Rationale: Respiratory muscles are skeletal muscles and, as we have seen, may become fatigued by overwork. But they may also become fatigued rapidly as a result of lack of work. Weaning by IMV is not always successful. The patient breathes spontaneously a few times per minute but never has the opportunity to breathe normally on his own or to fully use his own respiratory muscles. Placing the patient on a T-tube 1/2 hour at a time, etc. is also often too much for respiratory cripples or advanced COPD patients. RBT, even for breaths or minutes at a time, may strengthen the respiratory muscles. Inevitably, the patient will reach the point of muscle fatigue and should be placed back on the ventilator. The following process may be repeated often allowing adequate time for rest.

1. Connect a swivel adaptor (i.e. Portex swivel adaptor with PEEP Keep) to the monitoring adaptor (It may require a small piece of tape to prevent slipping.), 6" flex tube, and the Breather. Note: Use the 15-22 mm adaptor for monitoring pressures or supplemental O2.

2. Monitor the patient's SATS and heart rate during resistive breathing training

3. Prepare the patient. (i.e. suction/ sigh)

4. Put on clean gloves; place the swivel on the patient's trach tube.

5. Leave the cap of the swivel open. Place your finger over the opening of the swivel for the patient to begin breathing exercises. Note: The patient may initially be able to perform only a few breaths.

6. Take your finger on and off the swivel opening, progressing up to 1-2 minutes.

7. Give the patient adequate rest breaks. Note: When the patient becomes fatigued immediately place him back on the ventilator. Patients need patience when it comes to weaning and or exercise.

Note: Even if the patient isn't ready to be weaned but is trying to use a speaking valve (i.e. Passy-Muir Speaking Valve) respiratory muscles need strengthening/conditioning. Voice and swallow functions may be enhanced with strengthening of the respiratory muscles.

Medical abstract supports inspiratory muscle strength training for ventilator weaning.

Use of inspiratory muscle strength training to facilitate ventilator weaning* A series of 10 consecutive patients.
Martin A, Davenport PD, Franceschi A, Harman E. - Chest. 2002;122;192-96

Background and purpose: We instituted a low-repetition, high-intensity inspiratory muscle strength training (IMST) program and progressively longer spontaneous breathing periods (SBPs) in a group of medically complex patients who were dependent on mechanical ventilation (MV) and had failed to wean.
Case descriptions: IMST was provided to 10 consecutive patients (four men, six women; ­[± SD] age 59 ± 15 years) who had failed to wean from MV by conventional methods for > 7 days. Prior to initiating IMST, patients had received MV for a mean of 34 ± 31 days. Daily IMST consisted of four sets of six breaths through a threshold inspiratory muscle trainer that had been set at an intensity to yield and exertion rating of 6 to 8 of a maximal value of 10. At the start of IMST, patients were tolerating 2.1 ± 3.4 consecutive hours of SBPs. The duration of the SBPs was increased daily, as tolerated. Patients were considered to have been weaned from MV when they were able to breathe without MV support for 24 consecutive hours.
Outcomes: After 44 ± days of IMST, 9 of 10 patients were weaned from MV. The initial IMST pressure was 7 ± 3 cm H2O, and it was increased to 18± 7 cm H20 (p < 0.05).
Discussion: These results indicate that an IMST protocol that produces significant increases in threshold training pressure, in combination with progressive SBPs, aids in weaning patients from MV. Although promising, these preliminary observations must be tested in a controlled trial.