Weaning from mechanical
ventilation
Mechanical ventilation has gone through a
dramatic evolution over a relatively short
space of time. After the Copenhagen polio epi-
demic in 1952, negative pressure iron lungs
were replaced by intermittent positive pressure
ventilation. This was originally delivered at set
volumes and rates. The next step forward was
the introduction of intermittent mandatory
ventilation, and shortly thereafter this was
synchronized to the patients respiratory
effort. More recently, pressure support ventila-
tion and bi-level positive airway pressure
modes have become available. Modern ventil-
ators are increasingly sensitive, allowing easy
patient triggering of supported breaths,
modes such as tube compensation, and meas-
urement of numerous respiratory parameters.
Developments in weaning techniques have
paralleled these improvements in ventilator
functionality.
Conventional invasive ventilation is associ-
ated with a number of complications such as
pneumonia, tracheal stenosis and baro/volu-
trauma. Many of the complications increase
in likelihood with duration of ventilation. It
is therefore important to wean patients from
mechanical ventilation as quickly as possible.
Weaning from mechanical ventilation is the
process of reducing ventilatory support, ulti-
mately resulting in a patient breathing spontan-
eously and being extubated. This process can
be achieved rapidly in 80% of patients when
the original cause of the respiratory failure
has improved. The remaining cases will
require a more gradual method of withdrawing
ventilation.
Factors associated with
successful weaning
To enable weaning to be successful, thought
has to be given to the following areas:
(i) has the underlying condition improved?
(ii) is the patients general condition optimal?
(iii) have potential airway problems been
identified and remedied?
(iv) is breathing adequate?
doi 10.1093/bjaceaccp/mki031 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 4 2005
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Jeremy Lermitte BM FRCA
Mark J Garfield MB ChB FRCA
Cause of respiratory failure
In order for a patient to wean successfully, the Key points
cause of their respiratory failure has to have Weaning may be hastened by
been resolved to a reasonable level. Thought spontaneous breathing trials
has to be given to the patients state before and daily screening of
the current exacerbation to gauge what it is respiratory function.
possible to achieve, and allow setting of Respiratory rate/tidal
realistic aims. ventilation ratio is a good
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predictor of successful
General optimization weaning.
Synchronized intermittent
Careful preparation before potential weaning
mandatory ventilation is the
can make the difference in the numerous bor- least efficient method
derline weanable cases encountered in the of weaning.
intensive care. This is very important because
Use of non-invasive
those patients who are re-intubated in general
ventilation may improve
have worse outcomes. Common causes of outcome for some patients
weaning failure are listed in Table 1. Table 2 who develop respiratory
illustrates the usual preconditions that must be failure after extubation.
met before any consideration can be given to
the institution of a weaning programme.
Airway problems
To successfully wean a patient the artificial air-
way needs to be removed. For this to happen,
good upper airway reflexes are needed, includ-
ing an adequate cough and minimal secretions.
An adequate conscious level is required for
airway maintenance after extubation.
Airway (particularly laryngeal) oedema
may be under-recognized as a cause of diffi-
culty in breathing after extubation, occurring
Jeremy Lermitte BM FRCA
in 1015% of patients. The risk factors for post-
Specialist Registrar in Anaesthesia
extubation airway oedema include a medical Intensive Care Unit
reason for admission, a traumatic or difficult Ipswich Hospital NHS Trust
intubation, a history of self extubation, an Heath Road
Ipswich
overinflated tracheal tube cuff at admission, IP4 5UL
and intubation for extended periods. The abil-
Mark J Garfield MB ChB FRCA
ity to breathe around a deflated endotracheal
Consultant in Anaesthesia and Intensive
tube cuff, or the presence of a cuff leak >130 ml Care Medicine
during volume cycled ventilation, has been Intensive Care Unit
used to predict an adequate airway diameter.1 Ipswich Hospital NHS Trust
Heath Road
In those patients at risk, corticosteroids are Ipswich
commonly used, but there is little evidence to IP4 5UL
Tel: 01473 702016
support this practice.2 Post-extubation stridor
Fax: 01473 702323
may be ameliorated by epinephrine nebulizers E-mail: mark.garfield@doctors.org.uk
or inhalation of a helium/oxygen mixture. (for correspondence)
113
Weaning from mechanical ventilation

Table 1 Causes of weaning difficulty Table 3 Numerical indices used to predict successful weaning

Central drive Minute ventilation <10 litre min 1

Drive to breathe reduced by: Vital capacity/weight >10 ml kg 1
Sedatives Respiratory frequency <35 bpm
Direct insults to the respiratory centre Tidal volume/weight >5ml kg 1
Hyperventilation to abnormally low PaCO2 for a particular patient Maximum inspiratory pressure < 25 cm H2O
Metabolic alkalosis (commonly exacerbated by hypokalaemia) PaO2/PAO2 >0.35
Loss of hypoxic drive (COPD) Respiratory rate/tidal volume <100 litre 1
Clinically patients may fail to demonstrate respiratory distress and PaO2/FIO2 >200 mm Hg (26.3 kPa)
will in time develop Type II respiratory failure

Neuromuscular
A number of guidelines favour the use of the ratio of respiratory
Primary neurological disorders
GuillainBarre syndrome rate/tidal volume undertaken 1 min into a spontaneous breathing
Myasthenia Gravis trial (SBT).3 In addition, a reasonable level of oxygenation should
Botulism
be demonstrated, often assessed by the PaO2 /F IO2 ratio at a positive
Critical illness polyneuropathy (more common with steroids and
neuromuscular blocking agents) end-expiratory pressure (PEEP) <5 cm H2O. It is clear that

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Critical care myopathy/malnutrition despite their limitations, the systematic use of predictors produces
Electrolyte abnormalities
better outcomes than clinical judgement by physicians alone.4
Hypokalaemia
Hypophosphataemia
Hypomagnesaemia
Hypocalcaemia
Assessing adequacy of breathing
Hypothyroidism
The SBT is the traditional approach to weaning patients from
Increased respiratory load mechanical ventilation. This originally involved disconnecting
Increased resistance
Bronchospasm
the patient from the ventilator and connecting a device such as
Increased or thick secretions a T-piece. Other variants of SBTs include continuous positive
Reduced compliance airway pressure (CPAP), which may maintain the functional resid-
Pneumonia
Pulmonary oedema
ual capacity, and low level variable pressure support ventilation
Intrinsic PEEP (PSV) to overcome the resistance to breathing through an endo-
Pleural effusions tracheal tube (often called tube compensation).
Pneumothoraces
Paralytic ileus or abdominal distension
As well as assessing whether a patient is ready for extubation,
Increased ventilation SBTs of increasing duration can be used to aid the weaning process
Hypermetabolism (sepsis is a common cause) and can be performed without disconnecting the patient from the
Overfeeding
Metabolic acidosis
ventilator.
Shock When patients are considered ready to wean, the best way to
Pulmonary embolism assess whether they will breathe on their own is by undertaking an
SBT. It has been demonstrated that by doing this the weaning
Table 2 General preconditions for commencement of weaning
process may be hastened.
Trials comparing CPAP (5 cm H2O), PSV (7 cm H2O) and
Reversal of primary problem causing need for ventilation
Patient awake and responsive
T-piece methods to ascertain readiness for extubation do not dem-
Good analgesia, ability to cough onstrate any great superiority of one method relative to another. It
Reducing or minimal doses of inotropic support has also been shown that SBTs for 30 and 120 min are equivalent.4
Ideallyfunctioning bowels, absence of abdominal distension
Normalizing metabolic status
Evidence-based criteria for terminating weaning trials do not exist,
Adequate haemoglobin concentration so subjective clinical judgement is used backed up by arterial blood
gases. The criteria used in some clinical trials are shown in Table 4.
Continuous positive airway pressure administered after extuba- Patients successfully completing an SBT may proceed to
tion may also help. extubation. Those who fail SBTs may require a slower form of
weaning involving SBTs of a gradually increasing duration. Con-
Predicting successful weaning sideration may also be given to the formation of a tracheostomy.

Numerous numerical indices have been used to predict the out-

come of weaning, some of which are listed in Table 3. The sens-
itivities and specificities of each vary depending upon the cut-off
used. Many of the indices have good sensitivities but most have
low specificities. When looking at these indices, it is not only
important to look at the cut-off used but also the timing as to
when the test was undertaken.
Patients failing the spontaneous
breathing trial
Many patients will not pass a spontaneous breathing trial on their
first attempt (those with numerous comorbidities, the elderly and
patients who have been ventilated for long period of time often fall
into this category).

114 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 4 2005
 Weaning from mechanical ventilation

The best trials looking at the weaning of patients that fail their
initial spontaneous breathing trial have given conflicting results.
The ventilatory choices for these patients include the following:
(i) T-piece trials;
(ii) synchronized intermittent mandatory ventilation (SIMV); or
(iii) pressure support ventilation (PSV).
T-piece trials involve periods of supported ventilation being
gradually broken up by SBTs of increasing duration (most trials
increase these durations twice per day). There is some evidence
that once-daily breathing trials may be just as effective.6 Once the
Table 4 Criteria used in some trials to terminate (fail) SBTs
patient can manage 2 h without problems they are extubated
(see the criteria to terminate SBTs).
SIMV is undertaken by gradually reducing the mandatory
rate (most trials have done this by 24 bpm on a twice-daily
basis, or more regularly if tolerated). The end-point for these
SIMV patients is a rate of 45 min 1, for varying periods
of time depending upon the trial. Patients who meet preset criteria
are then extubated.
PSV involves gradually reducing the pressure to assist spon-
taneous breaths (most trials have done this by reducing the pres-
sure support by 24 cm H2O twice a day and more often if
tolerated). The end point is PSV at around 58 cm H2O for a
duration that varies from 2 to 24 h. Again, patients who have
reached this stage successfully are then extubated.

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Respiratory rate >35 bpm In the trial by Brochard and colleagues, PSV led to a signific-
SpO2 <90%
Heart rate >140 beats min 1 or change by >20% antly shorter duration of weaning relative to T-piece or SIMV
Systolic blood pressure >180 or <90 mm Hg methods.7 Esteban and colleagues, however, demonstrated
Agitation T-piece trials to be superior to either PSV or SIMV.6
Sweating
Anxiety or signs of increased In the majority of trials, SIMV was found to be the least effi-
work of breathing cient method of weaning. It must be noted, however, that in these
(paradoxical breathing, trials, there was no support for spontaneous breaths between trig-
intercostal retraction, nasal flaring)
gered mandatory breaths. Modern ventilators often combine

Reason for ventilation improved / resolved

Daily screening of respiratory function

Continue
(PaO2 /F IO2 >200, PEEP 5, adequate
ventilation
cough, f/VT<100, no vasopressors or
No
sedatives)

Yes
Gradual weaning
Spontaneous breathing trial
(daily T-piece trials
(30 min with T-piece, CPAP or low Poorly or pressure support
level pressure support)3 tolerated ventilation)4,5

Well
tolerated

Extubate

Respiratory failure post-

extubation

Intubate if
Consider trial of non-invasive
appropriate
ventilation for 12 h
(cardiogenic pulmonary oedema,
COPD, immunosuppressed, post-
thoracic surgery)6,9

Fig. 1 Algorithm for discontinuation of mechanical ventilation.

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 4 2005 115
Weaning from mechanical ventilation
SIMV or bi-level positive airway pressure and a form of PSV.
There is also evidence from both trials that protocols may
hasten weaning.
A suggested algorithm for discontinuation of mechanical
ventilation is shown in Figure 1.
Non-invasive ventilation
Patients who are re-intubated have higher complication and
mortality rates. Non-invasive ventilation could not only avoid
intubation in some patients, but may also have a role in preventing
re-intubation in patients who have failed extubation.8 Patients
with chronic obstructive pulmonary disease (COPD), and those
who are immunosuppressed with bilateral infiltrates, have been
shown to have reduced intubation and mortality rates with the
application of non-invasive ventilation. Benefit has also been
demonstrated for patients with cardiogenic pulmonary oedema.
Whether non-invasive ventilation has advantages over CPAP has
yet to be proven for this group of patients (one study actually
showed a higher rate of myocardial infarction with use of non-
invasive ventilation).
Studies looking at heterogeneous populations with acute
hypoxaemic respiratory failure have found no benefit in using
non-invasive ventilation to facilitate the discontinuation of con-
ventional ventilation or avoid re-intubation. Only trials looking at
patients with COPD or cardiogenic pulmonary oedema, or with
a predominance of such patients, have demonstrated improved
survival, decreased pneumonia rates and decreased length of
intensive care stays under these circumstances.911
Tracheostomies
It is a generally held belief, despite the lack of evidence demon-
strating direct benefit, that patients requiring long-term ventil-
atory support are better managed using a tracheostomy. Some
of the advantages include easier mouth care, improved mobility
of the patient, facilitation of oral nourishment; improved patient
comfort allowing decreased sedation and better communication.
Decreasing sedation use has been shown to reduce the length of
intensive care stay. In view of these advantages, it would prove
difficult to recruit patients for a trial comparing continued
translaryngeal and tracheostomy routes of ventilatory support.
Surgical and percutaneous tracheostomies have broadly been
shown to carry equal risk. The forthcoming randomized con-
trolled multi-centre Tracman trial is aiming to elucidate whether
there is an advantage to performing tracheostomies at a particular
time. One single centre randomized trial by Rumbak and col-
leagues,12 in a medical intensive care unit, demonstrated a reduced
length of stay, reduced mortality and nosocomial pneumonia rate
in the early tracheostomy group.
Patients proving difficult to wean
Equipment problems such as encrustation of the endotracheal
tube or secretions in the filter can influence the ability to wean.
116 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 4 2005
The endotracheal tube may itself cause bronchospasm. Obese
patients may require a higher level of PEEP while intubated to
prevent atelectasis. Those with severe restrictive disease may
normally breathe with a high respiratory rate. It may be appro-
priate in these sorts of patients to attempt an extubation.
Some patients will not wean quickly and may require the ser-
vices of a specialist-weaning unit. These units take a much longer-
term approach to weaning than most acute ICUs, and have a
number of ventilatory modalities at their disposal. In the UK,
they also have access to the resources required to arrange ongoing
ventilation in the community, whether invasive or non-invasive.
An example of referral criteria used in a recent study included
mechanical ventilation for more than 2 weeks, and having failed
two spontaneous breathing trials. Of 403 patients studied, 68%
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were successfully weaned from the ventilator. The hospital mor-
tality of those admitted was 25%. Only 50% of those admitted were
alive at 1 yr, and 38% at 3 yr.13
Weaning protocols
It is has been shown in many studies that use of a weaning protocol
reduces time on the ventilator and shortens ICU stay.14 Much of
this work has been conducted in open intensive care units in the
USA, many of which are not run by specialist intensive care physi-
cians. In these units, where a physician may only see patients once
per day, these nurse-led protocols clearly work. A recent study,
however, compared weaning by protocol with physician-directed
weaning in a closed ICU, staffed and directed by ICU-trained
physicians. The results showed no difference between the two
groups of patients with regard to duration of ventilation, ICU
stay, hospital and ICU mortality, and re-intubation rate.15 The
message from this study is that it is not the protocol that hastens
weaning, but the constant vigilance and attention that the protocol
necessitates.
Conclusion
All patients receiving ventilatory support should be assessed on a
daily basis for their suitability for weaning. This may involve
meeting several preconditions, and then an SBT. If unsuccessful,
weaning should be attempted using either PSV, or daily spontan-
eous breathing periods of increasing duration. A tracheostomy
may be helpful in patients who are difficult to wean. Over 95% of
patients should be weanable in this way. A few patients per year
may need referral to a long-term weaning unit.
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See multiple choice questions 8587.
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