ARISE

Awakening & Respiratory Integration for Safe Extubation
v4.3
MICU Awake & Breathe Protocol 2025 • Consensus Evidence
Complete the assessment to see recommendation
Q1: Inclusion Criteria MICU Protocol
Intubated >24h required (Day 2+). Shared with Pre-extubation.
Q2: SAT Exclusion Criteria MICU Protocol

Check any exclusion criteria present. SAT is contraindicated if ANY are checked.

✓ PROCEED WITH SAT — No exclusion criteria checked
Active seizures or alcohol withdrawal
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Seizures / Withdrawal Sedation discontinuation may lower seizure threshold. Abrupt withdrawal risks delirium tremens. Continue until seizure-free ≥24h or CIWA-Ar stable. MICU Protocol 2025; Kress 2000
Severe agitation (RASS +3 or +4)
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Severe Agitation (RASS +3/+4) Risk of self-harm, accidental extubation. Address underlying cause (pain, delirium, hypoxia) before SAT attempt. OR 2.1 for adverse events Sessler 2002; MICU Protocol 2025
Receiving neuromuscular blocking agents
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Neuromuscular Blockade Patient cannot demonstrate respiratory effort or consciousness while paralyzed. Discontinue NMBA, verify TOF ≥4 twitches before SAT. PADIS Guidelines 2018
Elevated intracranial pressure (ICP)
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Intracranial Hypertension Sedation interruption may increase ICP via coughing and Valsalva. Maintain ICP <20 mmHg, CPP >60 mmHg before considering SAT. Brain Trauma Foundation 2016; MICU Protocol
Active myocardial ischemia (last 24h)
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Myocardial Ischemia Awakening increases sympathetic tone, HR, BP — may worsen ischemia. Wait until troponins trending down, no active ECG changes. Girard 2010; ACC Guidelines
FiO2 >60%
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High Oxygen Requirements FiO2 >60% indicates severe hypoxemia and ongoing respiratory failure. Patient not stable for sedation interruption. MICU Protocol 2025; Eskesen 2018
Prone positioning
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Prone Positioning Patient requires deep sedation for prone positioning tolerance. Risk of accidental extubation if awakened. Complete prone cycle first. PROSEVA Trial; MICU Protocol 2025
Therapeutic hypothermia / TTM
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Targeted Temperature Management Sedation required to prevent shivering and maintain target temperature. Complete rewarming phase before SAT. TTM Guidelines; MICU Protocol 2025
Uncontrolled pain (CPOT ≥3)
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CPOT — Pain Assessment HIGH CPOT ≥3 indicates significant pain. Address before SAT. 24% of SAT failures due to uncontrolled pain/agitation. CPOT <3 required | Sens 100%, Spec 97% Zhai 2020; Balas 2022; PILOT trial
Planned procedure within 2 hours
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Pending Procedure Patient will require re-sedation for procedure. Defer SAT until after procedure to avoid unnecessary sedation cycling. MICU Protocol 2025
Dying / palliative care pathway
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Comfort Care Goals of care are comfort-focused. SAT/SBT not aligned with palliative goals. Focus on symptom management. MICU Protocol 2025
🌬️ SBT Readiness Criteria MICU Protocol

ALL criteria must be met to proceed with SBT.

✗ NOT READY FOR SBT — 0 of 7 criteria met
FiO2 ≤40%
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FiO2 Threshold ≤40% Higher FiO2 suggests ongoing hypoxemia. Target ≤40% indicates adequate gas exchange for breathing trial. MacIntyre 2001; MICU Protocol 2025
PEEP ≤8 cmH2O
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PEEP Threshold ≤8 cmH2O High PEEP requirements suggest ongoing lung pathology. ≤8 cmH2O approximates physiologic levels. Boles 2007; ERS/ATS Guidelines
P/F ratio >150
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P/F Ratio Threshold >150 PaO2/FiO2 >150 required for SBT. P/F >200 preferred for optimal extubation outcomes. ARDS Definition Task Force; Boles 2007
Noradrenaline <0.1 mcg/kg/min
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Vasopressor Threshold High vasopressor requirements indicate hemodynamic instability. <0.1 mcg/kg/min suggests cardiovascular stability. Higher doses: OR 1.7 for SBT failure MICU Protocol; Béduneau 2017; Zarrabian 2022
Adequate neurological function for airway protection
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Neurological Status — GCS General ICU: Target E4VTM5-6. Neuro patients: GCS-M alone is insufficient — assess cough, secretion handling. No single GCS-M threshold is validated as a safe extubation floor. Composite assessment > GCS alone Taran 2024; Asehnoune 2017; Da Silva 2022; McCredie 2017
Non-neuro (GCS-M ≥5)
Neuro patient (Stroke/TBI/Post-arrest)
RASS -1 to +1
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Sedation Level — RASS -1 Drowsy, 0 Alert and calm, +1 Restless. Too sedated or agitated predicts weaning difficulty. MICU Protocol 2025; PADIS Guidelines 2018
Underlying condition improving
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Clinical Trajectory Look for: Decreasing FiO2/PEEP over 24h, weaning vasopressors, CXR stable/improving, infection markers trending down, no new organ failure. MICU Protocol 2025; Boles 2007
SBT Protocol Settings MICU Protocol

Select ventilator mode for SBT. Duration: 30 minutes.

📋 Patient & Readiness Assessment HIGH
Linked from SAT tab
🧠 Airway Protection (from SBT Assessment)
Not yet assessed in Tab 2
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Airway Protection
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Sedation
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Pain
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🫁 Ventilator Settings HIGH
Target ≤40%
Target ≤8
🌬️ Post-SBT Assessment MOD
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SBT Pass Criteria Assessment after 30-120 min SBT. Pass requires: SpO2 ≥90%, pH ≥7.32, PaCO2 rise <8 mmHg, RR <35, no distress. SBT failure: SpO2 <90%, pH <7.32, PaCO2 rise ≥8, RR ≥35 AARC 2024; Boles 2007; MICU Protocol

📊 During/Post SBT Vitals

Target ≥90%
Target <35/min

Post-SBT ABG Values

Before SBT
After SBT
Target ≥7.35 (critical: ≥7.32)
Normal 22-26 (alert: <18)
Optional — for P/F ratio

Hemodynamic Values

Target <0.1
Target ≥7-8 (≥10 COPD)
PaCO2 Change (Delta)
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PaCO2 Rise — Dynamic SBT Measure HIGH Measures the CHANGE in PaCO2 from pre-SBT baseline to post-SBT. This tells you if the patient's ventilatory pump can sustain independent breathing. <8 mmHg rise = PASS (pump adequate) | ≥8 mmHg rise = SBT FAILURE (ventilatory pump failure — cannot sustain spontaneous breathing) Vallverdu 1998; Gong 2019; MICU Protocol
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Target <8 mmHg rise
SpO2 Status
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≥90%
RR Status
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<35/min
P/F Ratio
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Target >150
pH Status
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Target ≥7.35
PaCO2 (Absolute)
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Absolute PaCO2 — Static Measure MOD The absolute post-SBT PaCO2 level flags ongoing CO2 retention. Normal: 35-45 mmHg. For COPD patients, baseline may be chronically elevated (45-60) — use the PaCO2 CHANGE (delta) instead to judge SBT performance. 35-45 = Normal | >45 = Hypercapnia (warning) | >50 = Significant retention (concern, especially non-COPD) Boles 2007; Gong 2019; COPD ventilation guidelines
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35-45
Hb Status
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≥7-8
○ Post-SBT Assessment: Enter values to evaluate
💪 Respiratory Mechanics MOD
During SBT
mL during SBT
RSBI (Rapid Shallow Breathing Index)
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RSBI — Most Validated Weaning Predictor RSBI = RR ÷ Vt(L). Meta-analysis AUC ~0.81, moderate accuracy. Even low PS (5-8) significantly lowers RSBI and can mask failure. On PSV SBT, optimal cutoff is ~75 (vs ~100 on T-piece). Ideally measured at PS 0/T-piece. Serial RSBI (ΔRSBI >20-25%) improves prediction. Standard: <105 | COPD: ≤85 | On PSV: ~75 Yang & Tobin 1991; Trivedi 2021; Zhang & Qin 2014; Goncalves 2012
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breaths/min/L
Threshold: <105 (standard)
📊 Advanced Ventilator Mechanics (Optional) ▼

💡 Tip: Enter raw ventilator values — calculations are automatic

Target ≥110 mL
Static Compliance
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Static Compliance (Cst) Cst = Vt ÷ (Pplat - PEEP). Normal 50-100 mL/cmH2O. Low compliance (<30) indicates stiff lungs (ARDS, fibrosis, edema). Used to assess lung mechanics during weaning. Normal: 50-100 | Low: <30 Respiratory physiology; ARDS Network
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Vt ÷ (Pplat - PEEP)
Driving Pressure
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Driving Pressure (ΔP) ΔP = Pplat - PEEP. Target <15 cmH2O. Strong predictor of mortality in ARDS — each 1 cmH2O increase above 15 associated with increased mortality. Target <15 cmH2O | >20 = high risk Amato 2015; ARDS mortality studies
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Pplat - PEEP (target <15)

💧 Fluid Balance

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Extubation Risk Assessment 0 factors

Assess risk for post-extubation respiratory failure. Check applicable risk factors to determine post-extubation support recommendation.

Age >65 years
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Advanced Age HIGH Age >65: aOR 3.0 for extubation failure. Reduced respiratory muscle strength, impaired cough. aOR 3.0 (95% CI: 1.78-5.07) Taran 2022; Li 2022
APACHE II >12
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APACHE II Score HIGH APACHE II >12 during extubation indicates higher illness severity and increased risk of post-extubation failure. MICU Protocol 2025; Hernandez 2022
BMI >30
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Obesity MOD Risk mediated by OSA and CHF comorbidities. Prophylactic NIV beneficial especially for BMI >35. De Jong 2024; Pensier 2024
Unable to cope with secretions (poor cough/gag)
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Secretion Management HIGH Weak cough is the strongest single predictor of extubation failure. OR 4.5. Smailes 2013; Beuret 2009
More than 1 comorbidity
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Multiple Comorbidities Multiple comorbidities compound extubation failure risk. Consider each comorbidity individually. MICU Protocol 2025; Hernandez 2022
Heart failure
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Heart Failure HIGH LVEF <40% or NYHA II-IV. Removal of positive pressure may precipitate pulmonary edema. Thille 2016; Chang 2020
COPD
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COPD HIGH Failure rate 14.7-52%. Use RSBI <85. Prophylactic NIV strongly beneficial for hypercapnic patients. Failure rate 35-52% Goharani 2019; Robriquet 2006
Prolonged mechanical ventilation (>7 days)
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Prolonged MV HIGH >7 days associated with diaphragm atrophy (VIDD), ICU-acquired weakness. ~3% increased risk per day. Coplin 2000; Thille 2016
Difficult/prolonged weaning (failed 1st SBT, or >7 days)
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Weaning Classification HIGH Difficult weaning: 2-3 SBT attempts or <7 days after first SBT. Prolonged: >3 SBT or >7 days. Prolonged weaning: 25-40% failure rate Boles 2007; Funk 2010
Extubate To
Complete risk assessment above to see recommendation
Current Ventilator Mode Phase 2
Mode determines which parameters and step-down criteria apply.
Readiness Indicators All modes
Target ≤50% for weaning trial
Target ≥150 for SBT consideration
Target ≥7.30
>45 = warning; >50 = significant retention
Target −1 to +1 for weaning
Enter 0 if not on vasopressors. >0.2 = barrier.
Auto-filled when using ↻ Pull from Tabs 2–4
Advanced Assessment — optional ▼