Managing the apparent and hidden difficulties of weaning from mechanical ventilation
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In anaesthetized patients scheduled for surgery, tracheal intubation is performed with the expectation of subsequent smooth extubation. In critically ill patients, separation from the ventilator is often gradual and the time chosen for extubation may be either delayed or premature. Thus, weaning is challenging, represents a large part of the ventilation period and concerns all mechanically ventilated patients surviving their stay.
Definitions and management
Weaning may be stratified in three groups according to its difficulty and duration. In simple weaning the main issue is to detect the soonest time to start separation from the ventilator; this is frequently impeded by poor sedation management and excessive ventilator assistance. A two-step diagnostic approach is the most efficacious: screening for ascertained readiness to wean is confirmed by a diagnostic test simulating the post-extubation period, best performed by unassisted breathing (no PEEP). In case of test failure (difficult weaning), a structured and thorough diagnostic work-up regarding potentially reversible pathologies is required with a focus on cardiovascular dysfunction or fluid overload at the time of separation from the ventilator, respiratory or global muscle weakness and underlying infection. Prolonged weaning is exceptionally time- and resource-consuming, needs to properly appraise psychological problems, sleep and nutrition, and is probably best performed in specialized units.
Adequately managing simple and difficult weaning requires one to think about ICU policies in terms of sedation, fluid balance and having a systematic screening strategy; it also needs an individualized approach to understand and treat the failing patients. Prolonged weaning requires a holistic approach.
KeywordsMechanical ventilation Weaning Weaning groups Weaning failure
Conflicts of interest
LB’s research laboratory has received research grants from the following companies over the last 5 years: Drager (SmartCare), Covidien (PAV+), Vygon (CPAP), Philips Respironics (NIV), Fisher Paykel (Optiflow). There is no other conflict of interest.
- 1.Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melote C et al (2007) Weaning from mechanical ventilation. Statement of the Sixth International Consensus Conference on Intensive Care Medicine organized jointly by the European Respiratory Society (ERS), the American Thoracic Society (ATS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Francaise (SRLF). Eur Respir J 29:1033–1056PubMedCrossRefGoogle Scholar
- 5.Brochard L, Abroug F, Brenner M, Broccard AF, Danner RL, Ferrer M et al (2010) An official ATS/ERS/ESICM/SCCM/SRLF statement: prevention and management of acute renal failure in the ICU patient: an international consensus conference in intensive care medicine. Am J Respir Crit Care Med 181:1128–1155PubMedCrossRefGoogle Scholar
- 23.Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 371:126–134PubMedCrossRefGoogle Scholar
- 36.Thille AW, Richard JC, Brochard L (2013) The decision to extubate in the intensive care unit. Am J Respir Crit Care Med 187(12):1294–1302Google Scholar
- 54.Burns KEA, Meade MO, Lessard MR, Hand L, Zhou Q, Keenan SP et al (2013) Wean Earlier and Automatically with New Technology (The WEAN Study): a multicentre, pilot randomized controlled trial. Am J Respir Crit. Care Med 187(11):1203–1211Google Scholar
- 69.National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354:2564–2575Google Scholar
- 86.Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB (2004) A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32:1689–1694PubMedCrossRefGoogle Scholar
- 93.Nava S, Vitacca M (2006) Chronic ventilator facilities. In: Tobin MJ (ed) Principles and practice of mechanical ventilation, 2nd edn. McGraw-Hill, New York, pp 691–704Google Scholar
- 96.Jubran A, Grant BJB, Duffner LA, Collins EG, Lanuza DM, Hoffman LA et al (2013) Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA 309:671–677PubMedCrossRefGoogle Scholar