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.