RRT, Eric S. Yaeger, MD Kindred Hospital Denver, Denver, Colorado

INTRODUCTION: Patients on prolonged mechanical ventilation (PMV) who repeatedly fail traditional spontaneous breathing trials (SBT) are often deemed “unweanable” and ventilator dependent. Transtracheal Augmented Ventilation (TTAV) is the only technology that augments ventilation during SBT. It decreases work of breathing, dyspnea, and has proven to be an effective tool for weaning patients who are unable to wean for prolonged periods of time during SBT. TTAV is an advanced application of transtracheal oxygen therapy in which high flow rates of 10-15 liters per minute (LPM) of heated humidified air/oxygen mixture are delivered to the patient through a standard SCOOP transtracheal catheter. These case reports demonstrate how therapist driven protocols and TTAV successfully liberated two patients, previously deemed “unweanable” by a Long Term Acute Care Facility (LTAC), from mechanical ventilation (MV) in 21 and 9 days respectively.

CASE REPORT ONE: A 77-year-old white male diagnosed with hypercarbic respiratory failure, severe COPD, chronic bronchitis, obesity, aspiration pneumonia, S/P tracheostomy was referred to Kindred Hospital Denver (KHD) from another LTAC facility. The patient’s family requested a second opinion regarding the LTAC’s conclusion the patient was “unweanable”. The patient had been ventilator dependent for 90 days with repeated failed wean attempts. Spontaneous ventilatory parameters (SVP) on admission showed negative inspiratory force (NIF) –24, and rapid shallow breathing index (RSBI) 58. Weans were initiated using the Kindred* Denver Weaning Protocol Program (WPP). Within 9 days the patient had progressed to the point that SBT were started using TTAV. TTAV wean trials were initiated using a total flow of 10 LPM with an air/oxygen ratio of 8 LPM air and 2 LPM oxygen. The patient was successfully liberated from MV in 21 days using TTAV.

CASE REPORT TWO: A 60-year-old white male diagnosed with severe COPD, recurrent right lower lobe mucus plugging with atelectasis, ankylosing spondylitis, quadriplegic at C6 level, S/P tracheostomy was admitted to KHD from a referring LTAC after greater than 90 days on MV with repeated wean failures. SVP on admission showed NIF –60, RSBI 36. Within 8 days, the patient made significant progress and SBT was initiated using TTAV. TTAV wean trials were started using a total flow of 10 LPM with an air/oxygen ratio of 5 LPM air and 5 LPM oxygen. The patient was successfully liberated from MV in 9 days from the commencement of the WPP.

DISCUSSION: In the difficult to wean patient, TTAV is an effective weaning modality that augments ventilation during SBT. Additional benefits include the ability to verbalize and interact with medical staff, family and friends and to utilize the glottis as a variable regulator of expiratory flow and production of an effective cough while weaning. Two patients previously considered “unweanable” and ventilator dependent after greater than 90 days on MV with repeated failed wean attempts using traditional SBT were successfully liberated from MV in just 21 and 9 days respectively utilizing WPP and TTAV.

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