Weaning from Mechanical Ventilation

Introduction
Weaning a patient from mechanical ventilation is now supported by a
substantial body of good quality clinical trials. Weaning or liberation from
mechanical ventilation (MV) is the process where the level of ventilatory
assistance is reduced concomitant with resolution of the patients disease or
requirement for ventilatory assistance.
It is a distinct process from extubation of the trachea but naturally precedes
this.
Key Point: It is important to distinguish causes of extubation failure
from weaning failure.
Up to 40% of the time spent on a mechanical ventilator is during the
withdrawal process. Removal from MV needs to be prompt to avoid
nosocomial complications. To minimize the duration of MV it is necessary to:

define and treat the underlying cause of respiratory failure and

discontinue MV on the earliest possible day

An appropriate level of ventilatory support should be maintained until the

underlying disease and any complicating issues have shown some sign of
reversal .Patients will be able to be removed from MV when they are readyventilation mode or type cannot expedite recovery.
Table 1: Weaning categories ( adapted from Brochard , CCM 2009)
Group/ category

Definition

Clinical problem

Simple weaning

Proceed with no difficulty

on first attempt

Recognise these patients

as soon as able

Difficult weaning

fail initial attempt require

several SBT

Establish cause
of failure

Prolonged weaning

Fail 3 attempts , require >7d

Global Rx needed
eg nutrition, sleep

Key Point: Simple weaning occurs in 60-70% of patients, 20-25% will

require longer, and 5-15% require prolonged ventilation and have
difficult weaning usually mandating tracheostomy

Key point : Reversible contributors should always be sought.

Reversible contributors :

Neurological
Cardiovascular
Respiratory System - Muscle/Load Interactions
Metabolic
Psychological

Improve neuromuscular competence

Treat sepsis, provide nutritional support, correct electrolytes, assure periods
of rest, and avoid exhausting breathing trials
Consider: neurologic disease/occult seizures, hypothyroidism, sedation, and
myopathy/neuropathy

ICU acquired paresis is associated with prolonged weaning

Investigational/unproven: anabolic steroids, aminophylline, and growth

hormone

Reduce respiratory load

Resistance: bronchodilators, steroids, excess secretions
Compliance: Rx Pneumonia, pulmonary oedema, reduce auto peep, drain
large pleural effusions, and treat decompress ileus/gut, evacuate
pneumothoraces
Minute ventilation (VE)
Treat sepsis, antipyretics, avoid overfeeding, and correct metabolic disorders

Predictive weaning indexes: what is their role in decision making?

Some of the variables that have been used to predict weaning success:

Over 66 independent predictors have been identified

Evidence is strongest (Cook et al Agency for health care policy and
Research 1999) for:
1. Max Insp Pressure (PI max)
2. Airway Occlusion Pressure (P 0.1)
3. Negative inspiratory force (NIF)
4. CROP score (compliance, rate, oxygenation, pressure)
5. Minute Volume
6. RR &VT
7. Index rapid shallow breathing (RVR or f/VT)

Key point : All weaning indices have low likelihood ratios (LR*)
indicating clinical applicability to individual patients is low
* Expression of the odds that a given test result will be present in a patient
with a given condition compared to a patient without the condition; LR >1
probability of success increases ;< 1probability of failure increases

Key point : RVR or f/Vt index is probably the best weaning indices.
Shallow, rapid ventilation is an index of failure. f/Vt : this records spontaneous
tidal volume as measured with a spirometer divided by respiratory rate. A
value <105 has been demonstrated to be helpful in prediction of extubation
outcome.

Weaning indices: a summary

Weaning failure often multi factorial single indices often therefore

unhelpful

Weaning parameters; consider them as common sense safety criteria

applied prior to a spontaneous breathing trial (SBT)
Any single criteria used in isolation serves poorly and should only be
used as a adjunct to clinical experience
Allow patients to progress to a SBT at the earliest possible time point
If using weaning criteria standardize and be consistent

Standardized Weaning Strategies

Key point : It is essential to test the patient early for ability to breathe
spontaneously. This is based on review of simple criteria.
A formal assessment for discontinuation (readiness to progress) can be
made in patient who have

reasonable degree of reversal of underlying cause(s) of ARF

adequate oxygenation e.g. FIO2 < 40%, PEEP 5
haemodynamic stability:
temperature < 38 C
capable of inspiratory effort, effective cough
awake/cooperative

An example of a Daily Screen- Readiness for Spontaneous Breathing

Trail (SBT) score sheet:
DATE/TIME:
Strong effective cough
Sedation ceased
Alert & co-operative
PaO2/FiO2 200
RVR < 100
PEEP 5
PASS / FAIL?
Discuss at ward round

If so,
:

decrease sedation
establish pressure support ventilation (PSV)
decrease PSV in 2 cm H2O steps ( clinical judgment), as rapidly as
tolerated
the f/Vt ratio may be calculated ;if >100 predictive of failure of SBT
Extubate if PS 8-10 / PEEP 5, FIO2 < 40% and no
contraindications to extubation ( see below)
OR: undertake spontaneous breathing trial (SBT) as follows

Key point: In some patients a SBT may be useful prior to decisions

about extubation.

Patients who meet weaning criteria should undergo a trial of spontaneous

breathing. What is a spontaneous breathing trial (SBT?)

Allowing a patient to breath spontaneously with minimal or no

ventilatory support for a predetermined time usually 30 to 120minutes
during close monitoring
Patients tolerant of SBT that are 30 120 min in length had successful
discontinuations 77% of the time
Few studies have evaluated the best method for performance of the
SBT
Whether it is done with low level PS, T piece or 5 cm H2 O CPAP
appear to have little effect on outcome

Key point: A low level of (<7cmH2O) PSV has been shown to be

equivalent to a T-piece trial in both adults and infants when performing a
T-piece trial.

30 minute trials are probably equally as effective as 120 minutes

NOTE: It is unclear in those that fail a SBT how many could be

successfully extubated- use clinical judgement
The criteria used to determine success of the SBT are chiefly clinical
(see below for an example)

How to perform a SBT:

Set ventilator to PSV 7 / PEEP 5

Low resistance T-piece circuit may also be used ( not Swedish
nose)

Whilst assessing:

respiratory rate (f), tidal volume (VT), f/VT ratio

pattern of breathing, accessory muscles
gas exchange
HR, BP, myocardial ischemia
sweating
patient discomfort, mental status

If SBT tolerated for 30-120 min, consider permanent ventilator discontinuation

If any failure parameters present, cease trial immediately and return to prior
ventilator settings.

An example of a Spontaneous Breathing Trail (SBT) score sheet:

FAILURE PARAMETERS
DATE/TIME:
Tachypnea: RR > 30
SaO2 < 90%
*RVR 100
90< Systolic BP >180
HR >140
Agitation, distress, GCS
PASS / FAIL?

SUCCESSFUL SBT:
Consider removal of endotracheal tube (ETT) if:

clinical condition resolved/ing

upper airway patent ( History, clinical )
ability to protect airway:

airway reflexes intact response

to tracheal suction

ability to cough and clear

secretions

low frequency of suctioning

low /controlled secretion load

conscious, co-operative- GCS < 8 aspiration risk high

cuff leak test may be useful in some laryngeal odema( see below)

PROBLEMS AFTER EXTUBATION:

If subsequent respiratory failure:

Re-intubate immediately for failed extubation if patient deteriorating

quickly and evident that other measures not applicable, if patient
stable(without marked respiratory distress): may consider,
If stridor: nebulized adrenaline (4-5 mg 1:1000 in saline)
and corticosteroids (dexamethasone 4 mg 6 hourly).
Gauge response and be prepared to re-intubate.

Other:

Non-invasive ventilation (NIV) ventilatory support

-generally not shown to improve outcome in post
extubation respiratory failure but may be useful in
selected high risk patients when used PRIOR to
respiratory failure developing e.g. COPD.

Cuff leak test: may be useful to perform prior to

extubation to help confirm space around the ETT. Can be
both qualitative and quantitative.
o Qualitative- absence of audible air leak after
deflation of balloon
o Quantitative- cuff leak volume < 10-15% of
delivered tidal volume ( difference between
inspired and expired Vt)

If no cuff leak or reduced volumes consider use of Methypredisolone

20mg Q4 hourly IV 12 hrs prior to extubation (see Francois, Lancet
369, 2007) - it is important to note that this test has significant false
positive rates so that the absence of a cuff leak may not preclude safe
extubation. In all cases clinical discretion is needed.

Modes of prolonged weaning

Table 2 : Rate of successful weaning with various weaning techniques

SIMV ventilation has been shown to be the worst method of weaning from
MV.PS ventilation has been studied in two major trials. Esteban found PS
ventilation used in weaning to be inferior to once daily T piece trials. Brochard
found PS ventilation was superior to other approaches including IMV and T
piece trials.
Key points: PS ventilation can be used as a weaning strategy by gradual
reduction of the level of PS until a minimal level is attained. IMV can also
be used with a once daily trial spontaneous breathing.

Summary
The majority (2/3) of unselected patients with respiratory failure can be
extubated on their first attempt of spontaneous breathing without any
special weaning technique
Weaning strategies may influence the duration of mechanical
ventilation- once daily trial of spontaneous breathing expedites
weaning-constrained use of IMV and SBT may delay weaning
compared with pressure support Ventilation (PSV)

 In patients that fail their initial attempt at spontaneous breathing IMV

weaning is inferior to other approaches
Multiple daily trials have not been shown to be superior to a once daily
trial and may only serve to fatigue the patient.
In between trials a stable non fatiguing level of support should be given
and the patient adequately rested.
PSV and SBT are equivalent in terms of weaning efficacy

FAILED SBT or Failure to progress:

A failed SBT or failure to progress may reflect persistent or

unresolved respiratory system abnormality
Patients receiving MV who fail an SBT should receive a stable
non-fatiguing form of ventilatory support
o Full ventilatory support in SIMV mode
o PSV with adequate PS level

Search and correct reversible causes- more than one may be

present
Ventilator- optimally adjust trigger setting and set method of
trigger (flow superior to pressure),ensure circuit optimal and ETT
appropriate size
Adjust for intrinsic PEEP ( COPD) add external PEEP to 75% of
the level of intrinsic PEEP ( PEEPi) to aid triggering
Maintain patients usual PaCO2 ( COPD)
Optimise nutrition and general care
Support patient psychologically
Develop a plan
Consider performing a tracheostomy before further weaning attempts
Subsequently,
If criteria for SBT met or low levels PS and PEEP attained, perform SBT each
morning 0800

Initially SBT for as long as possible once per day- usually am

Although evidence not conclusive multiple trials of spontaneous
breathing may be used (2-3 periods per day) with duration set according
to capability
Rest patient between with intervening PSV with PS at adequate level

Reduction in the level of PS (e.g decrease PS level in 1-2cm H2O steps

as tolerated, 2-3 times per day etc. may also be used) with or without
SBT and is equivalent to daily SBT.

TRACHEOSTOMY

Perform a tracheostomy if:

likely that prolonged ventilatory support is needed

inability to protect the airway

repeated failure of SBT/failure to progress

To achieve likely benefits of:

decreased sedation
decreased airway resistance
enhanced ability to eat, speak and communicate
discharge from ICU whilst retaining suction access and airway
protection
avoid morbidity and mortality of extubation failure

Note: this procedure is elective. Most are done percutaneously however some
require surgical input. There is no set time for when a tracheosotomy should
be performed. In some patients it will be clear one is needed early in others
not. As a general rule about 7-10 days is reasonable to assess the patient and
determine the course of action but shorter or longer times are acceptable.

Reference : Brochard L, Thille AW, CritCareMed2009 ;37:10