Spontaneous Breathing Trial Procedure Note

Date/Time Started: [Date and time / Not documented]

Date/Time Ended: [Date and time / Not documented]

Location: [ICU / stepdown / ED / other]

Airway Type: [ETT / tracheostomy / Not documented]

Performing Clinician: [Name, role]

Ordering Clinician: [Name, role]

(Ensure all sections include actual measured values, not just interpretive statements. If the SBT was deferred without a trial being attempted, complete only the Readiness/Safety Screen, Outcome, and Post-SBT Plan sections.)

Indication / Context

[Brief indication for mechanical ventilation]. [Clinical trajectory: improving / stable / worsening]. [Goal of SBT: extubation expected if passed / liberation but not extubation due to airway concerns / diagnostic-assessment only]. [Code status and reintubation preferences if relevant to plan / Reintubation preferences not confirmed at time of SBT]

SBT Readiness / Safety Screen

Readiness Screen Result: [Pass / Fail / Not Assessed]

(If failed or not assessed, document specific reasons and plan for re-evaluation.)

• Underlying cause: [Met / Not met / Not assessed] — [Objective data demonstrating improvement or reversal]
• Oxygenation: [Met / Not met / Not assessed] — FiO₂ [value]%, PEEP [value] cmH₂O, SpO₂ [value]%
• Ventilatory capability: [Met / Not met / Not assessed] — [Evidence of patient-initiated inspiratory effort]
• Hemodynamic stability: [Met / Not met / Not assessed] — [Vasopressor/inotrope status; arrhythmia/ischemia status; recent HR/BP/MAP]
• Neurologic/sedation readiness: [Met / Not met / Not assessed] — [Level of arousal], RASS [value], SAT [performed today / not performed: reason], [SAT result if performed]
• Airway/secretions: [Met / Not met / Not assessed] — [Secretion burden; cough effectiveness; airway protection concerns] (Note if this may preclude extubation despite potential SBT pass.)

[If overall readiness failed or not assessed: Specific reasons and plan to re-evaluate with timing]

Baseline & Procedure Details

(Include this section only if an SBT was initiated.)

Ventilator settings prior to SBT: [Mode], rate [value] breaths/min, [Vt (mL) or pressure target (cmH₂O)], PS [value] cmH₂O, PEEP [value] cmH₂O, FiO₂ [value]%

Baseline vital signs: HR [value] bpm, BP [value] mmHg (MAP [value]), RR [value] breaths/min, SpO₂ [value]% on FiO₂ [value]%

Recent ABG/VBG: [ABG / VBG / Not obtained] — pH [value], PaCO₂ [value], PaO₂ [value], HCO₃⁻ [value], lactate [value if available]

SBT conduct:

• Technique: [T-piece / CPAP / low-level PSV / other]
• SBT settings: PS [value] cmH₂O, PEEP/CPAP [value] cmH₂O, FiO₂ [value]%
• FiO₂ change for trial: [Unchanged / Increased / Decreased] — [Rationale if changed] (Note: increasing FiO₂ during SBT can mask hypoxemia.)
• Duration: Planned [value] min, Actual [value] min

Tolerance & Observations

(Do not document "tolerated well" without accompanying objective values. Include time anchors where relevant.)

Stop/Failure criteria used:

• Respiratory: RR > [threshold]; sustained accessory muscle use; paradoxical breathing
• Oxygenation: SpO₂ < [threshold]% on FiO₂ ≤ [threshold]%
• Hemodynamic: HR [thresholds]; MAP [range]; new arrhythmia or ischemic changes
• Neurologic/comfort: [Agitation, decreased consciousness, or distress thresholds]

Observed during SBT:

• Highest RR: [value] breaths/min at [time]
• Lowest SpO₂: [value]% on FiO₂ [value]% at [time]
• Peak HR: [value] bpm at [time]
• BP/MAP changes: [Notable changes with timing or range]
• Work of breathing: [Narrative tied to observed findings and timing]
• RSBI: [value] (if measured) — measured on [T-piece / PS 0–5 / CPAP] at [time]

Outcome

SBT Outcome: [Passed / Failed / Aborted-Not completed / Deferred-Not performed]

(If not passed: [Brief reason])

Primary limiting factor: [Hypoxemia / Tachypnea-increased WOB / Hypercapnia-acidosis / Hemodynamic instability / Neurologic-agitation / Airway-secretions / Other / N/A if passed]

Post-SBT Plan

(Select the appropriate pathway and remove others.)

• If PASSED:
  • Plan: [Proceed to extubation / Proceed to tracheostomy collar / Continue mechanical ventilation despite pass: reason]
  • Timeframe: [Immediate / within specified time]
  • Prerequisites: [Suctioning, cuff leak if indicated, equipment readiness]
  • Post-extubation support: [Room air / Conventional O₂ / HFNC / NIV] — [Settings and rationale if high-risk]
• If FAILED or ABORTED:
  • Ventilator settings resumed: [Mode, rate, Vt/pressure, PS, PEEP, FiO₂]
  • Corrective actions: [Diuresis / Bronchodilation / Secretion management / Sedation optimization / Other]
  • Reassessment plan: [Timeframe and clinical targets for next SBT attempt]
• If DEFERRED:
  • Reason: [Domain(s) not met with objective data]
  • Plan: [Interventions and timeframe for reassessment]

Communication

[Team members notified] via [rounds / phone / secure chat / in-person] — [Shared decision: e.g., proceed with extubation / return to prior settings and reassess tomorrow]