Guideline sources The following summarized guidelines for the evaluation and management of weaning from mechanical ventilation are prepared by our editorial team based on guidelines from the European Society of Intensive Care Medicine (ESICM 2020), the Society of Critical Care Medicine (SCCM 2018), the Surviving Sepsis Campaign (SSC 2017), the American Thoracic Society (ATS/ACCP 2017), the European Respiratory Society (ERS 2017), the British Thoracic Society (BTS/ICS 2016), and the American Association for Respiratory Care (AARC/SCCM/ACCP 2001). 1 2 3 4 5 6 7 8 Guidelines 1. Screening and diagnosis Assessment for discontinuation: As per BTS 2016 guidelines, assess patients with hypercapnic respiratory failure daily for readiness to begin weaning from mechanical ventilation. B As per ACCP 2001 guidelines, obtain a formal assessment of readiness for discontinuation of mechanical ventilation if the following criteria are met: evidence for some reversal of the underlying cause for respiratory failure https://web.pathway.md/diseases/recJqy6Iju3qDwtJF 1/5 6/29/23, 3:15 AM Weaning from mechanical ventilation Pathway evidence for some reversal of the underlying cause for respiratory failure adequate oxygenation (such as PaO /FiO ratio > 150-200; requiring PEEP 5-8 cmH O; FiO 0.4-0.5) and pH ( 7.25) hemodynamic stability as defined by the absence of active myocardial ischemia and the absence of clinically significant hypotension (e.g. no vasopressor therapy or therapy with only low-dose vasopressors) capability to initiate an inspiratory effort. B Show 4 more 2. Diagnostic investigations Evaluation for ventilation dependence: Evaluate patients requiring mechanical ventilation for > 24 hours for all causes likely to contribute to ventilator dependence, especially if attempts at withdrawing the mechanical ventilator have failed. Reverse all possible ventilatory and non-ventilatory issues. B Determine the cause of a failed spontaneous breathing trial in patients receiving mechanical ventilation for respiratory failure. A 3. Diagnostic procedures Cuff-leak test: Consider performing a cuff leak test in mechanically ventilated adult patients deemed high risk for post-extubation stridor, such as: traumatic intubation intubation for more than 6 days large endotracheal tube for size female sex reintubation after an unplanned extubation. C 4. Respiratory support Spontaneous breathing trial: As per ATS 2017 guidelines, consider using inspiratory pressure augmentation (5-8 cmH O) rather than no inspiratory pressure augmentation (T-piece or CPAP) performing an initial spontaneous breathing trial in acutely hospitalized patients receiving mechanical ventilation for > 24 hours. C As per SSC 2017 guidelines, perform spontaneous breathing trials in mechanically ventilated patients with sepsis ready for weaning. A As per ACCP 2001 guidelines: Ensure slow-paced weaning and gradually lengthen self-breathing trials in patients with prolonged mechanical ventilation. B Perform subsequent spontaneous breathing trials every 24 hours once reversible causes for failure are corrected and if the patient still meets the following criteria: https://web.pathway.md/diseases/recJqy6Iju3qDwtJF 2/5 6/29/23, 3:15 AM Weaning from mechanical ventilation Pathway adequate oxygenation (such as PaO 60 mmHg on FiO 0.4, PEEP 5-10 cmH O, or PaO /FiO 150-300) stable cardiovascular system (HR 140, stable BP, no or minimal vasopressors) temperature < 38 C no significant respiratory acidosis stable metabolic status (acceptable electrolytes) hgb 8-10 g/dL adequate mentation (arousable, GCS 13, no continuous sedative infusions) resolution of disease acute phase discontinuation seems possible adequate cough. A Noninvasive ventilation: As per ATS 2017 guidelines, initiate preventative noninvasive ventilation following extubation in patients receiving mechanical ventilation for > 24 hours who are at high risk for extubation failure, such as patients with congestive HF, COPD, other serious comorbidities, or hypercapnia. B As per ERS 2017 guidelines, consider initiating noninvasive ventilation to facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure. C As per BTS 2016 guidelines: Initiate noninvasive ventilation to aid weaning from intermittent mechanical ventilation in patients with acute hypercapnic respiratory failure secondary to COPD. B Consider initiating noninvasive ventilation to reduce the duration of intermittent mandatory ventilation in other causes of acute hypercapnic respiratory failure if local expertise in its use exists (and of cough assist when indicated) and there are features indicating extubation is likely to be successful. C Intermittent mandatory ventilation: Switch from controlled to assisted intermittent mandatory ventilation as soon as patient recovery allows in patients with acute hypercapnic respiratory failure. B Ensure that patients receiving intermittent mandatory ventilation have a documented weaning plan. B Mechanical ventilation: provide a stable, non-fatiguing, comfortable form of ventilatory support in patients receiving mechanical ventilation for respiratory failure, if a spontaneous breathing trial has failed. B 5. Medical management Corticosteroids: consider administering systemic corticosteroids for at least 4 hours before extubation in adult patients who have failed a cuff-leak test, but are otherwise ready for extubation. C Anesthesia/sedation: As per SCCM 2018 guidelines, consider administering dexmedetomidine for delirium in adult patients receiving mechanical ventilation, if agitation is precluding weaning/extubation. C https://web.pathway.md/diseases/recJqy6Iju3qDwtJF 3/5 6/29/23, 3:15 AM Weaning from mechanical ventilation Pathway As per ATS 2017 guidelines, attempt to minimize sedation in acutely hospitalized patients ventilated for > 24 hours. B As per ACCP 2001 guidelines, use anesthesia/sedation strategies and ventilator management aimed at early extubation in postsurgical patients. A 6. Therapeutic procedures Extubation: decide on the removal of the artificial airway from a patient based on ability to interrupt ventilatory support, assessment of airway patency, and evaluation of the ability of the patient to protect the airway. B Tracheotomy: Consider performing tracheotomy after an initial period of stabilization on the ventilator when it becomes apparent that the patient will require prolonged ventilator assistance. Perform tracheotomy when the patient appears likely to gain 1 of the benefits ascribed to the procedure. Recognize that the following patients may derive particular benefit from early tracheotomy: patients requiring high levels of sedation to tolerate translaryngeal tubes patients with marginal respiratory mechanics (often manifested as tachypnea) if a tracheostomy tube having lower resistance might reduce the risk of muscle overload patients who may derive psychological benefit from the ability to eat PO, communicate by articulated speech and experience enhanced mobility patients in whom enhanced mobility may assist physical therapy efforts. C RBC transfusion thresholds: consider setting a restrictive transfusion threshold (7 g/dL) in critically ill adult patients with prolonged weaning from mechanical ventilation. C 7. Follow-up and surveillance Rehabilitation: consider offering protocolized rehabilitation directed toward early mobilization in acutely hospitalized adult patients undergoing mechanical ventilation for > 24 hours. C 8. Quality improvement Liberation protocols: As per ATS 2017 guidelines, consider using a a ventilator liberation protocol to manage acutely hospitalized adult patients mechanically ventilated for > 24 hours. C As per SSC 2017 guidelines, use a weaning protocol to assist in weaning patients with sepsis-induced respiratory failure from mechanical ventilation. B As per ACCP 2001 guidelines, develop and implement ICU weaning/discontinuation protocols designed for non-physician healthcare professionals. Develop and implement protocols aimed at optimizing sedation. A Studies https://web.pathway.md/diseases/recJqy6Iju3qDwtJF 4/5 6/29/23, 3:15 AM Weaning from mechanical ventilation Pathway 2020 REDECAP In critically ill adults in the ICU who had a tracheostomy tube after being weaned from mechanical ventilation, intervention was superior to control with respect to time to decannulation. Gonzalo Hern ndez Mart nez et al. N Engl J Med. 2020 Sep 10. References 1. N R MacIntyre, D J Cook, E W Ely Jr 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 Dec;120 6 Suppl):375S 95S. Open 2. Rhodes A, Evans LE, Alhazzani W et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43 3 304 377. Open 3. Daniel R Ouellette, Sheena Patel, Timothy D Girard 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 Jan;151 1 166 180. Open 4. Timothy D Girard, Waleed Alhazzani, John P Kress 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 Jan 1;195 1 120 133. Open 5. Devlin JW, Skrobik Y, G linas C et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018 Sep;46 9):e825-e873. Open 6. Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016 Apr;71 Suppl 2:ii1 35. Open 7. Alexander P Vlaar, Simon Oczkowski, Sanne de Bruin et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Apr;46 4 673 696. Open 8. Rochwerg B, Brochard L, Elliott MW et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug 31;50 2 . pii: 1602426. Open 9. DAS Taskforce, Ralf Baron, Andreas Binder et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 DAS Guideline 2015 short version. Ger Med Sci. 2015 Nov 12;13 Doc19. Open https://web.pathway.md/diseases/recJqy6Iju3qDwtJF 5/5