Management of the difficult-to-wean adult patient in the intensive care unit
- Scott K Epstein, MD
Scott K Epstein, MD
- Professor of Medicine
- Tufts University School of Medicine
- Martin F Joyce-Brady, MD
Martin F Joyce-Brady, MD
- Associate Professor of Medicine, The Pulmonary Center, Boston University School of Medicine
- Director, Ventilator Care Unit, Radius Specialty Hospital Boston
Patients are considered to have undergone simple weaning if they pass their first spontaneous breathing trial (SBT). They are considered difficult-to-wean if they fail their first SBT and then require up to three SBTs or seven days to pass a SBT. Finally, patients are considered to have undergone prolonged weaning if they fail at least three SBTs or require more than seven days to pass a SBT .
The management of patients who are difficult-to-wean in the intensive care unit is reviewed here. Details regarding readiness testing, methods of weaning, and the management of patients who require prolonged mechanical ventilation are provided separately. (See "Management and prognosis of patients requiring prolonged mechanical ventilation".)
Patients who are difficult-to-wean are common. In a prospective cohort study of 257 medical and surgical patients in whom weaning was attempted, the incidences of simple, difficult, and prolonged weaning were 59, 26, and 14 percent, respectively . Similarly, another prospective cohort study of 2714 patients mechanically ventilated for >12 hours found that the incidences of simple, difficult, and prolonged weaning were 55, 39, and 6 percent, respectively . Patients who required more than seven days to wean were found to be at increased risk for death. Patients with difficult or prolonged weaning are also more likely to fail extubation compared to those with simple weaning .
IDENTIFY AND CORRECT THE CAUSE
Repeatedly unsuccessful attempts at weaning usually signify incomplete resolution of the illness that precipitated mechanical ventilation and/or the development of one or more new problems. Further weaning attempts should be withheld once a patient has failed multiple attempts at weaning until the potential causes of the ongoing ventilator dependency are identified and corrected.
The potential causes of difficult weaning can be categorized according to whether they are respiratory/ventilatory or cardiac.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J 2007; 29:1033.
- Funk GC, Anders S, Breyer MK, et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 2010; 35:88.
- Peñuelas O, Frutos-Vivar F, Fernández C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med 2011; 184:430.
- Jeong BH, Ko MG, Nam J, et al. Differences in clinical outcomes according to weaning classifications in medical intensive care units. PLoS One 2015; 10:e0122810.
- Razazi K, Thille AW, Carteaux G, et al. Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc 2014; 11:1018.
- Lemaire F, Teboul JL, Cinotti L, et al. Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 1988; 69:171.
- Jubran A, Mathru M, Dries D, Tobin MJ. Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof. Am J Respir Crit Care Med 1998; 158:1763.
- Mekontso-Dessap A, de Prost N, Girou E, et al. B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med 2006; 32:1529.
- Grasso S, Leone A, De Michele M, et al. Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease. Crit Care Med 2007; 35:96.
- Chien JY, Lin MS, Huang YC, et al. Changes in B-type natriuretic peptide improve weaning outcome predicted by spontaneous breathing trial. Crit Care Med 2008; 36:1421.
- Mekontso Dessap A, Roche-Campo F, Kouatchet A, et al. Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med 2012; 186:1256.
- Lamia B, Maizel J, Ochagavia A, et al. Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 2009; 37:1696.
- Tanios M, Epstein S, Sauser S, Chi A. Noninvasive monitoring of cardiac output during weaning from mechanical ventilation: a pilot study. Amer J Crit Care 2016; 25:257.
- Dres M, Teboul JL, Anguel N, et al. Passive leg raising performed before a spontaneous breathing trial predicts weaning-induced cardiac dysfunction. Intensive Care Med 2015; 41:487.
- Dres M, Teboul JL, Anguel N, et al. Extravascular lung water, B-type natriuretic peptide, and blood volume contraction enable diagnosis of weaning-induced pulmonary edema. Crit Care Med 2014; 42:1882.
- Routsi C, Stanopoulos I, Zakynthinos E, et al. Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study. Crit Care 2010; 14:R204.
- Cabello B, Thille AW, Roche-Campo F, et al. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med 2010; 36:1171.
- Jubran A, Lawm G, Kelly J, et al. Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med 2010; 36:828.
- Holliday JE, Hyers TM. The reduction of weaning time from mechanical ventilation using tidal volume and relaxation biofeedback. Am Rev Respir Dis 1990; 141:1214.
- Teixeira C, da Silva NB, Savi A, et al. Central venous saturation is a predictor of reintubation in difficult-to-wean patients. Crit Care Med 2010; 38:491.
- Sassoon CS, Del Rosario N, Fei R, et al. Influence of pressure- and flow-triggered synchronous intermittent mandatory ventilation on inspiratory muscle work. Crit Care Med 1994; 22:1933.
- Giuliani R, Mascia L, Recchia F, et al. Patient-ventilator interaction during synchronized intermittent mandatory ventilation. Effects of flow triggering. Am J Respir Crit Care Med 1995; 151:1.
- Aslanian P, El Atrous S, Isabey D, et al. Effects of flow triggering on breathing effort during partial ventilatory support. Am J Respir Crit Care Med 1998; 157:135.
- Ward ME, Corbeil C, Gibbons W, et al. Optimization of respiratory muscle relaxation during mechanical ventilation. Anesthesiology 1988; 69:29.
- Marini JJ, Rodriguez RM, Lamb V. The inspiratory workload of patient-initiated mechanical ventilation. Am Rev Respir Dis 1986; 134:902.
- Puddy A, Younes M. Effect of inspiratory flow rate on respiratory output in normal subjects. Am Rev Respir Dis 1992; 146:787.
- Laghi F, Segal J, Choe WK, Tobin MJ. Effect of imposed inflation time on respiratory frequency and hyperinflation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 163:1365.
- Coussa ML, Guérin C, Eissa NT, et al. Partitioning of work of breathing in mechanically ventilated COPD patients. J Appl Physiol (1985) 1993; 75:1711.
- Jubran A, Van de Graaff WB, Tobin MJ. Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995; 152:129.
- Tobin MJ, Jubran A, Laghi F. Patient-ventilator interaction. Am J Respir Crit Care Med 2001; 163:1059.
- Tobin MJ. Advances in mechanical ventilation. N Engl J Med 2001; 344:1986.
- Rossi A, Gottfried SB, Zocchi L, et al. Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation. The effect of intrinsic positive end-expiratory pressure. Am Rev Respir Dis 1985; 131:672.
- Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med 1997; 155:1940.
- Ranieri VM, Giuliani R, Cinnella G, et al. Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 1993; 147:5.
- Smith TC, Marini JJ. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol (1985) 1988; 65:1488.
- DiNino E, Gartman EJ, Sethi JM, McCool FD. Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax 2014; 69:423.
- Martin AD, Smith BK, Davenport PD, et al. Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial. Crit Care 2011; 15:R84.
- Girault C, Breton L, Richard JC, et al. Mechanical effects of airway humidification devices in difficult to wean patients. Crit Care Med 2003; 31:1306.
- Georgopoulos D, Prinianakis G, Kondili E. Bedside waveforms interpretation as a tool to identify patient-ventilator asynchronies. Intensive Care Med 2006; 32:34.
- Mancebo J, Amaro P, Lorino H, et al. Effects of albuterol inhalation on the work of breathing during weaning from mechanical ventilation. Am Rev Respir Dis 1991; 144:95.
- Dhand R, Jubran A, Tobin MJ. Bronchodilator delivery by metered-dose inhaler in ventilator-supported patients. Am J Respir Crit Care Med 1995; 151:1827.
- Heffner JE, Martin-Harris B. Care of the mechanically ventilated patient with a tracheotomy. In: Principles and Practice of Mechanical Ventilation, Tobin MJ (Ed), McGraw Hill, Inc., New York 2006. p.847.
- Diehl JL, El Atrous S, Touchard D, et al. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med 1999; 159:383.
- Martin U, Criner GJ. Psychological problems in the ventilated patient. In: Principles and Practice of Mechanical Ventilation, Tobin MJ (Ed), McGraw Hill, Inc., New York 2006. p.1137.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:1874.
- Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36:2238.
- Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37:2499.
- Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010; 91:536.
- Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med 2003; 168:10.
- Krishnan JA, Parce PB, Martinez A, et al. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest 2003; 124:297.
- Stapleton RD, Jones N, Heyland DK. Feeding critically ill patients: what is the optimal amount of energy? Crit Care Med 2007; 35:S535.
- Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009; 35:1728.
- Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr 2009; 101:1079.
- Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation. Chest 2007; 131:76.
- Kahn JM, Benson NM, Appleby D, et al. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303:2253.
- Jubran A, Grant BJ, Duffner LA, et al. Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA 2013; 309:671.
- IDENTIFY AND CORRECT THE CAUSE
- Respiratory or ventilatory causes
- Cardiac causes
- PSYCHOLOGICAL PREPARATION
- WEANING STRATEGY
- During weaning trials
- Between weaning trials
- - Ventilator settings
- - Respiratory muscle training
- RESPIRATORY CARE
- Ventilator circuit
- Airway management
- PHYSICAL THERAPY
- TRANSFER TO LONG-TERM ACUTE CARE
- SUMMARY AND RECOMMENDATIONS