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.
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- 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