Ventilator Weaning

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Mechanical ventilation is an established supportive treatment for patients with various forms of respiratory failure. Despite the widespread use and clear benefits of mechanical ventilation, it is not a risk-free intervention. Prolonged mechanical ventilation increases the risk of pneumonia, barotrauma, tracheal injuries, and musculoskeletal deconditioning. At the same time, delayed weaning is associated with increased morbidity, mortality, hospital stay, and risk of long-term care facility discharge. The weaning process comprises almost 42% of the total duration of the ventilation. This activity describes the methods used to wean from the mechanical ventilator and highlights the interprofessional team's role in managing these patients.

Objectives:

  • Identify the etiology of respiratory failure that lead to the need for ventilation.

  • Outline the assessment of a patient being weaned from the ventilator.

  • Summarize the approaches to weaning a patient from a ventilator.

  • Explain interprofessional team strategies for improving care and outcomes in patients being weaned from the ventilator.

Introduction

Mechanical ventilation is an established supportive treatment for patients with various forms of respiratory failure. Despite the widespread use and clear benefits of mechanical ventilation, it is not a risk-free intervention. Prolonged mechanical ventilation increases the risk of pneumonia, barotrauma, tracheal injuries, and musculoskeletal deconditioning. At the same time, delayed weaning is associated with increased morbidity, mortality, hospital stay, and risk of long-term care facility discharge.[1][2]

For most patients (70%), weaning from mechanical ventilation is a straightforward process. That usually entails extubation after the passage of the first spontaneous breathing trial (SBT). The remaining 30% of patients represent a challenge for ICU physicians. Difficulties usually arise in patients with chronic obstructive and restrictive pulmonary disease, heart failure, and neuromuscular disorders, among other potential causes.

The weaning process comprises almost 42% of the total duration of the ventilation.[3] In our discussion, we review the most common barriers to successful ventilator weaning and the various extubation readiness assessment tools.[4][5][6]

Anatomy and Physiology

Respiratory Insufficiency

Arguably the most common mechanism underlying failure to wean patients off the ventilator. In its simplest form, the problem stems from an imbalance between respiratory pump capacity and demands.

Reduced Ventilatory Capacity  

The prolonged duration of mechanical ventilation, especially when accompanied by the use of passive modes of ventilation, can lead to diaphragmatic weakness and atrophy. Other factors contributing to respiratory muscle weakness include excessive steroids, sedatives, paralytic agent use, critical illness myopathy, a systemic inflammatory response associated with sepsis, malnutrition, and immobility. All of these factors are inherent to the ICU patient population; together, they trap the patient in a vicious circle where more weakness leads to more difficulty in weaning off the vent, leading to prolonged ICU stay and so forth.

Cardiovascular Insufficiency

Heart failure is another risk factor that can compound the ventilator weaning process. Important physiological changes occur during the process of transition from mechanical ventilation to spontaneous breathing. The most notable of which is a loss of positive intra-thoracic pressure. That results in an increase in venous return to the right ventricle and an increase in both preload and afterload. This is particularly relevant in the ICU patient population, most of whom have variable degrees of positive fluid balance. That increase in cardiac work can raise myocardial oxygen demand and precipitate ischemia in patients with coronary artery disease. 

Technique or Treatment

There are many barriers to safe liberation from mechanical ventilation.[7] The aim is to accomplish opportune weaning (weaning within 24 hours of fulfilling the required criteria) while preventing premature or delayed weaning.[8]

Critical Steps in the Weaning and Extubation Process

  1. Induction of Intermittent Mandatory Ventilation (IMV) after confirming the patient's readiness.
  2. Spontaneous breathing trial (SBT) for at least 30 minutes.
  3. Cuff-leak test. [9]

The most critical component in the weaning process is appropriately determining the patient's readiness to initiate the weaning process.[10]

Examining Readiness to Wean From Mechanical Ventilation

Despite the known hazards associated with prolonged mechanical ventilation, many patients remain unnecessarily intubated for more extended periods than needed. This knowledge stems from the fact that patients who accidentally self-extubate have a 31-78% risk of reintubation. That means the same patient population has a 22-69% chance of successfully weaning off mechanical ventilation. Even the most experienced clinicians may underestimate a patient's readiness for ventilator weaning.

This is why major critical care societies strongly encourage the implementation of protocols for daily sedation interruption and spontaneous breathing trials. However, before a patient is considered for ventilator weaning, the following questions are well worth considering to ensure maximum chances of successful ventilator weaning:

  • Has the disease process that led to mechanical ventilation resolved or improved?
  • Is the patient hemodynamically stable? Absence of shock or requirement for pressors or significant arrhythmias
  • Is the patient adequately oxygenated? (Fraction of inspired oxygen <50% and/or low PEEP requirements)
  • Is the patient adequately awake and communicative? (absence of encephalopathy, agitation, or overtly altered mental status)

Note that the presence of any of the above parameters doesn't guarantee weaning failure. The opposite also holds true. Because clinical judgment may sometimes over or underestimate a patient's readiness, a need for objective measures exists. Those indices should ideally be easily measurable and widely applicable.

Some suggested indices correlate directly with ventilatory parameters, such as minute ventilation (VE) or vital capacity(VC). Other indices correlate with the degree of oxygen requirements, such as the ratio of arterial to alveolar oxygen ratio (Pao2/PAo2), the ratio of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) ratio, or the alveolar-arterial oxygen gradient (A-a gradient). Also, some parameters examine respiratory muscle strength, such as maximal inspiratory pressure (MIP).

There are so many indices because none of them is perfect. There is a wide degree of variability in the performance of the above tests, and their predictive value is far from optimal. The reason being is that these indices only measure one aspect of the respiratory function, while the weaning process is complex and multifactorial.

Rapid Shallow Breathing Index (RSBI)

Defined as the ratio of respiratory rate (f) to tidal volume (VT), initially described by Yang and Tobin 1991. Their trial found that RSBI <105 correlated with weaning success, while a score >105 correlated with weaning failure.[11] The reported sensitivity, specificity, positive predictive value, and negative predictive values were  97, 64, 78, and 95 percent, respectively. Since the initial description, their results were confirmed in multiple subsequent trials, and their test has gained wide popularity and is integrated into ventilator liberation protocols in many ICUs.The test is ideally conducted over 30 minutes while the patient is on minimal pressure support ventilation (PSV) and/or a small PEEP value. 

Diaphragmatic rapid shallow breathing index comprising:

  • Diaphragmatic excursion rapid shallow breathing index (DE-RSBI)
  • Respiratory rate [RR]/DE) and the
  • Diaphragm thickening fraction rapid shallow breathing index (DTF-RSBI, RR/DT showed a higher predictability value compared to RSBI alone.[12][13]

Adjuncts to Predict and Facilitate Safe Weaning

  • Diaphragmatic ultrasound to assess Diaphragm thickening fraction (DTF).[14] A point-of-care ultrasound comprising of the lung, diaphragm (diaphragmatic thickness fraction), and cardiac dynamic assessment of changes to velocity time integral (VTI) following passive leg raise is also helpful in assessing the readiness for the weaning process.[15]
  • Assessment of Airway occlusion pressure (P0.1), central venous-to-arterial pO2 gradient, and central venous oxygen saturation during SBT.[11]
  • Daily sedation interruption (DSI) facilitates weaning.[16]
  • An early rise in CVP after starting an SBT has a high risk of extubation failure.[17]
  • The frailty index is also crucial.[18]
  • Diaphragm EMG.[19]
  • Extubation predictive score (ExPreS) score of ≥59 points has an OR of 23.07 for safe extubation.[9]
  • Machine learning.[20]
  • Brain natriuretic peptide (BNP).[21]
  • Mechanical Ventilation-Respiratory Distress Observation Scale (MV-RDOS.)[22]

Complications

Spontaneous Breathing Trial (SBT)

Patients should be assessed daily for readiness to wean off mechanical ventilation. Trials are often part of an ICU protocol for ventilator liberation and usually start after the patient fulfills many of the criteria mentioned previously. Trials should be conducted with the patient off sedation, on minimal ventilator support (pressure support ventilation PSV of 5-8 mmHg or less and/or a small amount of PEEP. There is some data to suggest using zero PSV and zero PEEP (known as ZEEP trials), which seems to correlate with higher chances of successful ventilator weaning.

For a spontaneous breathing trial to be considered successful, a patient should be able to breathe for at least 30 minutes without signs of hemodynamic derangement (respiratory rate <35, no significant elevation or drop in blood pressure, oxygen saturation >90%), and with the absence of signs of distress or anxiety is usually combined with one of the readiness indices, such as the RSBI calculated at the beginning and end of each trial. Other factors to consider include respiratory secretions burden, the presence of a strong cough, and the ability to maintain adequate wakefulness. A successful trial is usually followed by a cuff leak test and removal of the endotracheal tube, and discontinuation of mechanical ventilation.

The cuff leak test is to ensure there is an adequate gas leak around the endotracheal tube after the cuff is deflated. This ensures the airway is patent without significant laryngeal edema. Failure to fulfill one or more of the aforementioned parameters usually correlates with higher chances of weaning failure and reintubation. Those patients should be placed back on comfortably, controlled mode with appropriate sedation. A careful work-up should be done to examine underlying barriers to a successful weaning process. It is worth mentioning that the clinician’s judgment is an important consideration when considering extubation. An experienced clinician can often combine all the data and see through an apparently failed weaning parameter.SBT duration (30–120 min) has almost an 80% chance of safe extubation.[3]

Extubation to Non-invasive Ventilation (NIV)

Although previously thought of as a failed weaning attempt, it is currently endorsed by the American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) to extubate patients to preventive non-invasive ventilation. Multiple studies correlated extubation to NIV with shorter ICU length of stay and short-term mortality. Patients who should be considered for such intervention include high-risk intubated patients, including those who repeatedly fail their SBT, patients with advanced COPD or CHF, hypercapnic patients, and those >65 years of age. NIV is applied to patients with failed weaning from prolonged ventilation.[23] NIV had fewer days requiring IMV and a shorter antibiotic duration for respiratory infections.[24] This achieved de-cannulation in 43% of chronic ventilator-dependent patients.[25]

If the patient fails SBT, gradual reduction in pressure support (PS) or daily T-piece trials), or following ventilatory setup can be adopted:

  • Synchronized intermittent mandatory ventilation (SIMV)
  • Continuous positive airway pressure (CPAP)
  • Adaptive support ventilation (ASV)
  • Airway pressure release ventilation (APRV)
  • Proportional assist ventilation (PAV) or
  • Neurally adjusted ventilator assist (NAVA)[26]

The protocol-based approach is recommended for a safe and effective weaning process.[11][27] Dichotomizing the “right patients” and weaning these patients at the “right time” is fundamental in the weaning process.[11]

Clinical Significance

Common reasons for failed weaning include:

  • Cardiac dysfunction
  • Cognitive dysfunction
  • Respiratory pump failure
  • Respiratory muscle and diaphragmatic dysfunction
  • Metabolic disorders

Details

Author

Mario Fadila

Author

Venkat Rajasurya

Editor:

Hariharan Regunath

Updated:

12/10/2022 6:59:17 PM

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References

[1]

Wawrzeniak IC, Regina Rios Vieira S, Almeida Victorino J. Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management. BioMed research international. 2018:2018():5423639. doi: 10.1155/2018/5423639. Epub 2018 Oct 9     [PubMed PMID: 30402484]

Level 3 (low-level) evidence

[2]

Yeung J, Couper K, Ryan EG, Gates S, Hart N, Perkins GD. Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis. Intensive care medicine. 2018 Dec:44(12):2192-2204. doi: 10.1007/s00134-018-5434-z. Epub 2018 Oct 31     [PubMed PMID: 30382306]

Level 1 (high-level) evidence

[3]

Augustus Oglesby HJ, Cataldo SH, Pedro MJ. Automated Near Real-Time Ventilator Data Feedback Reduces Incidence of Ventilator-Associated Events: A Retrospective Observational Study. Critical care explorations. 2021 Apr:3(4):e0379. doi: 10.1097/CCE.0000000000000379. Epub 2021 Apr 2     [PubMed PMID: 33834169]

Level 2 (mid-level) evidence

[4]

Perkins GD, Mistry D, Gates S, Gao F, Snelson C, Hart N, Camporota L, Varley J, Carle C, Paramasivam E, Hoddell B, McAuley DF, Walsh TS, Blackwood B, Rose L, Lamb SE, Petrou S, Young D, Lall R, Breathe Collaborators. Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial. JAMA. 2018 Nov 13:320(18):1881-1888. doi: 10.1001/jama.2018.13763. Epub     [PubMed PMID: 30347090]

Level 1 (high-level) evidence

[5]

Jung YT, Kim MJ, Lee JG, Lee SH. Predictors of early weaning failure from mechanical ventilation in critically ill patients after emergency gastrointestinal surgery: A retrospective study. Medicine. 2018 Oct:97(40):e12741. doi: 10.1097/MD.0000000000012741. Epub     [PubMed PMID: 30290686]

Level 2 (mid-level) evidence

[6]

Obi ON, Mazer M, Bangley C, Kassabo Z, Saadah K, Trainor W, Stephens K, Rice PL, Shaw R. Obesity and Weaning from Mechanical Ventilation-An Exploratory Study. Clinical medicine insights. Circulatory, respiratory and pulmonary medicine. 2018:12():1179548418801004. doi: 10.1177/1179548418801004. Epub 2018 Sep 18     [PubMed PMID: 30245572]

[7]

Burns KEA, Agarwal A, Bosma KJ, Chaudhuri D, Girard TD. Liberation from Mechanical Ventilation: Established and New Insights. Seminars in respiratory and critical care medicine. 2022 Jun:43(3):461-470. doi: 10.1055/s-0042-1747929. Epub 2022 Jun 27     [PubMed PMID: 35760299]

[8]

Diaz-Soto MP, Morgan BW, Davalos L, Herrera P, Denney J, Roldan R, Paz E, Jaymez AA, Chirinos EE, Portugal J, Quispe R, Brower RG, Checkley W, INTENSIVOS Cohort Study. Premature, Opportune, and Delayed Weaning in Mechanically Ventilated Patients: A Call for Implementation of Weaning Protocols in Low- and Middle-Income Countries. Critical care medicine. 2020 May:48(5):673-679. doi: 10.1097/CCM.0000000000004220. Epub     [PubMed PMID: 31934892]

[9]

Baptistella AR, Mantelli LM, Matte L, Carvalho MEDRU, Fortunatti JA, Costa IZ, Haro FG, Turkot VLO, Baptistella SF, de Carvalho D, Nunes Filho JR. Prediction of extubation outcome in mechanically ventilated patients: Development and validation of the Extubation Predictive Score (ExPreS). PloS one. 2021:16(3):e0248868. doi: 10.1371/journal.pone.0248868. Epub 2021 Mar 18     [PubMed PMID: 33735250]

Level 1 (high-level) evidence

[10]

Awang S, Alias N, DeWitt D, Jamaludin KA, Abdul Rahman MN. Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training. Frontiers in public health. 2021:9():726647. doi: 10.3389/fpubh.2021.726647. Epub 2021 Nov 12     [PubMed PMID: 34869147]

Level 1 (high-level) evidence

[11]

Wang Y, Lei L, Yang H, He S, Hao J, Liu T, Chen X, Huang Y, Zhou J, Lin Z, Zheng H, Lin X, Huang W, Liu X, Li Y, Huang L, Qiu W, Ru H, Wang D, Wu J, Zheng H, Zuo L, Zeng P, Zhong J, Rong Y, Fan M, Li J, Cai S, Kou Q, Liu E, Lin Z, Cai J, Yang H, Li F, Wang Y, Lin X, Chen W, Gao Y, Huang S, Sang L, Xu Y, Zhang K. Weaning critically ill patients from mechanical ventilation: a protocol from a multicenter retrospective cohort study. Journal of thoracic disease. 2022 Jan:14(1):199-206. doi: 10.21037/jtd-21-1217. Epub     [PubMed PMID: 35242382]

Level 2 (mid-level) evidence

[12]

Shamil PK, Gupta NK, Ish P, Sen MK, Kumar R, Chakrabarti S, Gupta N. Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2022 Sep:26(9):1000-1005. doi: 10.5005/jp-journals-10071-24316. Epub     [PubMed PMID: 36213711]

[13]

Song J, Qian Z, Zhang H, Wang M, Yu Y, Ye C, Hu W, Gong S. Diaphragmatic ultrasonography-based rapid shallow breathing index for predicting weaning outcome during a pressure support ventilation spontaneous breathing trial. BMC pulmonary medicine. 2022 Sep 7:22(1):337. doi: 10.1186/s12890-022-02133-5. Epub 2022 Sep 7     [PubMed PMID: 36071420]

Level 2 (mid-level) evidence

[14]

Mahmoodpoor A, Fouladi S, Ramouz A, Shadvar K, Ostadi Z, Soleimanpour H. Diaphragm ultrasound to predict weaning outcome: systematic review and meta-analysis. Anaesthesiology intensive therapy. 2022:54(2):164-174. doi: 10.5114/ait.2022.117273. Epub     [PubMed PMID: 35792111]

Level 1 (high-level) evidence

[15]

Kundu R, Baidya D, Anand R, Maitra S, Soni K, Subramanium R. Integrated ultrasound protocol in predicting weaning success and extubation failure: a prospective observational study. Anaesthesiology intensive therapy. 2022:54(2):156-163. doi: 10.5114/ait.2022.115351. Epub     [PubMed PMID: 35413786]

Level 2 (mid-level) evidence

[16]

Vagionas D, Vasileiadis I, Rovina N, Alevrakis E, Koutsoukou A, Koulouris N. Daily sedation interruption and mechanical ventilation weaning: a literature review. Anaesthesiology intensive therapy. 2019:51(5):380-389. doi: 10.5114/ait.2019.90921. Epub     [PubMed PMID: 31893604]

[17]

Dubo S, Valenzuela ED, Aquevedo A, Jibaja M, Berrutti D, Labra C, Lagos R, García MF, Ramírez V, Tobar M, Picoita F, Peláez C, Carpio D, Alegría L, Hidalgo C, Godoy K, Bruhn A, Hernández G, Bakker J, Castro R. Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure? PloS one. 2019:14(12):e0225181. doi: 10.1371/journal.pone.0225181. Epub 2019 Dec 5     [PubMed PMID: 31805071]

[18]

Matsuda W, Uemura T, Yamamoto M, Uemura Y, Kimura A. Impact of frailty on protocol-based weaning from mechanical ventilation in patients with sepsis: a retrospective cohort study. Acute medicine & surgery. 2020 Jan-Dec:7(1):e608. doi: 10.1002/ams2.608. Epub 2020 Nov 30     [PubMed PMID: 33299566]

Level 2 (mid-level) evidence

[19]

Arboleda A, Amado L, Rodriguez J, Naranjo F, Giraldo BF. A new protocol to compare successful versus failed patients using the electromyographic diaphragm signal in extubation process. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference. 2021 Nov:2021():5646-5649. doi: 10.1109/EMBC46164.2021.9629815. Epub     [PubMed PMID: 34892403]

[20]

Otaguro T, Tanaka H, Igarashi Y, Tagami T, Masuno T, Yokobori S, Matsumoto H, Ohwada H, Yokota H. Machine Learning for Prediction of Successful Extubation of Mechanical Ventilated Patients in an Intensive Care Unit: A Retrospective Observational Study. Journal of Nippon Medical School = Nippon Ika Daigaku zasshi. 2021 Nov 17:88(5):408-417. doi: 10.1272/jnms.JNMS.2021_88-508. Epub 2021 Mar 9     [PubMed PMID: 33692291]

Level 2 (mid-level) evidence

[21]

Deschamps J, Webber J, Featherstone R, Sebastianski M, Vandermeer B, Senaratne J, Bagshaw SM. Brain natriuretic peptide to predict successful liberation from mechanical ventilation in critically ill patients: protocol for a systematic review and meta-analysis. BMJ open. 2019 Feb 12:9(2):e022600. doi: 10.1136/bmjopen-2018-022600. Epub 2019 Feb 12     [PubMed PMID: 30760513]

Level 1 (high-level) evidence

[22]

Decavèle M, Rozenberg E, Niérat MC, Mayaux J, Morawiec E, Morélot-Panzini C, Similowski T, Demoule A, Dres M. Respiratory distress observation scales to predict weaning outcome. Critical care (London, England). 2022 Jun 6:26(1):162. doi: 10.1186/s13054-022-04028-7. Epub 2022 Jun 6     [PubMed PMID: 35668459]

[23]

Ceriana P, Nava S, Vitacca M, Carlucci A, Paneroni M, Schreiber A, Pisani L, Ambrosino N. Noninvasive ventilation during weaning from prolonged mechanical ventilation. Pulmonology. 2019 Nov-Dec:25(6):328-333. doi: 10.1016/j.pulmoe.2019.07.006. Epub 2019 Sep 10     [PubMed PMID: 31519534]

[24]

Perkins GD, Mistry D, Lall R, Gao-Smith F, Snelson C, Hart N, Camporota L, Varley J, Carle C, Paramasivam E, Hoddell B, de Paeztron A, Dosanjh S, Sampson J, Blair L, Couper K, McAuley D, Young JD, Walsh T, Blackwood B, Rose L, Lamb SE, Dritsaki M, Maredza M, Khan I, Petrou S, Gates S. Protocolised non-invasive compared with invasive weaning from mechanical ventilation for adults in intensive care: the Breathe RCT. Health technology assessment (Winchester, England). 2019 Sep:23(48):1-114. doi: 10.3310/hta23480. Epub     [PubMed PMID: 31532358]

[25]

Ghiani A, Tsitouras K, Paderewska J, Milger K, Walcher S, Weiffenbach M, Neurohr C, Kneidinger N. Incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning. Therapeutic advances in chronic disease. 2022:13():20406223221109655. doi: 10.1177/20406223221109655. Epub 2022 Aug 5     [PubMed PMID: 35959504]

Level 3 (low-level) evidence

[26]

Lewis KA, Chaudhuri D, Guyatt G, Burns KEA, Bosma K, Ge L, Karachi T, Piraino T, Fernando SM, Ranganath N, Brochard L, Rochwerg B. Comparison of ventilatory modes to facilitate liberation from mechanical ventilation: protocol for a systematic review and network meta-analysis. BMJ open. 2019 Sep 5:9(9):e030407. doi: 10.1136/bmjopen-2019-030407. Epub 2019 Sep 5     [PubMed PMID: 31492786]

Level 1 (high-level) evidence

[27]

Akella P, Voigt LP, Chawla S. To Wean or Not to Wean: A Practical Patient Focused Guide to Ventilator Weaning. Journal of intensive care medicine. 2022 Nov:37(11):1417-1425. doi: 10.1177/08850666221095436. Epub 2022 Jul 11     [PubMed PMID: 35815895]

[28]

Gunther I, Pradhan D, Lubinsky A, Urquhart A, Thompson JA, Reynolds S. Use of a Multidisciplinary Mechanical Ventilation Weaning Protocol to Improve Patient Outcomes and Empower Staff in a Medical Intensive Care Unit. Dimensions of critical care nursing : DCCN. 2021 Mar-Apr 01:40(2):67-74. doi: 10.1097/DCC.0000000000000462. Epub     [PubMed PMID: 33961373]

[29]

Vahedian-Azimi A, Bashar FR, Jafarabadi MA, Stahl J, Miller AC, MORZAK Collaborative. Protocolized ventilator weaning verses usual care: A randomized controlled trial. International journal of critical illness and injury science. 2020 Oct-Dec:10(4):206-212. doi: 10.4103/IJCIIS.IJCIIS_29_20. Epub 2020 Dec 29     [PubMed PMID: 33850830]

Level 1 (high-level) evidence

[30]

Ramirez KE, Wettstein RW, Cuevas S, Gardner DD, Restrepo RD. Adherence to an Oxygen-Weaning Protocol in Mechanically Ventilated Adults in the Medical ICU. Respiratory care. 2020 Oct:65(10):1496-1501. doi: 10.4187/respcare.07432. Epub 2020 Mar 24     [PubMed PMID: 32209711]

[31]

Surani S, Sharma M, Middagh K, Bernal H, Varon J, Ratnani I, Anjum H, Khan A. Weaning from Mechanical Ventilator in a Long-term Acute Care Hospital: A Retrospective Analysis. The open respiratory medicine journal. 2020:14():62-66. doi: 10.2174/1874306402014010062. Epub 2020 Dec 18     [PubMed PMID: 33425068]

Level 2 (mid-level) evidence

[32]

Burns KEA, Rizvi L, Cook DJ, Dodek P, Slutsky AS, Jones A, Villar J, Kapadia FN, Gattas DJ, Epstein SK, Meade MO, Canadian Critical Care Trials Group. Variation in the practice of discontinuing mechanical ventilation in critically ill adults: study protocol for an international prospective observational study. BMJ open. 2019 Sep 8:9(9):e031775. doi: 10.1136/bmjopen-2019-031775. Epub 2019 Sep 8     [PubMed PMID: 31501132]

Level 2 (mid-level) evidence

[33]

Haaksma ME, Tuinman PR, Heunks L. Weaning the patient: between protocols and physiology. Current opinion in critical care. 2021 Feb 1:27(1):29-36. doi: 10.1097/MCC.0000000000000790. Epub     [PubMed PMID: 33337620]

Level 3 (low-level) evidence

[34]

Leung CHC, Lee A, Arabi YM, Phua J, Divatia JV, Koh Y, Du B, Tan CC, Palo JEM, Burns KEA, Kim TH, Egi M, Faruq MO, Shrestha BR, Liu SF, Nguyen TD, Wahjuprajitno B, Hashmi M, Patjanasoontorn B, Latif Z, Indraratna K, Al Rahma HN, Hashemian SMR, Gomersall CD. Mechanical Ventilation Discontinuation Practices in Asia: A Multinational Survey. Annals of the American Thoracic Society. 2021 Aug:18(8):1352-1359. doi: 10.1513/AnnalsATS.202008-968OC. Epub     [PubMed PMID: 33284738]

Level 3 (low-level) evidence

[35]

Balas MC, Tate J, Tan A, Pinion B, Exline M. Evaluation of the Perceived Barriers and Facilitators to Timely Extubation of Critically Ill Adults: An Interprofessional Survey. Worldviews on evidence-based nursing. 2021 Jun:18(3):201-209. doi: 10.1111/wvn.12493. Epub 2021 Feb 8     [PubMed PMID: 33555122]

Level 3 (low-level) evidence

[36]

Sánchez-Maciá M, Miralles-Sancho J, Castaño-Picó MJ, Pérez-Carbonell A, Maciá-Soler L. Reduction of ventilatory time using the multidisciplinary disconnection protocol. Pilot study. Revista latino-americana de enfermagem. 2019:27():e3215. doi: 10.1590/1518-8345.2923.3215. Epub 2019 Dec 5     [PubMed PMID: 31826158]

Level 3 (low-level) evidence

[37]

Starnes E, Palokas M, Hinton E. Nurse-initiated spontaneous breathing trials in adult intensive care unit patients: a scoping review. JBI database of systematic reviews and implementation reports. 2019 Nov:17(11):2248-2264. doi: 10.11124/JBISRIR-2017-004025. Epub     [PubMed PMID: 31584485]

Level 2 (mid-level) evidence

[38]

Brault C, Mancebo J, Suarez Montero JC, Bentall T, Burns KEA, Piraino T, Lellouche F, Bouchard PA, Charbonney E, Carteaux G, Maraffi T, Beduneau G, Mercat A, Skrobik Y, Zuo F, Lafreniere-Roula M, Thorpe K, Brochard L, Bosma KJ. The PROMIZING trial enrollment algorithm for early identification of patients ready for unassisted breathing. Critical care (London, England). 2022 Jun 23:26(1):188. doi: 10.1186/s13054-022-04063-4. Epub 2022 Jun 23     [PubMed PMID: 35739553]

[39]

Nitta K, Okamoto K, Imamura H, Mochizuki K, Takayama H, Kamijo H, Okada M, Takeshige K, Kashima Y, Satou T. A comprehensive protocol for ventilator weaning and extubation: a prospective observational study. Journal of intensive care. 2019:7():50. doi: 10.1186/s40560-019-0402-4. Epub 2019 Nov 6     [PubMed PMID: 31719990]

Level 2 (mid-level) evidence

[40]

Van Hollebeke M, Poddighe D, Clerckx B, Muller J, Hermans G, Gosselink R, Langer D, Louvaris Z. High-Intensity Inspiratory Muscle Training Improves Scalene and Sternocleidomastoid Muscle Oxygenation Parameters in Patients With Weaning Difficulties: A Randomized Controlled Trial. Frontiers in physiology. 2022:13():786575. doi: 10.3389/fphys.2022.786575. Epub 2022 Feb 9     [PubMed PMID: 35222072]

Level 1 (high-level) evidence

[41]

Ferreira NA, Ferreira AS, Guimarães FS. Cough peak flow to predict extubation outcome: a systematic review and meta-analysis. Revista Brasileira de terapia intensiva. 2021 Jul-Sep:33(3):445-456. doi: 10.5935/0103-507X.20210060. Epub     [PubMed PMID: 35107557]

Level 1 (high-level) evidence

[42]

da Silva AR, Novais MCM, Neto MG, Correia HF. Predictors of extubation failure in neurocritical patients: A systematic review. Australian critical care : official journal of the Confederation of Australian Critical Care Nurses. 2023 Mar:36(2):285-291. doi: 10.1016/j.aucc.2021.11.005. Epub 2022 Feb 21     [PubMed PMID: 35197209]

Level 1 (high-level) evidence

[43]

Trudzinski FC, Neetz B, Bornitz F, Müller M, Weis A, Kronsteiner D, Herth FJF, Sturm N, Gassmann V, Frerk T, Neurohr C, Ghiani A, Joves B, Schneider A, Szecsenyi J, von Schumann S, Meis J. Risk Factors for Prolonged Mechanical Ventilation and Weaning Failure: A Systematic Review. Respiration; international review of thoracic diseases. 2022:101(10):959-969. doi: 10.1159/000525604. Epub 2022 Aug 17     [PubMed PMID: 35977525]

Level 1 (high-level) evidence

[44]

Lo SC, Ma KS, Li YR, Li ZY, Lin CH, Lin HC, Yang SF. Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation. Scientific reports. 2022 Jul 14:12(1):12044. doi: 10.1038/s41598-022-15917-w. Epub 2022 Jul 14     [PubMed PMID: 35835785]

[45]

Santibañez-Velázquez M, Medina-García G, Ocharán-Hernández ME. Association of independent risk factors with post-extubation failure in patients undergoing mechanical ventilation weaning. Gaceta medica de Mexico. 2020:156(6):539-545. doi: 10.24875/GMM.M21000493. Epub     [PubMed PMID: 33877109]

[46]

Schults JA, Charles K, Harnischfeger J, Erikson S, Burren J, Waak M, Blackwood B, Tume LN, Long D, Australian and New Zealand Intensive Care Society Paediatric Study Group. Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice. Australian critical care : official journal of the Confederation of Australian Critical Care Nurses. 2023 Jul:36(4):509-514. doi: 10.1016/j.aucc.2022.06.004. Epub 2022 Aug 27     [PubMed PMID: 36038459]

Level 3 (low-level) evidence

[47]

Duyndam A, Houmes RJ, van Rosmalen J, Tibboel D, van Dijk M, Ista E. Implementation of a nurse-driven ventilation weaning protocol in critically ill children: Can it improve patient outcome? Australian critical care : official journal of the Confederation of Australian Critical Care Nurses. 2020 Jan:33(1):80-88. doi: 10.1016/j.aucc.2019.01.005. Epub 2019 Mar 13     [PubMed PMID: 30876696]

[48]

Rackley CR, MacIntyre NR. Finding the Value of the Specialized Weaning Center. Respiratory care. 2022 Mar:67(3):375-376. doi: 10.4187/respcare.09985. Epub     [PubMed PMID: 35190480]

[49]

Burns KEA, Raptis S, Nisenbaum R, Rizvi L, Jones A, Bakshi J, Tan W, Meret A, Cook DJ, Lellouche F, Epstein SK, Gattas D, Kapadia FN, Villar J, Brochard L, Lessard MR, Meade MO. International Practice Variation in Weaning Critically Ill Adults from Invasive Mechanical Ventilation. Annals of the American Thoracic Society. 2018 Apr:15(4):494-502. doi: 10.1513/AnnalsATS.201705-410OC. Epub     [PubMed PMID: 29509509]

[50]

Borges LGA, Savi A, Teixeira C, de Oliveira RP, De Camillis MLF, Wickert R, Brodt SFM, Tonietto TF, Cremonese R, da Silva LS, Gehm F, Oliveira ES, Barth JHD, Macari JG, de Barros CD, Vieira SRR. Mechanical ventilation weaning protocol improves medical adherence and results. Journal of critical care. 2017 Oct:41():296-302. doi: 10.1016/j.jcrc.2017.07.014. Epub 2017 Jul 12     [PubMed PMID: 28797619]

[51]

Béduneau G,Pham T,Schortgen F,Piquilloud L,Zogheib E,Jonas M,Grelon F,Runge I,Nicolas Terzi,Grangé S,Barberet G,Guitard PG,Frat JP,Constan A,Chretien JM,Mancebo J,Mercat A,Richard JM,Brochard L,WIND (Weaning according to a New Definition) Study Group and the REVA (Réseau Européen de Recherche en Ventilation Artificielle) Network ‡, Epidemiology of Weaning Outcome according to a New Definition. The WIND Study. American journal of respiratory and critical care medicine. 2017 Mar 15;     [PubMed PMID: 27626706]