What are the strategies for weaning patients off mechanical ventilation (MV) devices?

From the Guidelines

The most effective strategy for weaning patients off mechanical ventilation (MV) devices is to use a combination of spontaneous breathing trials (SBTs) and pressure support reduction, as recommended by the American College of Chest Physicians/American Thoracic Society clinical practice guideline 1.

Key Strategies for Weaning

• Start with daily SBTs lasting 30-120 minutes, using either a T-piece or low levels of pressure support (5-8 cmH2O) 1.
• During SBTs, closely monitor the patient's respiratory rate, tidal volume, oxygen saturation, and work of breathing.
• If the patient tolerates the trial well, consider extubation.
• For patients not ready for SBTs, gradually reduce pressure support by 2-4 cmH2O every 4-6 hours, as tolerated, aiming to maintain a respiratory rate of 20-30 breaths per minute and tidal volumes of 4-8 mL/kg ideal body weight.

Multidisciplinary Approach

• Use a multidisciplinary approach involving respiratory therapists, nurses, and physicians to implement weaning protocols.
• Implement a daily sedation vacation to assess neurological status and optimize patient participation in weaning.
• Address underlying issues that may hinder weaning, such as fluid overload, electrolyte imbalances, or respiratory muscle weakness.

Additional Considerations

• Consider using inspiratory muscle training devices to strengthen respiratory muscles in prolonged ventilation cases, as recommended by the European Respiratory Society and European Society of Intensive Care Medicine task force on physiotherapy for critically ill patients 1.
• Noninvasive ventilation (NIV) may be used as a weaning strategy in a selected population of hypercapnic patients, and patients at risk of post-extubation ventilatory failure should be identified and considered for NIV 1.

Prioritizing Patient Readiness

• Assessment of the readiness for weaning should be undertaken daily, and a switch from controlled to assisted IMV should be made as soon as the patient recovery allows, as recommended by the BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults 1.

From the Research

Strategies for Weaning Patients Off Mechanical Ventilation (MV) Devices

The strategies for weaning patients off mechanical ventilation (MV) devices include:

• Frequent spontaneous breathing trials to shorten the time until ventilator liberation 2
• Early noninvasive mechanical ventilation to shorten invasive ventilation time 2
• Novel ventilatory modes, such as neurally adjusted ventilatory assist 2
• Use of drugs to enhance the contractile efficiency of respiratory muscles 2
• Use of ultrasound to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome 2
• Protocol-based weaning to study the duration of MV in ICUs 3
• Different techniques to conduct spontaneous breathing trials (SBT) 3
• Strategies to eventually extubate a patient whose initial SBT failed 3
• Weaning protocols and use of spontaneous breathing trials to promote timely weaning 4
• Bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility 4
• Use of automated weaning systems and modes that improve patient-ventilator interaction 4
• Mechanical insufflation-exsufflation as a weaning adjunct 4
• Early extubation to non-invasive ventilation and high flow humidified oxygen 4
• Early screening of weaning readiness based on established criteria 5
• Choice of the concept of ventilation and ventilator modes 5
• Use of weaning protocols, "closed loop" automated ventilation and weaning 5
• Ventilator weaning interventions, including enteral nutrition, tracheostomy, physical treatment, ventilation modes and settings, intervention bundles, and pharmacological interventions 6

Effective Interventions

Effective interventions for weaning patients off MV devices include:

• Ventilation modes and settings, such as novel ventilatory modes and automated weaning systems 2, 4, 6
• Pharmacological interventions, including analgesic agents, sedative agents, and other agents 6
• Intervention bundles, including bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility 4, 6
• Physical treatment, including early mobility and mechanical insufflation-exsufflation 4, 6

Areas for Future Research

Areas for future research include:

• Combining different interventions and investigating their interconnection 6
• Investigating the effects of nutrition, delirium treatment, and sleep promotion on ventilator weaning 6