Difficulty weaning is an important ICU challenge
- 20% to 30% of patients are difficult to wean from invasive mechanical ventilation
The general approach to ventilator weaning and extubation is covered here:
Classification of weaning by duration
- “Simple” — ventilator discontinued after the first assessment
- “Difficult” — ventilator discontinued from 2–7d after initial assessment
- “Prolonged” — ventilator discontinued in >7d after initial assessment
- Weaning failure is defined as the failure to pass a spontaneous-breathing trial or the need for reintubation within 48 hours following extubation
- predicting success is important to reduce rates of reintubation
- reintubation is associated with a 7-11x increase in hospital mortality
- reintubation rates of 10 to 15% are typical for most well-run ICUs (a target of 0% is unrealistic and would lead to prolonged ventilation)
RISKS OF DELAYED WEANING
- infection e.g. VAP
- ventilator-associated lung injury (VALI)
- need for sedation and associated complications
- airway trauma from prolonged intubation
- psychological effects
REASONS FOR VENTILATOR DEPENDENCY
Two types of factors:
- Disease-imposed factors — e.g. mechanical and/or gas exchange issues that continue to require PPV
- Clinician-imposed factors — e.g. clinician delay in recognizing the ability of a patient to have mechanical ventilation discontinued — e.g. inappropriate ventilator settings that overload (or underload) respiratory muscles, preventing recovery
APPROACH TO DIFFICULTY WEANING AND THE PROLONGED MECHANICAL VENTILATION PATIENT
Aggressively seek and treat reversible causes of ventilator dependence (e.g. “WHEANS NOT”) and optimise factors discussed in Weaning from mechanical ventilation.
- wheeze (especially COPD and asthma)
- heart disease and fluid overload
- electrolytes and metabolic derangement
- neuromuscular disease and wekaness
- nutrition insufficiency
- opiates and other sedatives
- thyroid disease
If patient failed SBT but passed ‘wean screen’:
- consider an extubation attempt to ensure that the irritant and loading effects (e.g. demand-valve insensitivity/unresponsiveness) of the artificial airway are not the cause of the SBT failure
- careful reevaluation of the need(s) for ongoing ventilatory support should be coupled with a daily reassessment for the appropriateness of repeat SBTs
- Ventilatory support between SBTs should be comfortable interactive support that does not necessarily have to be “weaned”
- do not perform SBTs more often than daily (i.e. q24h) to avoid fatigue
Multidisciplinary rehabilitation interventions aimed at optimizing all of the factors that contribute to ventilator dependence, such as:
- psychosocial support
A strategy of slow-paced gradual reduction in ventilation support is used by most experts for patients with prolonged mechanical ventilation
- wean patients to about 50% of their maximal support levels (ie, 50% of their initial inspiratory pressure settings) without using daily SBTs
- When that has been achieved, gradually lengthening daily SBTs should be re-instituted
Consider tracheostomy if likely to remain intubated for >7-14 days in patients:
- requiring high levels of sedation to tolerate translaryngeal tubes
- with marginal respiratory mechanics and reduced airway resistance from tracheostomy may reduce risk of muscle overload
- that may psychological benefit from ability to eat orally, to communicate by speaking, and enhanced mobility
- in whom enhanced mobility may assist physiotherapy
Unless there is evidence for clearly irreversible disease (eg, high spinal cord injury, amyotrophic lateral sclerosis), a patient requiring prolonged ventilatory support should not be considered permanently ventilator-dependent until 3 months of weaning attempts have been made.
References and Links
- CCC — Weaning from mechanical ventilation
- CCC — Non-invasive ventilation for weaning
- CCC — Spontaneous breathing trial
- CCC — Indices that predict difficulty weaning
- CCC — Weaning from mechanical ventilation (Hot Case)
- CCC — Extubation assessment in ICU
Journal articles and textbooks
- El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care. 2008;12(4):221. PMC2575571.
- Macintyre NR. Evidence-based assessments in the ventilator discontinuation process. Respir Care. 2012 Oct;57(10):1611-8. PMID: 23013898. [free full text]
- MacIntyre NR, Epstein SK, Carson S. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 128(6):3937-54. 2005. [pubmed] [free full text]
- MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007 Sep;132(3):1049-56. PMID: 17873200. [free full text]
- O’Callaghan DJ, Wyncoll D. What size tube doctor? Bigger may be better – at least for weaning. Crit Care. 2013 Mar 27;17(2):422. PMID: 23535005. [free full text]
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.