Principles of Weaning from Ventilatory Support: When and Why to Wean and When to Consider a Tracheostomy

  • G. PizzilliEmail author
  • E. Brogi
  • V. Agnoletti
  • L. Ansaloni
  • F. Coccolini
Part of the Hot Topics in Acute Care Surgery and Trauma book series (HTACST)


Weaning and tracheostomy are two high-priority topics in intensive because extubation failure and prolonged mechanical ventilation both increase mortality. Still there are no clinical guidelines or gold standards to suggest the best practice for both, and many controversies are evinced by literature. It is crucial to screen systematically each day patient’s readiness to discontinuation because mortality risk increases every day after the first separation attempt; thus categorizing patients according to length of weaning process is fundamental to understand the prognosis. Key points of weaning are those reducing time to successful extubation. The suspicion that extubation may be possible should start a daily assessment or weaning and discontinuation readiness. When in doubt screening tests like f/Vt ratio could be performed before spontaneous breathing trial (SBT). Tracheostomy has become a common intervention in critically ill patients especially after the introduction of percutaneous techniques. Techniques and timing are issues of significant and often inconclusive debate in literature. Mortality of tracheostomized ventilated patients at 1 year is more than 50%. Therefore the current strategy should be to individualize the approach to tracheostomy taking into consideration the patient underlying comorbidities, reason for mechanical ventilation, potential complications, and life expectancy.


Weaning Tracheostomy Extubation Liberation Mechanical ventilation Spontaneous breathing trial Rapid shallow breathing index Early vs. late tracheostomy 


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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • G. Pizzilli
    • 1
    Email author
  • E. Brogi
    • 2
  • V. Agnoletti
    • 1
  • L. Ansaloni
    • 3
  • F. Coccolini
    • 3
  1. 1.Department of Anesthesia and Intensive CareM. Bufalini HospitalCesenaItaly
  2. 2.Department of Anesthesia and Intensive CareUniversity of PisaPisaItaly
  3. 3.Department of Emergency and Trauma SurgeryM. Bufalini HospitalCesenaItaly

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