Ventilator Weaning and Extubation Protocol for DNR Patients
For DNR patients, the ventilator weaning and extubation process should follow the same clinical protocols as other patients, with special attention to comfort measures and anticipatory symptom management to ensure dignity and minimize suffering during the process. 1
Assessment of Readiness for Weaning
Initial Evaluation
- Perform a 30-minute Spontaneous Breathing Trial (SBT) to assess suitability for extubation 1
- Use pressure-augmented SBT with pressure support of 5-8 cmH₂O and PEEP of 5 cmH₂O 2
- Monitor for signs of poor tolerance during SBT:
- Respiratory rate > 35 breaths/min
- SpO₂ < 90%
- Heart rate > 140 beats/min
- Systolic BP > 180 mmHg or < 90 mmHg 2
Risk Assessment for Extubation Failure
Carefully identify factors that increase risk of extubation failure:
- Capacity-load imbalance (severe airflow obstruction or neuromuscular weakness)
- Impaired bulbar function
- Ineffective cough
- Non-respiratory issues (cardiac dysfunction, encephalopathy, abdominal distension) 1
Weaning Process
Approach Selection
Two primary methods can be used based on patient needs and family preferences:
- Terminal extubation: Immediate removal of endotracheal tube
- Terminal weaning: Gradual reduction of inspired oxygen concentration and/or mandatory ventilator rate 1
Pre-Extubation Preparation
- Discontinue neuromuscular blockers if in use and allow effects to wear off
- Administer anticipatory titrated doses of opioids and benzodiazepines to alleviate dyspnea 1
- Consider discontinuing antibiotics and other life-prolonging treatments
- Reduce intravenous fluids that may cause respiratory congestion 1
- Ensure family is prepared for potential respiratory changes after extubation
Non-Invasive Ventilation Consideration
- NIV can be used to aid weaning from invasive mechanical ventilation, particularly in patients with COPD 1
- NIV has been shown to reduce mortality and pneumonia incidence without increasing re-intubation rates 2
- Consider prophylactic NIV immediately after extubation for high-risk patients 2
Post-Extubation Management
Symptom Management
- Continue to titrate opioids and benzodiazepines to maintain control of any signs of discomfort 1
- Regularly assess for signs of dyspnea and pain after removal from assisted breathing 1
- For noisy breathing ("death rattle") that may distress family:
- Eliminate intravenous fluids
- Consider anticholinergic agents for bronchial secretions 1
Family Support
- Inform family in advance about potential "agonal breathing" (slow, irregular, noisy breathing) that may occur before death 1
- Clarify that agonal breathing is part of the dying process and doesn't necessarily indicate patient discomfort 1
- Ensure a healthcare team member remains available to the patient and family until death occurs 1
Special Considerations for DNR Patients
- DNR status does not change the clinical approach to weaning but shifts focus to comfort and dignity
- The chosen method of withdrawal should balance benefits and burdens while respecting patient's (or surrogate's) preferences 1
- Involve the patient (if capable) and family members in decisions about how to proceed 1
- Consider location of care after extubation based on monitoring needs and family presence
Common Pitfalls and Caveats
- Avoid assuming DNR status means immediate terminal extubation; follow proper weaning protocols when appropriate
- Don't underestimate symptom management needs; pre-emptive medication is essential
- Remember that agonal breathing and death rattle by themselves are not indications for increasing opioid doses 1
- Terminal weaning may help avoid noisy breathing due to airway secretions that could disturb family 1
- Recognize that approximately 25% of imminently dying patients will have noisy breathing that may distress families despite reassurance 1
By following this structured approach, clinicians can ensure that DNR patients receive appropriate ventilator weaning and extubation care that prioritizes comfort, dignity, and family support during the end-of-life process.