Hi, I'm Jaspal Singh, today to talk to you about Spontaneous Breathing Trials. I'm co-chair of the Society of Critical Care Medicine's ICU Liberation Committee, the Medical Director of Critical Care Education at Atrium Health, as well as the Respiratory Therapy Training Program at Central Piedmont Community College in Charlotte, North Carolina. This module is about the SBT, however, it behooves us not to talk a little bit about the SAT and SBT and how they both are part of the B for the ICU Liberation Bundle. They both are helpful in determining the need for ongoing mechanical ventilation and ICU care. They both require that the patient participate, and then patient spontaneous efforts are important. They both reliably predict needs. If you practice and do them both well, they can actually be very helpful and predict the needs for ongoing mechanical ventilation and other critical care issues. And I think traditionally, a lot of us clinicians were too conservative, and myself included. And so standardizing and systematizing and using the whole care team can be very helpful. But they do require a lot of coordination and communication by the entire care team, not just your bedside nursing colleagues, but your respiratory therapists, the other therapy teams. And I think as we get better with the bundle, we realize that in the SBT, to do it well, you got to make sure you notify your physical therapy, occupational therapy, speech and speech pathologists, and other teams that you might have available, nutritionists and such, to know what is happening in this regard to the B or the spontaneous breathing trials specifically. However, when we do these consistently well, they're safe. They can improve quality, outcomes, and efficiencies, but they do require practice and attention. The spontaneous breathing trial has a few key elements. One is a safety screen. Two is the nuances of the spontaneous breathing trial in itself. And then, of course, recognizing potential successes and failures, and if they're unsuccessful, how to optimize for success at the next earliest opportunity. Few key definitions. We have to think about liberation, which is removal of the ventilator, and really the true goal. But that weaning is sometimes necessary. And so weaning, we call ventilator adjustments. Eventually, the goal still is liberation from the ventilator. If the SBT, it's time-tested, it's evidence-based, and the process may be individualized to patients and units and such. And many of you have done this really well over many years. I think COVID-19 has induced specific fears and issues that we'll address, but many of us have gone back to doing the SBT with a couple of small caveats, which we'll mention. Different protocols exist. Here's an example of the protocol from the wake-up-and-breathe protocol flowchart that is in the most recent edition of the ICU liberation textbook. However, other protocols are out there. We use a different protocol that's adapted to our institution. But the principles are essentially the same. You may have to adapt it to your institution. And then if you don't have a protocol, the SCCM ICU liberation resource library is a fantastic resource. You can go to that for a number of other protocols to look at. But then adapt your institution, practice, and refining it. And then we're going to discuss some key steps, which you can see them outlined here on the safety screen in the top on the right, the SAT failure criteria, the SBT safety screen, and then also SBT failure criteria. And so recognizing those is important. First part is a safety check. You got to make sure the patient is awake enough. And some people quantify this. But the idea is basically you want to make sure the patient's capable of spontaneous breathing, minimal agitation. Sometimes patients are agitated when you do these, but be able to control the situation ideally. Hemodynamic stability is important. You want minimal or no vasopressor use ideally. And you don't want uncontrolled arrhythmias. Respiratory status should be also stable or improving. You normally don't want advanced mechanical modes of ventilation here at this point. You really want the FiO2 less than at least 50% or so, the PEEP less than or equal to 8, typically in our institution as well. And you want a decent oxygenation situation in these situations and the patient with a reasonable minute ventilation. The other factors to consider is you want stable intracranial pressure in neurology patients. But more importantly than that is you want to make sure that you have the logistics and coordination worked out, meaning that the staff is aware that this is happening. They're available to assist if anything is needed. The patient's not going to suddenly in the midst of a trial go and go for a transport for some testing procedure, some other procedure, or undergo some important therapy that they've been waiting for. So just coordinating all of that is part of your safety check and make sure this is feasible. If the patient fails a safety screen, they'll have to wait. You might want to use that time, however, to clinically optimize if there's something to be worked out. For example, either some diuresis or additional respiratory treatments or cardiac optimization. These are all just things to consider. You want to document your reasons for failure. And for those who are using the ICU liberation to its truest form, we're hopefully collecting your data on the minimum data set as to why that patient failed, ideally within your medical record. But more importantly than that, you want to communicate with your team what happened, why they're failing, and what we can need to work on. And then consider repeating it. If it's something simple, they failed because of some easily correctable factor, you may want to do it later in the day or the next day, depending on the situation. Now ideally, if the patient passes the safety screen, you want to perform the spontaneous breathing trial. You want to place the patient on minimal ventilator support. Most of us use pressure support modes. FIO2 is roughly 40%. And the PEEP anywhere between 5 to 8 centimeters of water. Some of you may feel comfortable with more or less PEEP, depending on the clinical situation. The protocols around have minor variation. But generally, these protocols will all work well. And then you want to observe for failure. Is the patient in respiratory distress, or are they not getting enough breaths? Are they desaturating? Are they having worsening encephalopathy, hemodynamic instability, dysrhythmias? These are all sort of signs of failure. And you may define that differently. And I think all of us over the years have refined that. But the general gestalt is that you want to make sure that they're comfortable breathing. They may have a little tachypnea early on, but you want to observe them for a little while and see if they settle in on this minimal pressure support mode, typically. Now, the patients on the spontaneous breathing trial. A couple of common questions we get asked. How long should it continue? Probably at least 30 to 60 minutes to say if they passed. Beyond an hour, it's not clear how much value there is. So some of you may try that in certain patients. If the patient fails the SPT during that time, then what? We typically put them back on the previous ventilator settings. You may even restart analgesia and sedation. But you want to document and communicate with the team to make sure that all are on the same page of what exactly happened. Let's look at the situation and see if there's anything we can do to optimize the situation for next time. And then with COVID-19, there has been some chatter of whether we should consider a longer SPT, having a higher threshold for potentially these patients. Honestly, most of us are going back to what we did pre-COVID-19 protocols that we've outlined that we know are time-tested and proven. Some have advocated for longer spontaneous breathing trials or TPS trials, which may sort of increase the amount of effort that the patient needs to do to sort of prove themselves worthy of extubation trial. None of that is necessarily studied well, as I'm aware, but is something that some people are trying to do. But honestly, a lot of us, like I said, are going back to our previous pre-COVID-19 protocols and getting those patients extubated as soon as able. If the patient also passed the SPT, maybe we're considering extubating as soon as possible and communicating with that team. Extubation, well, extubation is considered an aerosol-generating procedure. So we do that in full personal protective equipment for the COVID-19 patient. Post-extubation monitoring, however, many of you have expressed concerns related to patients having less clinicians at the bedside readily available. So if you have that situation, you want to pay attention to alarms, vitals, you may want to monitor the patient through a window or telehealth solution like in our institution. Just be aware that post-extubation monitoring may be a little more challenging in those patients in certain institutions. And so you want to also monitor them closely, but also be prepared to potentially re-intubate and have your backup equipment really nearby, as well as the people that are going to re-intubate. If that's an anesthesiologist, you want to make them aware that patient may not be doing well and have them readily available in case you need them sooner than later. You want to have your check. Some people have checklists, including intubation checklists, including filters or special tools they might use, like intubation boxes that they may be comfortable with. It all depends on your institution and your protocol. And then you want to leave the ventilator in the room if possible. Obviously that ventilator has already been exposed to that patient, and so why put another circuit in the room? And so you want to sort of have that available as long as able, assuming that we have enough ventilators in your institution to not be able to have to rush that ventilator out of that room right away when that patient is extubated. These are all considerations. So in summary, when the spontaneous breathing trial is done consistently well, it is safe, it can improve quality, outcomes, and efficiencies. We have to all know our safety screen criteria and how to perform the spontaneous breathing trial, as well as what are success criteria and failure criteria, and pay attention to that patient as they move along this journey. For most of us, the process is similar in patients with COVID-19-associated respiratory failure, in that we want to get them off the ventilator at the earliest opportune time. There are some nuances, of course, that we're still learning about in managing this pandemic, but I think enough of us have had some experience now with this process that we can kind of work around these issues, knowing when to use full PPE, for example, knowing how to monitor the patient closely when there might be less patients and less staff in the room. But we also need to know that we need to be very vigilant about coordination and communication by the entire healthcare team. We did review some protocols and processes, but then recognize that they need to be adapted to the patients and institutions, especially as the pandemic evolves, and then practice this, refine it, and then do this all over again. And if you learn additional things, let us know. The SCCM resources library is up to date and available for any help you might need. And of course, feel free to reach out if you have any questions or concerns. Thank you. I'm Jaspal Singh. Thank you for your time.

Spontaneous Breathing Trials

mechanical ventilation

ICU care

patient participation

care team coordination