We have a comprehensive ventilator management protocol called CAARES (Continuous Assessment of Airway, Respiration and Extubation in the SICU) that covers every patient who requires mechanical ventilation in the SICU. It is composed of an initiation phase that determines which subsequent protocol applies to the individual patient. Only ICU attendings or fellows can order the patient to not be placed on CAARES (e.g. patient with difficult airway).
1) Breathing Spontaneous Trial (BEST) – This occurs between 0430 and 0630 every day on all SICU patients that are mechanically ventilated. The patient’s sedation is decreased to achieve a RASS -1-0, then each patient undergoes a safety screen (pressors, spinal precautions, etc.) followed by a 2-minute screen (apnea, tachypnea, rapid desaturation) by the nursing staff and respiratory therapists. If the patient passes the first two phases, they undergo a 30 minute spontaneous breathing trial at which time a decision on extubation is made by the physicians taking care of the patient. A plan to extubate or keep intubated should be made immediately after the BEST trial, the respiratory therapist will call the fellow directly immediately after BEST passed to facilitate timely extubation without re-sedation in most cases. These results should be noted on the door of the patient’s room daily. When a patient repeatedly fails the BEST, there is a tracheostomy protocol to evaluate need for tracheostomy. After a patient receives a tracheostomy, there are two protocols to wean off the ventilator:
2) Short-term Trach Assessment of Respiration (STAR) – For patients with a tracheostomy, this allows a rapid wean of patients off of mechanical ventilation if the patient is ready to wean.Following a readiness screen, the patient is placed on trach collar for 4 hours and reassessed.
3) Slow Wean after Trach (SWAT) – For patients who fail STAR 3 days in a row (or sooner at attending discretion), are entered into the SWAT protocol. This is similar to the PICRU protocol.Patients are started on a CPAP = 5 cmH2O, PSV = 10 cmH2O wean for 30 minutes and are scored by nursing and RT based upon a number of physiologic variables. Depending on a patient’s score, weaning trials are increased slowly (maximal increase is 100%) with a two hour rest in between trials. No more than two breathing trials are done each day. When a patient tolerates CPAP for 12 hours, they are placed on trach collar.
BJC ADULT Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT)