Table of contents

Weaning from mechanical ventilation

What's new

Updated 2024 AARC guidelines on spontaneous breathing trials for weaning from mechanical ventilation.


Key sources

The following summarized guidelines for the evaluation and management of weaning from mechanical ventilation are prepared by our editorial team based on guidelines from the American Association for Respiratory Care (AARC 2024), the European Society of Intensive Care Medicine (ESICM 2020), the Society of Critical Care Medicine (SCCM 2018), the American Thoracic Society (ATS/ACCP 2017), the European Respiratory Society (ERS ...
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Screening and diagnosis

Assessment for discontinuation: as per BTS/ICS 2016 guidelines, assess patients with hypercapnic respiratory failure daily for readiness to begin weaning from mechanical ventilation.
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Diagnostic investigations

Evaluation for ventilation dependence: as per AARC 2024 guidelines, avoid using the rapid shallow breathing index to determine readiness for spontaneous breathing trials.

Diagnostic procedures

Cuff-leak test: as per ACCP/ATS 2017 guidelines, consider performing a cuff leak test in mechanically ventilated adult patients deemed high risk for post-extubation stridor, such as:
traumatic intubation
intubation for more than 6 days
large endotracheal tube for size
female sex
reintubation after an unplanned extubation.

Respiratory support

Spontaneous breathing trial: as per AARC 2024 guidelines, consider performing spontaneous breathing trials with or without low-level pressure support ventilation (≤ 8 cmH₂O).
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More topics in this section

  • Noninvasive ventilation

  • Intermittent mandatory ventilation

  • Mechanical ventilation

Medical management

Corticosteroids: as per ACCP/ATS 2017 guidelines, consider administering systemic corticosteroids for at least 4 hours before extubation in adult patients who have failed a cuff-leak test, but are otherwise ready for extubation.

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  • Anesthesia/sedation

Therapeutic procedures

Extubation: as per AARC/ACCP/SCCM 2001 guidelines, decide on the removal of the artificial airway from a patient based on ability to interrupt ventilatory support, assessment of airway patency, and evaluation of the ability of the patient to protect the airway.

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  • Tracheotomy

  • RBC transfusion thresholds

Follow-up and surveillance

Rehabilitation: as per ACCP/ATS 2017 guidelines, consider offering protocolized rehabilitation directed toward early mobilization in acutely hospitalized adult patients undergoing mechanical ventilation for > 24 hours.

Quality improvement

Liberation protocols: as per ACCP/ATS 2017 guidelines, consider using a a ventilator liberation protocol to manage acutely hospitalized adult patients mechanically ventilated for > 24 hours.