Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Respiratory Failure 355

■If not intubated:

➣Consider non-invasive ventilation (BiPAP) as a bridge while treat-

ing underlying etiology

➣Some patients may benefit from intermittent BiPAP (e.g., over-

night) at home

■If intubated:

➣Continue serial weaning trials

No one method of weaning has been established as superior:

T-piece trials

Pressure support wean

IMV wean

➣Recent literature favors T-piece wean, with daily estimates of

suitability for extubation

➣Assure adequate analgesia; Consider regional anesthesia (epidu-

ral, intercostal blocks)

➣Assure adequate sleep/wake cycles; Consider increased ventila-

tory support at night

➣Consider tracheostomy after 14–21 days of weaning attempts

➣Chronic intermittent ventilation if weaning requires > 6 months

and patient has been clinically optimized

specific therapy

Indications for Treatment

■Therapy should be instituted once a diagnosis is considered and

work up initiated

Treatment Options

Non-Invasive Ventilation

■BiPAP – nasal or mask

■Startat10cmH 2 O inspiration/5 cm H 2 O expiration

Weaning Protocols

■T-piece:

➣Start with 15–30 mins BID or TID

➣Increase in 15–30 min increments if RR <25

■Pressure Support:

➣Start at PS level that provides an adequate TV

➣Decrease by 2 cm H 2 O every 1–2 days

■IMV: Decrease RR by 2 breaths TID to qD if RR <25

Tracheostomy:

■Decreased work of breathing may facilitate weaning