Methods of weaning from mechanical ventilation
- Scott K Epstein, MD
Scott K Epstein, MD
- Professor of Medicine
- Tufts University School of Medicine
- Allan Walkey, MD, MSc
Allan Walkey, MD, MSc
- Assistant Professor of Medicine
- The Pulmonary Center, Boston University School of Medicine
Discontinuation of mechanical ventilation is a two-step process, consisting of readiness testing and weaning:
●Readiness testing – Readiness testing is the evaluation of objective criteria to determine whether a patient might be able to successfully and safely wean from mechanical ventilation.
●Weaning – Weaning is the process of decreasing the amount of support that the patient receives from the mechanical ventilator, so the patient assumes a greater proportion of the ventilatory effort. The purpose is to assess the probability that mechanical ventilation can be successfully discontinued. Weaning may involve either an immediate shift from full ventilatory support to a period of breathing without assistance from the ventilator or a gradual reduction in the amount of ventilator support [1,2]. Weaning has also been referred to as the discontinuation of mechanical ventilation or liberation from the mechanical ventilator.
Patients who wean successfully have less morbidity, mortality, and resource utilization than patients who require prolonged mechanical ventilation or the reinstitution of mechanical ventilation [3-6]. The most successful weaning strategies include a daily assessment of the patient's readiness to wean and the careful use of sedatives [7,8].
Weaning methods are reviewed here. Assessment of a patient's readiness to wean and the extubation process are described separately. (See "Weaning from mechanical ventilation: Readiness testing" and "Extubation management".)
- Slutsky AS. Mechanical ventilation. American College of Chest Physicians' Consensus Conference. Chest 1993; 104:1833.
- Tobin MJ, Jubran A. Weaning from mechanical ventilation. In: Principles and Practice of Mechanical Ventilation, Jubran A, Tobin MJ (Eds), McGraw Hill, New York 2006. p.1185.
- Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287:345.
- Coplin WM, Pierson DJ, Cooley KD, et al. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000; 161:1530.
- Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med 2010; 153:167.
- Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997; 112:186.
- Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371:126.
- Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:1864.
- Esteban A, Ferguson ND, Meade MO, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 2008; 177:170.
- Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med 1995; 332:345.
- Haberthür C, Mols G, Elsasser S, et al. Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation. Acta Anaesthesiol Scand 2002; 46:973.
- Ezingeard E, Diconne E, Guyomarc'h S, et al. Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing. Intensive Care Med 2006; 32:165.
- Esteban A, Alía I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1997; 156:459.
- Matić I, Majerić-Kogler V. Comparison of pressure support and T-tube weaning from mechanical ventilation: randomized prospective study. Croat Med J 2004; 45:162.
- Zhang B, Qin YZ. Comparison of pressure support ventilation and T-piece in determining rapid shallow breathing index in spontaneous breathing trials. Am J Med Sci 2014; 348:300.
- Ouellette DR, Patel S, Girard TD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest 2017; 151:166.
- Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017; 195:115.
- Naughton MT, Rahman MA, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circulation 1995; 91:1725.
- Bradley TD, Holloway RM, McLaughlin PR, et al. Cardiac output response to continuous positive airway pressure in congestive heart failure. Am Rev Respir Dis 1992; 145:377.
- Tobin MJ. Extubation and the myth of "minimal ventilator settings". Am J Respir Crit Care Med 2012; 185:349.
- Ladeira MT, Vital FM, Andriolo RB, et al. Pressure support versus T-tube for weaning from mechanical ventilation in adults. Cochrane Database Syst Rev 2014; :CD006056.
- Jones DP, Byrne P, Morgan C, et al. Positive end-expiratory pressure vs T-piece. Extubation after mechanical ventilation. Chest 1991; 100:1655.
- Cohen JD, Shapiro M, Grozovski E, et al. Extubation outcome following a spontaneous breathing trial with automatic tube compensation versus continuous positive airway pressure. Crit Care Med 2006; 34:682.
- Cohen J, Shapiro M, Grozovski E, et al. Prediction of extubation outcome: a randomised, controlled trial with automatic tube compensation vs. pressure support ventilation. Crit Care 2009; 13:R21.
- Wilson AM, Gray DM, Thomas JG. Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest 2009; 136:1006.
- Mehta S, Nelson DL, Klinger JR, et al. Prediction of post-extubation work of breathing. Crit Care Med 2000; 28:1341.
- Straus C, Louis B, Isabey D, et al. Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 1998; 157:23.
- DeHaven CB, Kirton OC, Morgan JP, et al. Breathing measurement reduces false-negative classification of tachypneic preextubation trial failures. Crit Care Med 1996; 24:976.
- Kirton OC, DeHaven CB, Morgan JP, et al. Elevated imposed work of breathing masquerading as ventilator weaning intolerance. Chest 1995; 108:1021.
- Esteban A, Alía I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999; 159:512.
- Vitacca M, Vianello A, Colombo D, et al. Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days. Am J Respir Crit Care Med 2001; 164:225.
- 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.
- Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150:896.
- Imsand C, Feihl F, Perret C, Fitting JW. Regulation of inspiratory neuromuscular output during synchronized intermittent mechanical ventilation. Anesthesiology 1994; 80:13.
- Jounieaux V, Duran A, Levi-Valensi P. Synchronized intermittent mandatory ventilation with and without pressure support ventilation in weaning patients with COPD from mechanical ventilation. Chest 1994; 105:1204.
- Laghi F, Cattapan SE, Jubran A, et al. Is weaning failure caused by low-frequency fatigue of the diaphragm? Am J Respir Crit Care Med 2003; 167:120.
- Laghi F, D'Alfonso N, Tobin MJ. Pattern of recovery from diaphragmatic fatigue over 24 hours. J Appl Physiol (1985) 1995; 79:539.
- Burns KE, Adhikari NK, Keenan SP, Meade MO. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev 2010; :CD004127.
- Betbesé AJ, Pérez M, Bak E, et al. A prospective study of unplanned endotracheal extubation in intensive care unit patients. Crit Care Med 1998; 26:1180.
- Saura P, Blanch L, Mestre J, et al. Clinical consequences of the implementation of a weaning protocol. Intensive Care Med 1996; 22:1052.
- Dries DJ, McGonigal MD, Malian MS, et al. Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia. J Trauma 2004; 56:943.
- Jordan J, Rose L, Dainty KN, et al. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. Cochrane Database Syst Rev 2016; 10:CD011812.
- Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med 2017; 195:120.
- Blackwood B, Alderdice F, Burns K, et al. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ 2011; 342:c7237.
- Krishnan JA, Moore D, Robeson C, et al. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med 2004; 169:673.
- Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 2001; 163:658.
- Navalesi P, Frigerio P, Moretti MP, et al. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med 2008; 36:2986.
- Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med 2006; 174:894.
- Stahl C, Dahmen G, Ziegler A, Muhl E. Protocolised automated versus non-protocolised physician-directed weaning from mechanical ventilation: a controlled clinical trial. Intensivemed Prax 2009; 46:441.
- Rose L, Presneill JJ, Johnston L, Cade JF. A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartCare/PS. Intensive Care Med 2008; 34:1788.
- Burns KE, Meade MO, Lessard MR, et al. Wean earlier and automatically with new technology (the WEAN study). A multicenter, pilot randomized controlled trial. Am J Respir Crit Care Med 2013; 187:1203.
- Schädler D, Engel C, Elke G, et al. Automatic control of pressure support for ventilator weaning in surgical intensive care patients. Am J Respir Crit Care Med 2012; 185:637.
- Rose L, Schultz MJ, Cardwell CR, et al. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children. Cochrane Database Syst Rev 2014; :CD009235.
- Burns KE, Lellouche F, Lessard MR, Friedrich JO. Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults. Cochrane Database Syst Rev 2014; :CD008639.
- Burns KE, Lellouche F, Nisenbaum R, et al. Automated weaning and SBT systems versus non-automated weaning strategies for weaning time in invasively ventilated critically ill adults. Cochrane Database Syst Rev 2014; :CD008638.