How should I wean and extubate an adult Intensive Care Unit patient intubated for a reversible acute illness who is hemodynamically stable (minimal vasopressor support, mean arterial pressure ≥ 65 mm Hg), has adequate oxygenation (fraction of inspired oxygen ≤ 0.4–0.5, positive end‑expiratory pressure ≤ 5–8 cm H₂O, PaO₂/FiO₂ ratio > 150–200 mm Hg), is awake and able to protect the airway, has normal respiratory drive (respiratory rate ≤ 30 breaths/min, tidal volume ≥ 5 ml/kg predicted body weight, minute ventilation ≤ 15 L/min), and passes a cuff‑leak test?

Liberation from Mechanical Ventilation: Evidence-Based Protocol

For this patient who meets all readiness criteria and passes a cuff-leak test, perform a 30-minute spontaneous breathing trial using pressure support ventilation (5-8 cm H₂O) with PEEP 5 cm H₂O, then proceed directly to extubation with standard supplemental oxygen therapy targeting SpO₂ 88-92%.

Step 1: Confirm Daily Readiness Criteria (Already Met)

Your patient satisfies all prerequisites for weaning 1:

• Reversible illness resolved or significantly improved 2, 1
• Hemodynamic stability: minimal vasopressor support with MAP ≥ 65 mm Hg 1, 3
• Adequate oxygenation: FiO₂ ≤ 0.4-0.5, PEEP ≤ 5-8 cm H₂O, PaO₂/FiO₂ > 150-200 1, 3
• Awake with airway protection capability 2, 1
• Normal respiratory drive: RR ≤ 30/min, Vt ≥ 5 ml/kg PBW, minute ventilation ≤ 15 L/min 1, 3
• Positive cuff-leak test 2

Step 2: Conduct the Spontaneous Breathing Trial

Use pressure support ventilation (5-8 cm H₂O) with PEEP 5 cm H₂O rather than a T-piece 1, 4. This approach increases SBT success rates from 76.7% to 84.6% and extubation success from 68.9% to 75.4%, with a trend toward lower ICU mortality (8.6% vs 11.6%) 1, 4, 5.

SBT Parameters:

• Duration: 30 minutes for standard-risk patients 1, 4, 6
• FiO₂: Maintain at ≤ 40% (do not increase during the trial) 1, 6
• PEEP: 5 cm H₂O 1, 4
• Pressure support: 5-8 cm H₂O 1, 4

Monitor for SBT Failure Criteria:

Stop the trial immediately if any of the following occur 1, 4:

• Respiratory rate > 35/min or increasing trend
• SpO₂ < 90%
• Heart rate > 140 bpm or sustained increase > 20%
• Systolic BP > 180 or < 90 mm Hg
• Increased anxiety or diaphoresis
• Use of accessory muscles or abdominal paradox

Most SBT failures occur within the first 30 minutes 1, 4, 6, so close monitoring during this period is critical.

Step 3: Proceed to Extubation

Since your patient passes the SBT and has a positive cuff-leak test, extubate directly to standard supplemental oxygen 1, 3. This patient does not meet high-risk criteria that would require prophylactic NIV.

High-Risk Criteria (NOT present in your patient):

• Age > 65 years with multiple comorbidities 1, 3
• Cardiac failure as primary cause of respiratory failure 1, 3
• Failure of more than one prior SBT 1, 3
• PaCO₂ > 45 mm Hg after extubation 1
• Weak cough or excessive secretions 2, 3

Post-Extubation Management:

• Target SpO₂ 88-92% using face mask or nasal cannula 1, 3
• Monitor continuously for the first 24 hours 1
• Maintain head of bed elevation 30-45 degrees 1
• Avoid over-oxygenation, particularly if chronic hypercapnia is present 1

Critical Pitfalls to Avoid

Do not use T-piece for the initial SBT 1, 4, 5. While T-piece trials may be more specific for high-risk patients, they are unnecessarily stringent for standard-risk patients and may delay extubation without improving outcomes 4, 5.

Do not repeat the SBT on the same day if it fails 4. Failed SBTs indicate respiratory muscle fatigue requiring time to resolve; focus instead on identifying and correcting the underlying cause 4.

Do not delay extubation in patients who pass their first SBT and lack high-risk features 1. The acceptable extubation failure rate is 5-10% 2, 3; attempting to achieve zero failures leads to unnecessarily prolonged mechanical ventilation 2.

Recognize that approximately 10% of patients who pass an SBT will still fail extubation 1, 4, 3. This is an acceptable rate and does not indicate inadequate assessment 2.

Why This Protocol Works

Protocol-driven weaning reduces mechanical ventilation duration by approximately 25 hours and shortens ICU stay by about 1 day 1, 7. The use of pressure support during SBTs (rather than T-piece) provides modest inspiratory assistance that more closely mimics post-extubation conditions while still adequately assessing the patient's ability to breathe independently 1, 4, 5.

The 2017 Anaesthesia guidelines strongly recommend performing an SBT before any extubation in ICU patients ventilated > 48 hours 2, but emphasize that the SBT alone is inadequate for detecting all patients at risk of extubation failure 2. This is why screening for specific risk factors (upper airway obstruction, ineffective cough, excessive secretions, swallowing disorders, altered consciousness) is essential 2—all of which your patient has passed.

Your patient's positive cuff-leak test significantly reduces the risk of post-extubation stridor, which accounts for 15% of early reintubations 2, 3. The cuff-leak test should be performed in all patients with risk factors for laryngeal edema (female gender, nasal intubation, difficult/traumatic intubation, large ETT, high cuff pressures) 2, 3.