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Adult Respiratory Care Protocols v1.0

With collaborators & support from multiple institutions, including:

Last updated March 10, 2020

This work is licensed under a Creative Commons Attribution-NonCommercial-Sharealike 4.0 International License.

Table of Contents

Spontaneous breathing and awakening trials protocol

Cuff leak protocol

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How to Use This Document

Table of Contents

Strategies for SBT

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Adults:

• Pressure support (PS): Δ 5-7 cmH₂O over PEEP 5-8 cmH₂O
• CPAP: 5-8 cm H₂O
• T-piece

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Pediatrics:

• If ETT 3-3.5 mm: PS Δ 10 cmH₂O over PEEP 5 cmH₂O
• If ETT 4-4.5 mm: PS Δ 8 cmH₂O over PEEP 5 cmH₂O
• If ETT > or = 5 mm: PS Δ 5 cmH₂O over PEEP 5 cmH₂O
• T-piece alone is not recommended

Perform SBT

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• Choose appropriate strategy based on patient and ETT size (see box ‘strategies for SBT’)
• Monitor for signs of failure and intolerance (see box ‘SBT failure’)

SBT Failure

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Any sign of respiratory failure:

• Sustained tachypnea (> 5 min)
• Hypoventilation or apnea
• SpO2 < ~90% (except for patients with cyanotic heart lesions)

> Two signs of intolerance:

• Agitation or diaphoresis
• Accessory muscle use
• Hemodynamic instability
• Tidal volume < 4 cc/kg
• Significant (> 20%) increase in HR
• Increased or labile ICP

Sedation Interruption Failure

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• Anxiety, agitation or pain
• Significant tachypnea
• SpO₂ ~< 90%
• Respiratory distress
• Hemodynamic instability

MV = minute ventilation

Sedation Interruption Safety Screen*

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• No active seizures
• No active withdrawal (e.g. alcohol)
• No neuromuscular blockade
• No myocardial ischemia
• No elevated ICP

Sedation Interruption Safety Screen*

Consider daily if FiO2 < ~50

Discontinue Sedation

or decrease for > 30 min.

Analgesia should be titrated to patient needs.

SBT Readiness Screen

Resume sedatives at ½ dose

• Treat cause
• Consider cuff leak test if concern for airway edema (Figure 11.2)
• Consider tracheostomy

Extubate

Pass

Fail

Fail

Fail

Every 24 hours

Airway ok

Airway not ok

Pass

Pass

Assess Airway Protection

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• Adequate cough and gag
• No significant secretions or suctioning requirement (<q2-4h)
• Adequate mental status
• No risk factors for airway edema (See Figure 11.2)

Fail

Resume assisted ventilation

• Address reversible processes
• Avoid muscle fatigue
• Avoid asynchrony

Repeat** SBT Screen

(Every 24h)

Pass SBT

* Sedation interruptions (i.e. spontaneous awakening trials) may not be suitable or safe for pediatric patients

** Consider repeating SAT and SBT if failure due to easily reversible cause (e.g. oversedation, pain)

*Oxygenation Index (OI) = Fi02 x MAP / Pa02

SBT Readiness Screen

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• Adequate spontaneous breathing effort
• Disease trajectory: Resolving or stable
• Oxygenation: SpO₂ > 90% & stable FiO₂ < 50% & PEEP < 8 cmH₂0
• Pediatrics: Oxygenation index*** < 6
• Ventilation: pH > 7.3 & no significant ↑MV
• Hemodynamics: No significant vasopressor requirement or myocardial ischemia
• No elevated intracranial pressure

Spontaneous breathing and awakening trials protocol

Difference between expired TV before and

after cuff deflation is >110 mL

Difference between expired TV before and

after cuff deflation is <110 mL

Cuff leak test necessity screen

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Patient meets criteria for SBT* and >1 of the following:

• Traumatic intubation
• Intubation more than 6 days
• Large endotracheal tube (ETT)
• Female sex
• Multiple recent intubations
• Other clinical concern for airway swelling (e.g. prone positioning or anasarca)

Prepare patient for cuff leak test

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• Ensure patient is synchronous with ventilator and adequately sedated (a transient RASS goal of -4 should be considered)
• Set ventilator to volume control mode with tidal volume (TV) 8-10 ml / kg predicted body weight
• Suction oropharynx to prevent oral secretions from passing into the trachea with cuff deflation

Perform the cuff leak test

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• Observe and record the measured expired TV
• Deflate the ETT cuff by attaching syringe to the pilot balloon and pulling back on syringe until the balloon is flat.
• Observe the measured expired TV on the vent over six breaths

Cuff leak test has been FAILED

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• Address potential causes of failure
• Consider dexamethasone 5-10 mg IV q6-12h x 2 doses and then reassess for extubation in 12-24h
• Elevate head of bed

Cuff leak test has been PASSED

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• Proceed to extubation if all other parameters in place as in 11.1

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*SBT - Spontaneous breathing trial criteria - See Figure 11.1

Cuff leak protocol