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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 European Society of Intensive Care Medicine (ESICM 2020), the Society of Critical Care Medicine (SCCM 2018), the American Thoracic Society (ATS/ACCP 2017), the Surviving Sepsis Campaign (SSC 2017), the European Respiratory Society (ERS 2017), the British Thoracic Society (BTS/ICS 2016), and the American Association for Respiratory Care (AARC/SCCM/ACCP 2001).
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Guidelines

1.Screening and diagnosis

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

Evaluation for ventilation dependence
Evaluate patients requiring mechanical ventilation for > 24 hours for all causes likely to contribute to ventilator dependence, especially if attempts at withdrawing the mechanical ventilator have failed. Reverse all possible ventilatory and non-ventilatory issues.
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Determine the cause of a failed spontaneous breathing trial in patients receiving mechanical ventilation for respiratory failure.
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3.Diagnostic procedures

Cuff-leak test: 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
C

4.Respiratory support

Spontaneous breathing trial: as per ATS 2017 guidelines, consider using inspiratory pressure augmentation (5-8 cmH₂O) rather than no inspiratory pressure augmentation (T-piece or CPAP) performing an initial spontaneous breathing trial in acutely hospitalized patients receiving mechanical ventilation for > 24 hours.
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More topics in this section

  • Noninvasive ventilation

  • Intermittent mandatory ventilation

  • Mechanical ventilation

5.Medical management

Corticosteroids: 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

6.Therapeutic procedures

Extubation: 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.
B

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  • Tracheotomy

  • RBC transfusion thresholds

7.Follow-up and surveillance

Rehabilitation: consider offering protocolized rehabilitation directed toward early mobilization in acutely hospitalized adult patients undergoing mechanical ventilation for > 24 hours.
C

8.Quality improvement

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