Since the inception of critical care medicine and artificial ventilation, literature and research on weaning has transformed daily patient care in intensive care units (ICU). As our knowledge of mechanical ventilation (MV) improved, so did the need to study patient-ventilator interactions and weaning predictors. Randomized trials have evaluated the use of protocol-based weaning (vs. usual care) to study the duration of MV in ICUs, different techniques to conduct spontaneous breathing trials (SBT), and strategies to eventually extubate a patient whose initial SBT failed. Despite considerable milestones in the management of multiple diseases contributing to reversible respiratory failure, in the application of early rehabilitative interventions to preserve muscle integrity, and in ventilator technology that mitigates against ventilator injury and dyssynchrony, major barriers to successful liberation from MV persist. This review provides a broad encompassing view of weaning classification, causes of weaning failure, and evidence behind weaning predictors and weaning modes.
TobinMJ. Remembrance of weaning past: the seminal papers. Intensive Care Med. 2006;32(10):1485‐1493.
2.
IbsenB. The Anaesthetist’s Viewpoint on the Treatment of Respiratory Complications in Poliomyelitis During the Epidemic in Copenhagen, 1952. Sage Publications; 1954.
3.
BjorkVOEngstromCG. The treatment of ventilatory insufficiency after pulmonary resection with tracheostomy and prolonged artificial ventilation. J Thorac Surg. 1955;30(3):356‐367.
HenningRJShubinHWeilMH. The measurement of the work of breathing for the clinical assessment of ventilator dependence. Crit Care Med.1977;5(6):264‐268.
6.
MacintyreNR. Evidence-based assessments in the ventilator discontinuation process. Respir Care. 2012;57(10):1611‐1618.
7.
AliaIEstebanA. Weaning from mechanical ventilation. Crit Care. 2000;4(2):72‐80.
BolesJMBionJConnorsA, et al.Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033‐1056.
10.
HeunksLMvan der HoevenJG. Clinical review: the ABC of weaning failure--a structured approach. Crit Care. 2010;14(6):245.
11.
DoorduinJHaansAJCHoevenJHeunksL. Difficult weaning: principles and practice of a structured diagnostic approach. Netherlands Journal of Critical Care. 2013;17(4):11.
12.
Sandoval MorenoLMCasas QuirogaICWilches LunaECGarciaAF. Efficacy of respiratory muscle training in weaning of mechanical ventilation in patients with mechanical ventilation for 48 hours or more: a randomized controlled clinical trial. Med Intensiva. 2019;43(2):79‐89.
13.
DoorduinJvan der HoevenJGHeunksLM. The differential diagnosis for failure to wean from mechanical ventilation. Curr Opin Anaesthesiol. 2016;29(2):150‐157.
14.
IshaayaAMNathanSDBelmanMJ. Work of breathing after extubation. Chest. 1995;107(1):204‐209.
15.
JubranATobinMJ. Passive mechanics of lung and chest wall in patients who failed or succeeded in trials of weaning. Am J Respir Crit Care Med. 1997;155(3):916‐921.
16.
JubranATobinMJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med. 1997;155(3):906‐915.
17.
WindischWGeiselerJSimonKWalterspacherSDreherMCommissionG. German National guideline for treating chronic respiratory failure with invasive and non-invasive ventilation - revised edition 2017: part 2. Respiration. 2018;96(2):171‐203.
18.
SchmidtGAGirardTDKressJP, et al.Official executive summary of an American thoracic society/American college of chest physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med.2017;195(1):115‐119.
19.
HashemianSMMortazEJamaatiH, et al.Budesonide facilitates weaning from mechanical ventilation in difficult-to-wean very severe COPD patients: association with inflammatory mediators and cells. J Crit Care. 2018;44:161‐167.
20.
RoutsiCStanopoulosIKokkorisSSiderisAZakynthinosS. Weaning failure of cardiovascular origin: how to suspect, detect and treat-a review of the literature. Ann Intensive Care.2019;9(1):6.
21.
TeboulJL. Weaning-induced cardiac dysfunction: where are we today?Intensive Care Med. 2014;40(8):1069‐1079.
22.
VetrugnoLBrussaAGuadagninGM, et al.Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 2. The Ultrasound Journal. 2020;12(1):15.
23.
KuriyamaAJacksonJLKameiJ. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. Crit Care.2020;24(1):640.
24.
GirardTDAlhazzaniWKressJP, et al.An official American thoracic society/American college of chest physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med.2017;195(1):120‐133.
25.
OuelletteDRPatelSGirardTD, et al.Liberation from mechanical ventilation in critically ill adults: an official American college of chest physicians/American thoracic society clinical practice guideline: inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation. Chest. 2017;151(1):166‐180.
26.
VogaG. Early and simple detection of diastolic dysfunction during weaning from mechanical ventilation. Crit Care.2012;16(4):137.
27.
LemaireFTeboulJLCinottiL, et al.Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology. 1988;69(2):171‐179.
28.
DresMTeboulJLAnguelNGuerinLRichardCMonnetX. Extravascular lung water, B-type natriuretic peptide, and blood volume contraction enable diagnosis of weaning-induced pulmonary edema. Crit Care Med. 2014;42(8):1882‐1889.
29.
Mekontso-DessapAde ProstNGirouE, et al.B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med. 2006;32(10):1529‐1536.
30.
RoutsiCStanopoulosIZakynthinosE, et al.Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study. Crit Care. 2010;14(6):R204.
31.
PandharipandePPGirardTDJacksonJC, et al.Long-term cognitive impairment after critical illness. N Engl J Med.2013;369(14):1306‐1316.
32.
KaplowR. Sleep disturbances and critical illness. Crit Care Nurs Clin North Am.2016;28(2):169‐182.
33.
KacmarekRMVillarJParrillaD, et al.Neurally adjusted ventilatory assist in acute respiratory failure: a randomized controlled trial. Intensive Care Med. 2020;46(12):2327‐2337.
34.
MayoPVolpicelliGLerolleNSchreiberADoelkenPVieillard-BaronA. Ultrasonography evaluation during the weaning process: the heart, the diaphragm, the pleura and the lung. Intensive Care Med. 2016;42(7):1107‐1117.
35.
AtayaASilvermanEPBagchiASarwalACrinerGJMcDonaghDL. Temporary transvenous diaphragmatic neurostimulation in prolonged mechanically ventilated patients: a feasibility trial (RESCUE 1). Crit Care Explor. 2020;2(4):e0106.
36.
DresMGama De AbreuMSimilowskiT. Late breaking abstract - temporary transvenous diaphragm neurostimulation in difficult-to-wean mechanically ventilated patients - results of the RESCUE 2 randomized controlled trial. Eur Respir J.2020;56(suppl 64):4352.
37.
HuangCJLinHC. Association between adrenal insufficiency and ventilator weaning. Am J Respir Crit Care Med.2006;173(3):276‐280.
38.
DattaDScaliseP. Hypothyroidism and failure to wean in patients receiving prolonged mechanical ventilation at a regional weaning center. Chest. 2004;126(4):1307‐1312.
39.
El-GazzarAGEl-SalahyMMEsswayTSMohammedSNElnaggarME. Effect of acute kidney injury on weaning from mechanical ventilation in chronic obstructive pulmonary diseases patients with respiratory failure. The Egyptian Journal of Bronchology. 2020;14(1):13.
40.
MacIntyreNRCookDJElyEWJr., et al.Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American college of chest physicians; the American association for respiratory care; and the American college of critical care medicine. Chest. 2001;120(6 Suppl):375S‐395S.
41.
YangKLTobinMJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med.1991;324(21):1445‐1450.
42.
MeadeMGuyattGCookD, et al.Predicting success in weaning from mechanical ventilation. Chest. Dec 2001;120(6 Suppl):400S‐424S.
43.
TaniosMANevinsMLHendraKP, et al.A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med. 2006;34(10):2530‐2535.
44.
BrochardLRaussABenitoS, et al.Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994;150(4):896‐903.
45.
ThilleAWCoudroyRGacouinA, et al.T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised controlled trial (TIP-EX). BMJ Open.2020;10(11):e042619.
46.
GuerinCTerziNMezidiM, et al.Low-pressure support vs automatic tube compensation during spontaneous breathing trial for weaning. Ann Intensive Care.2019;9(1):137.
47.
SchweickertWDGehlbachBKPohlmanASHallJBKressJP. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004;32(6):1272‐1276.
48.
BarrJFraserGLPuntilloK, et al.Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263‐306.
49.
JakobSMRuokonenEGroundsRM, et al.Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307(11):1151‐1160.
50.
LatronicoNBoltonCF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011;10(10):931‐941.
51.
De JongheBSharsharTLefaucheurJP, et al.Paresis acquired in the intensive care unit: a prospective multicenter study. Jama.2002;288(22):2859‐2867.
52.
GriffithsRDHallJB. Intensive care unit-acquired weakness. Crit Care Med. 2010;38(3):779‐787.
53.
AlhazzaniWAlshahraniMJaeschkeR, et al.Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care.2013;17(2):R43.
54.
LaiCCChouWChanKS, et al.Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Arch Phys Med Rehabil. 2017;98(5):931‐939.
55.
DubbRNydahlPHermesC, et al.Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc. 2016;13(5):724‐730.
56.
EstebanAFrutosFTobinMJ, et al.A comparison of four methods of weaning patients from mechanical ventilation. Spanish lung failure collaborative group. N Engl J Med.1995;332(6):345‐350.
57.
ThilleAWCoudroyRNayMA, et al.Pressure-Support ventilation vs T-piece during spontaneous breathing trials before extubation among patients at high risk of extubation failure: a post-hoc analysis of a clinical trial. Chest. 2020;158(4):1446‐1455.
58.
DadamMMGoncalvesARRMortariGL, et al.The effect of reconnection to mechanical ventilation for 1 hour after spontaneous breathing trial on reintubation among patients ventilated for more than 12 hours A randomized clinical trial. Chest. 2021;160(1):148‐156.
59.
BurnsKEARizviLCookDJ, et al.Ventilator weaning and discontinuation practices for critically ill patients. JAMA.2021;325(12):1173‐1184.
60.
GershengornHB. International variation in intubation and extubation practices and adverse events among critically ill patients receiving mechanical ventilation. JAMA.2021;325(12):1157‐1159.
61.
ElyEWBakerAMDunaganDP, et al.Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med.1996;335(25):1864‐1869.
62.
KollefMHShapiroSDSilverP, et al.A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567‐574.
63.
MarelichGPMurinSBattistellaFInciardiJVierraTRobyM. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118(2):459‐467.
64.
KrishnanJAMooreDRobesonCRandCSFesslerHE. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med.2004;169(6):673‐678.
