Long term weaning and rehabilitation

Classification
As there is widespread variation for classifying long term weaning, the insertion of a tracheostomy for ventilatory purposes is an indication that the patient will be having a prolonged stay on the ICU.

Weaning
Weaning of a critically ill patient can vary depending on the cause for the prolonged use of ventilation and the preferred method of the particular Trust. Documented methods have included protocols; daily spontaneous breathing trials; integrating periods of non-invasive ventilation with invasive ventilation and gradual decreasing of support over a period of time. All of these techniques have advantages and disadvantages and may suit some patients better than others, however all methods require

These may include alteration in respiratory pattern; changes in saturations or arterial blood gases and identifiable changes to work of breathing for example increased use of accessory muscles.

Multidisciplinary approach
During this time of weaning the patient should also be seen and assessed for rehabilitation by the multi-professional Therapy team. The patient’s physical; psychological; communication and dietetic requirements should all be considered with access to the relevant professionals as required. Early physical rehabilitation has been shown to be safe and effective (Bailey 2007, Schweickert 2009) with patients being able to mobilise whilst on ventilation through the use of portable ventilators; use static bikes or even go outside of the AICU with sufficient supervision/monitoring and emergency equipment.
The use of smaller portable ventilators has transformed the ability to be more proactive with regards to levels of sedation and physical rehabilitation and should be considered in this patient cohort where appropriate.

Ongoing care
You may also need to consider ongoing care needs for long term weaning patients. The planning of this is best done as soon as the team are clear that the patient may require long term/home ventilatory support, either through Non-Invasive ventilation or formal tracheostomy ventilation.

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