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
Many patients in intensive care units (ICUs) are difficult-to-wean off of mechanical ventilation, thereby delaying extubation. The management of patients who are difficult-to-wean in the ICU is reviewed here. Details regarding readiness testing, methods of weaning, and the management of patients who require prolonged mechanical ventilation in long-term care facilities are provided separately. (See "Management and prognosis of patients requiring prolonged mechanical ventilation".)
DEFINITION AND INCIDENCE
Weaning can be classified as simple, difficult, or prolonged.
●Simple wean – Patients are considered to have undergone a simple wean when they pass their first spontaneous breathing trial (SBT). Approximately half to two-thirds of patients in intensive care units (ICUs) undergo simple weaning, many of which will proceed with extubation. Details regarding what constitutes an SBT and extubation management are discussed separately [1,2]. (See "Methods of weaning from mechanical ventilation" and "Extubation management".)
●Difficult-to-wean – Patients are considered difficult-to-wean if they fail their first SBT and then require up to three SBTs or seven days to pass an SBT . The incidence ranges from 26 to 39 percent [1,2]. This population mostly includes patients intubated in the first few weeks of acute ICU admission. This population is discussed in this topic review.
●Prolonged weaning – Patients are considered to have undergone prolonged weaning if they fail at least three SBTs or require more than seven days to pass an SBT. The incidence ranges from 6 to 14 percent [1,2]. Patients who require more than seven days to wean are at increased risk for death  and are also more likely to fail extubation compared with those who undergo simple weaning . While in the ICU, many of these patients are managed similarly to patients who are difficult to wean, many will require tracheostomy and be managed accordingly. (See "Overview of tracheostomy" and "Management and prognosis of patients requiring prolonged mechanical ventilation".)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:
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- DEFINITION AND INCIDENCE
- IDENTIFY AND CORRECT THE CAUSE
- Respiratory or ventilatory causes
- Cardiac causes
- Psychological causes
- Ventilator circuit issues
- Nutritional issues
- RESUMING WEANING TRIALS
- General strategies
- - Posture
- - Airway management
- Trials longer than 30 minutes
- Method of weaning trial
- Mechanical ventilation between weaning trials
- IMPROVING RESPIRATORY MUSCLE STRENGTH
- Physical therapy
- Investigational strategies (respiratory muscle training)
- REFRACTORY PATIENTS
- Transfer to long-term acute care
- SUMMARY AND RECOMMENDATIONS