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Management of the difficult-to-wean adult patient in the

intensive care unit
Authors: Scott K Epstein, MD, Martin F Joyce-Brady, MD
Section Editor: Polly E Parsons, MD
Deputy Editor: Geraldine Finlay, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: May 02, 2019.

INTRODUCTION

Many patients in intensive care units (ICUs) are difficult-to-wean off of mechanical ventilation, thereby
delaying extubation. The management of patients who are difficult-to-wean in the ICU is reviewed
here. Details regarding readiness testing, methods of weaning, and the management of patients who
require prolonged mechanical ventilation in long-term care facilities are provided separately. (See
"Management and prognosis of patients requiring prolonged mechanical ventilation".)

DEFINITION AND INCIDENCE

Weaning can be classified as simple, difficult, or prolonged.

● Simple wean – Patients are considered to have undergone a simple wean when they pass their
first spontaneous breathing trial (SBT). Approximately half to two-thirds of patients in intensive
care units (ICUs) undergo simple weaning, many of which will proceed with extubation. Details
regarding what constitutes an SBT and extubation management are discussed separately [1,2].
(See "Methods of weaning from mechanical ventilation" and "Extubation management in the
adult intensive care unit".)

● Difficult-to-wean – Patients are considered difficult-to-wean if they fail their first SBT and then
require up to three SBTs or seven days to pass an SBT [3]. The incidence ranges from 26 to 39
percent [1,2]. This population mostly includes patients intubated in the first few weeks of acute
ICU admission. This population is discussed in this topic review.
 ● Prolonged weaning – Patients are considered to have undergone prolonged weaning if they fail
at least three SBTs or require more than seven days to pass an SBT. The incidence ranges from 6
to 14 percent [1,2]. Patients who require more than seven days to wean are at increased risk for
death [2] and are also more likely to fail extubation compared with those who undergo simple
weaning [4]. While in the ICU, many of these patients are managed similarly to patients who are
difficult to wean, many will require tracheostomy and be managed accordingly. (See "Overview of
tracheostomy" and "Management and prognosis of patients requiring prolonged mechanical
ventilation".)

IDENTIFY AND CORRECT THE CAUSE

Repeat unsuccessful attempts at weaning usually signify incomplete resolution of the illness that
precipitated mechanical ventilation and/or the development of one or more new problems that
prevent weaning. The clinician should identify and treat these issues before resuming further weaning
trials.

● Identify the cause(s) – Numerous factors contribute to failure to wean (table 1) by causing an
imbalance between respiratory muscle strength and the work of breathing. Respiratory and
cardiac issues are common while psychological, ventilator, or nutrition-related issues are less
common. Most of the etiologies are apparent on routine clinical examination, laboratory testing,
arterial blood gas analysis, electrocardiography, and chest radiography, as well as an assessment
of sedative medications and the ventilator circuit. Additional investigations may be indicated
depending upon the suspicion for select etiologies. (See 'Respiratory or ventilatory causes' below
and 'Cardiac causes' below and 'Psychological causes' below and 'Ventilator circuit issues' below
and 'Nutritional issues' below.)

● Treat the cause – When feasible, identified etiologies that contribute to difficult weaning should
be treated to improve the probability of successful weaning. As an example, in a series of 12
difficult-to-wean patients who failed weaning due to the development of hypertension during their
spontaneous breathing trial (SBT), antihypertensive therapy during the SBT was associated with
successful weaning in the majority (92 percent) [5]. In another study of 42 patients who failed
weaning, nine of whom were assessed as having heart failure succeeded on a later occasion
after diuretic therapy [6].

● Resume weaning – Once it is felt that the likely cause of ventilator dependency has been
corrected, readiness testing (table 2) should be performed to determine whether weaning can be
resumed. (See "Weaning from mechanical ventilation: Readiness testing".)
Respiratory or ventilatory causes — Respiratory/ventilatory causes of failure to wean, their detection
and treatment are listed in the table (table 1).

Manifestations are often nonspecific and include tachycardia, tachypnea, respiratory distress, or
oxygen desaturation during a breathing trial.

Routine testing including chest, cardiac, and neurological examination (including an assessment
for delirium), complete blood count and chemistries (including calcium, magnesium, and
phosphate), chest radiography, arterial blood gas analysis, and nutrition assessment will narrow
the differential considerably. Additional testing is individualized and targeted at specific
suspected etiologies (eg, computed tomography [CT] of the chest and/or abdomen, CT
pulmonary angiography, nerve conduction studies, bronchoscopy [to look for airway pathology]).

Frequently overlooked causes include:

● Auto-positive end-expiratory pressure (auto-PEEP) – The detection and treatment of auto-PEEP

are discussed separately. (See "Positive end-expiratory pressure (PEEP)", section on 'Auto
(intrinsic) PEEP'.)

● Overventilation – A common mistake made is to ventilate patients who have chronic hypercapnia
with a minute ventilation that normalizes the arterial carbon dioxide tension (PaCO2). This
causes the pH to rise and prompts renal excretion of bicarbonate over three to five days until the
pH normalizes. When the patient resumes spontaneous ventilation, such as that during an SBT,
an acute respiratory acidosis will result because there is insufficient bicarbonate for buffering
(thereby constituting a failed SBT). Thus, patients with chronic hypercapnia should be
mechanically ventilated in between SBTs with a minute ventilation that maintains the patient's
usual PaCO2.

● Imposed work of breathing by endotracheal tubes – Small-sized endotracheal tubes (ETTs) or

ETTs narrowed by secretions can significantly increase the work of breathing and produce a
pattern of rapid shallow breathing observed in patients with weaning failure (akin to breathing
through a straw) [7]. Use of a pressure support SBT may overcome the imposed work of
breathing by the ETT, and facilitate successful weaning [8].

Large pleural effusions, which are common in ventilated patients are sometimes thought to
contribute to failure to wean. However, while drainage may improve oxygenation and lung volumes [9],
it has not been conclusively shown to reduce mechanical ventilation days. Thus, we typically avoid
large volume thoracentesis in this setting unless indicated for another reason.

Cardiac causes — Weaning-induced myocardial ischemia or cardiac dysfunction (ie, heart failure)

may contribute to difficult weaning in 20 to 60 percent of patients and when identified, should be
treated accordingly (eg, optimize beta-blockade, diuresis) (table 1) [10,11]. Because of the increased
work involved in spontaneous breathing, myocardial demand increases, thereby resulting in ischemia
in susceptible individuals, and pulmonary edema in those with underlying cardiac dysfunction.
Ischemia and/or pulmonary edema, in turn, further increase the work of breathing, creating a vicious
cycle.

Because PEEP is a treatment for heart failure, weaning-induced cardiac dysfunction may be hard to
detect when SBT strategies that include PEEP, rather than a t-tube or non-PEEP strategies, are used
[12]. Thus, cardiac dysfunction should be suspected in patients who pass an SBT that included PEEP
but who fail extubation and require re-intubation because of acute heart failure.

Manifestations include tachycardia, tachypnea, oxygen desaturation, hypertension or even

hypotension during a breathing trial. Patients rarely complain of chest pain, and ST depressions are
only occasionally appreciated on a bedside monitor. Risk factors identified in one retrospective study
included chronic obstructive pulmonary disease, previous cardiomyopathy, and obesity [10].

When ischemia is suspected, most experts use continuous multi-lead electrocardiography (EKG)
during the SBT, or record an EKG pre- and post-the trial. Rarely, patients require cardiac
catheterization for diagnosis. If ischemia is identified, it should be treated. The treatment of
myocardial ischemia and cardiac dysfunction are described separately. (See "Overview of the acute
management of non-ST elevation acute coronary syndromes".)

When cardiac dysfunction is suspected, transthoracic echocardiography is used in conjunction with

clinical examination and brain natriuretic peptide (BNP) to justify optimizing cardiac medications and
altering fluid management. (See "Treatment and prognosis of heart failure with preserved ejection
fraction" and "Overview of the management of heart failure with reduced ejection fraction in adults".)

● BNP levels – The possibility that weaning is limited by cardiac dysfunction is suggested by an
elevated BNP or N-terminal pro-BNP prior to the weaning trial, an elevated N-terminal pro-BNP at
the end of the trial, or a >20 percent increase in BNP during the SBT [6,13-15]. Interventions
based upon BNP levels alone are not typically routine. However, one randomized trial reported
that BNP-guided fluid management, particularly in patients with left ventricular systolic
dysfunction, and reduced time to extubation (59 versus 42 hours) [16].

● Echocardiography – The identification of systolic or diastolic dysfunction by transthoracic

echocardiography (TEE) may favor cardiac dysfunction as cause of failure to wean. However, TEE
is nonspecific and only identifies patients who are at risk of failure to wean [15], rather than
proving that failure to wean in an individual is due to cardiac dysfunction. (See "Transthoracic
echocardiography: Normal cardiac anatomy and tomographic views".)
 While not routine, some echocardiographic parameters and stress echocardiography have been
described as potentially useful in identifying weaning-induced cardiac dysfunction. One
retrospective study reported that an elevated ratio of early ventricular filling velocity (E) to late
ventricular filling velocity (A) measured by echocardiography during weaning was associated
with an elevated pulmonary artery occlusion pressure during weaning; whether this increased the
likelihood of failure to wean was not determined [17]. In another study of 161 patients
mechanically ventilated for cardiogenic shock who were stable and had an ejection fraction of 45
percent, dobutamine stress echocardiography was useful in identifying silent systolic and
diastolic dysfunction in patients with weaning failure compared with those who successfully
passed an SBT [18].

● Other reported methods that require further validation include:

• Passive leg raising (PLR) – One study reported that patients who fail to increase cardiac
output by >10 percent during PLR (negative PLR test) are significantly more likely to fail an
SBT with a pulmonary artery occlusion pressure (PAOP) >18 mmHg at the end of the trial
[19]. In another trial, a positive PLR was associated with a successful weaning trial while a
negative one was associated with failure [10]. (See "Novel tools for hemodynamic
monitoring in critically ill patients with shock", section on 'Passive leg raising or fluid bolus
challenge'.)

• Others – Other methods include the demonstration of a >5 to 6 percent increase in plasma
protein and hemoglobin during an SBT [20] and carbon dioxide rebreathing [21]. Lung
ultrasound, by the demonstration of B lines has also been reported to identify pulmonary
edema during weaning [22].

Psychological causes — Psychological issues (eg, depression, anxiety, delirium, pain) can be

significant impediments to successful weaning. When suspected as contributors to difficult weaning,
sedative medications should be adjusted and the psychological issue treated, if feasible (eg, anti-
psychotic, anxiolytic, analgesic).

Depression, anxiety, and delirium are common in ventilated individuals. Depressive disorders are
present in approximately 40 percent of patients undergoing weaning from prolonged mechanical
ventilation and their presence adversely affects weaning success [23]. In another study, patients with
delirium were twice as likely to be difficult-to-wean compared with those without delirium [24].

Such disorders may be hard to assess and may simply manifest as agitation, grimacing,
disorientation, tachycardia, and hypertension during the trial.
Interventions that may minimize these factors include explaining the weaning plan to the patient,
family, and other caretakers; arranging for a trusted caretaker to provide reassurance and explanation
during weaning trials; biofeedback (if feasible or available) that displays the breathing pattern [25];
ensuring adequate sleep; and environmental stimulation during the trial, such as television, radio, or
books. Efforts to optimize medications for treating delirium, anxiety (eg, switching anxiolytic to
dexmedetomidine), and pain should also be performed. Oversedation should be avoided. (See
"Sedative-analgesic medications in critically ill adults: Selection, initiation, maintenance, and
withdrawal" and "Sedative-analgesic medications in critically ill adults: Properties, dosage regimens,
and adverse effects".)

Ventilator circuit issues — Ventilator circuit-related problems can increase the work of breathing and
contribute to SBT failure. Potential problems include equipment dead space, poor circuit compliance,
low gas compression volume, exhalation valve function, and increased resistance caused by the ETT,
inspiratory circuit, or expiratory circuit [26]. Consulting respiratory therapy and examining the pressure
and flow tracings on the ventilator screen can help identify and eliminate potential ventilator-related
problems. As examples:

● An elevated peak inspiratory airway pressure (Ppeak) with a sizeable difference between the
Ppeak and plateau pressure (Pplat) may suggest an obstructed ETT or abnormally increased
resistance in ventilator circuit tubing (assuming that the patient is on volume cycled ventilation).
Examining the ETT and circuit for obstructions or secretions may reveal an obvious source that
needs to be treated accordingly (eg, replace ETT or tubing, frequent suctioning, remove the
obstruction).

● An increase in both Ppeak and Pplat may suggest a malfunction of the exhalation valve, which
should be checked if this waveform abnormality is found. However, such changes may also
result from issues not related to the ventilator circuit (ie, processes that decrease respiratory
system compliance such as pulmonary edema, pneumothorax, pleural effusion).

● Ventilator asynchrony may be evident on waveforms. This manifests as minimal or no inspiratory

flow, despite patient inspiratory effort due to continued neural inspiration (contraction of
inspiratory muscles) after the ventilator has cycled to the expiratory phase (ie, premature opening
of the exhalation valve). This may lead to a transient but prominent decrease in peak expiratory
flow, followed by increase and then a slow decrease again as neural expiration ends [27]. Such
inspiratory effort increases the work of breathing and may injure the inspiratory muscles as they
contract eccentrically (eg, the muscle contracts while lengthening). If suspected, the cause of
ventilator asynchrony should be sought and treated (eg, auto-PEEP).
Nutritional issues — Protein catabolism induced by critical illness leads to decreased respiratory
muscle mass, strength, and endurance, which may lead to difficulty weaning from mechanical
ventilation [28]. Although it is rare for malnutrition to be the sole cause, it can contribute to difficulty
weaning such that this population should be evaluated by a nutrition expert and their nutrition support
optimized. This approach is based upon studies that report a possible decrease the number of
ventilator-free days when adequate nutrition is provided, the details of which are discussed
separately. (See "Nutrition support in critically ill patients: An overview".)

Overfeeding with excessive carbohydrates can impair weaning success [29], presumably by leading to
excess carbon dioxide production and an increased ventilatory load on the respiratory muscles. While
in the past overfeeding was common, it is now a rare phenomenon.

RESUMING WEANING TRIALS

Once the potential causes have been identified and treated, weaning trials may resume.

General strategies

Posture — Patients should be placed in the posture that they prefer during a weaning trial. For
example, patients with diaphragmatic paralysis generally prefer and perform better in an upright
position because their vital capacity decreases when they are horizontal. In contrast, patients with
intercostal muscle weakness (eg, due to a low cervical cord lesion) may prefer being supine because
their lung volumes tend to increase when they move from an upright to a supine position. In patients
with chronic obstructive pulmonary disease, the optimal posture varies. Some patients have less
dyspnea when they are lying supine, whereas others prefer to lean forward.

Airway management — Airway secretions should be suctioned before every weaning trial.

Theoretically, bronchodilators may facilitate weaning in patients with airway obstruction by reducing
airway resistance and the work of breathing [30,31]. We use short-acting inhaled beta-adrenergic
and/or anticholinergic agents prior to a weaning trial in patients with airflow obstruction unrelated to
the artificial airway. (See "Invasive mechanical ventilation in acute respiratory failure complicating
chronic obstructive pulmonary disease", section on 'Bronchodilators'.)

Trials longer than 30 minutes — In patients who are difficult-to-wean, spontaneous breathing trials
(SBTs) are the same as those in patients who are weaning for the first time with one major difference,
that trials are longer than the typical 30 minutes in duration (often up to two hours long). Data to
support this strategy are discussed separately. (See "Methods of weaning from mechanical
ventilation".)
Importantly, a weaning trial should be terminated early if the patient is failing, since respiratory
muscle fatigue may develop and further decrease the chances of successful weaning. Rest is the
only treatment for such fatigue, and recovery can take several days.

Method of weaning trial — SBT methods are no different with one exception, that in patients with
failure due to cardiac dysfunction, some experts prefer to resume SBTs using a T-tube or pressure
support without positive end-expiratory pressure (PEEP) as opposed to the preferred method of
pressure support with PEEP; this preference ensures that weaning-induced heart failure is not
concealed by the use of PEEP (which is a therapy for heart failure). (See "Methods of weaning from
mechanical ventilation", section on 'Choosing a weaning method'.)

Mechanical ventilation between weaning trials — Appropriate ventilator settings in between SBTs

allow the muscles to rest and recover from the fatigue caused by the weaning trial. In contrast,
inappropriate settings can create more work than is required for spontaneous breathing, leading to
respiratory muscle fatigue and impairing successful weaning.

● Mode, tidal volume, respiratory rate, and/or pressure level – Any mode may be used, as long as
the settings (ie, tidal volume, respiratory rate, and/or pressure level) are such that the patient is
comfortable and performing minimal work. Reasonable settings are those that result in a
respiratory rate between 12 and 20 breaths per minute, a tidal volume between 6 and 8 mL/kg,
and a minute volume between 6 and 12 L/min. For those on pressure-controlled ventilation a
reasonable goal is a plateau pressure <30 cm H2O (the lower the better). For those on pressure
support ventilation (PSV), a pressure of 7 to 15 cm H2O usually achieves these goals. Most
patients who undergo weaning have a PEEP between 5 and 8 cm H2O. Importantly, patients who
have chronic hypercapnia should receive a minute ventilation that targets their baseline arterial
carbon dioxide tension. (See "Overview of initiating invasive mechanical ventilation in adults in
the intensive care unit", section on 'Settings' and 'Respiratory or ventilatory causes' above and
"Weaning from mechanical ventilation: Readiness testing", section on 'Clinical criteria'.)

● Trigger method, trigger sensitivity, and inspiratory flow – A reasonable initial approach is to use
flow triggering in patients receiving intermittent mandatory ventilation and in patients receiving
PSV who have increased inspiratory effort during triggering. Either pressure or flow triggering is
acceptable in other patients. A trigger sensitivity of -1 to -2 cm H2O during pressure triggering or
-1 to -2 L/min during flow triggering is appropriate. An initial inspiratory flow rate of 60 L/min
reasonable for most patients. The flow rate can be increased to as needed if a patient appears to
be struggling. (See "Overview of initiating invasive mechanical ventilation in adults in the
intensive care unit", section on 'Flow rate and pattern' and "Overview of initiating invasive
mechanical ventilation in adults in the intensive care unit", section on 'Trigger sensitivity'.)
IMPROVING RESPIRATORY MUSCLE STRENGTH

Respiratory muscle weakness is common among mechanically ventilated patients; it may be present
at the time of intubation or result from intensive care unit (ICU)-acquired paresis or ventilator-induced
respiratory muscle weakness. One study found diaphragm dysfunction, defined by vertical excursion
of <10 mm or paradoxical motion during inspiration, in 29 percent of patients ready for weaning.
Another study found that 27 percent of patients demonstrated less than a 30 percent increase in
diaphragm thickening during inspiration, an indication of dysfunction [32]. Another study reported that
41 percent of patients developed signs of diaphragm atrophy (>10 percent decrease in thickness) by
day four of mechanical ventilation [33].

Respiratory muscle strength is typically evaluated by clinical examination at the bedside by asking the
patient to take a maximal inspiratory effort; weak effort or low lung volumes suggest respiratory
muscle weakness. While not routine, more objective bedside measures such as a low negative
inspiratory force (eg, <60 cm H2O) and poor diaphragmatic excursion by ultrasound can be used to
support clinical findings. (See "Respiratory muscle weakness due to neuromuscular disease: Clinical
manifestations and evaluation" and "Tests of respiratory muscle strength".)

Physical therapy is the mainstay of treatment. Inspiratory muscle strength training (IMST) is of
unclear benefit and not routinely used. Importantly, methods that improve muscle strength typically
take days to weeks for efficacy.

Physical therapy — Early mobilization/physical therapy in mechanically ventilated patients is

supported by the American Thoracic Society and American College of Chest physicians as a
preventive measure to promote liberation from mechanical ventilation [34,35]. However, specific
therapeutic strategies for difficult-to-wean patients have not been studied. Data discussing early
ambulation in the ICU are provided separately. (See "Post-intensive care syndrome (PICS)", section on
'Prevention and treatment'.)

Investigational strategies (respiratory muscle training) — Inspiratory muscles can be trained to

improve strength and endurance so that fatigue occurs less easily. However, whether IMST
consistently results in earlier liberation from mechanical ventilation remains unproven. Consequently,
it is not routinely used.

IMST is performed by adding a resistance device to the inspiratory limb of the ventilator circuit. A
systematic review of small randomized trials and observational studies reported that compared with
sham or no training, inspiratory muscle training improved maximal inspiratory pressures (increase by
-7 cm H2O), rapid shallow breathing index (+15 breaths/minute/L) (see "Weaning from mechanical
ventilation: The rapid shallow breathing index") and weaning success (risk ratio 1.34) [36]. Duration of
mechanical ventilation improved only in the subgroup with known weaning difficulty. However, there
was significant heterogeneity among trials suggesting that larger trials are needed to confirm or
exclude this benefit.

REFRACTORY PATIENTS

Some patients remain difficult-to-wean even though their acute illness and factors contributing to
failure to wean have been resolved. In such patients, a tracheostomy is frequently placed and the
patient transferred to a long term acute care facility/hospital (LTAC/LTACH) where further weaning
efforts can be undertaken (ie, prolonged weaning). (See 'Definition and incidence' above.)

Tracheostomy — A tracheostomy can be advantageous in those in whom weaning is expected to be

prolonged. The advantages, disadvantages and timing of tracheostomy are discussed in detail
separately. (See "Overview of tracheostomy".)

Transfer to long-term acute care — The number of patients in specialized weaning units increased
three-times between 1997 and 2006, reflecting the trend to manage such patients outside of the
intensive care unit (ICU) [37]. However, one single institution LTAC ventilator weaning trial reported
that as many as a third of this population could have completed their wean in the ICU [38].

Several factors are considered when determining whether a patient is appropriate for transfer to a
specialized weaning center. First, the acute illness should be resolved. Second, the patient should not
be dyspneic or hypoxemic during mechanical ventilation. Third, patients should have a stable airway
and route to receive nutrition, which usually consists of a tracheostomy and enteral feeding tube,
respectively [39].

LTAC facilities provide a site where weaning and rehabilitation are the primary focus of care. They
foster involvement of the patient in decision-making and provide an environment that integrates the
family and other caregivers into a supportive health care team. This team includes intensivists,
internists, nurses, and respiratory therapists who identify weaning goals and coordinate the weaning
process. In addition, there is daily patient-centered rehabilitation that includes physical exercise for
regaining muscle strength and practice performing activities of daily living. Skilled therapists are also
available to focus on issues such as speech and communication, nutrition support, physical and
recreational activities, and counseling. Strategies for weaning patients who are in an LTAC facility for
prolonged mechanical ventilation and their outcomes are described in detail separately. (See
"Discussing goals of care" and "Management and prognosis of patients requiring prolonged
mechanical ventilation".)
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Weaning from mechanical
ventilation".)

SUMMARY AND RECOMMENDATIONS

● Patients are considered difficult-to-wean if they fail their first spontaneous breathing trial (SBT)
and then require up to three SBTs or seven days to pass an SBT. Up to 40 percent of patients
mechanically ventilated for an acute illness in the intensive care unit (ICU) are difficult-to-wean.
(See 'Definition and incidence' above.)

● Repeat unsuccessful attempts at weaning usually signify incomplete resolution of the illness that
precipitated mechanical ventilation and/or the development of one or more new problems that
prevent weaning. The clinician should identify and treat these issues (eg, respiratory, cardiac,
psychological, circuit, nutritional) (table 1) before resuming further weaning trials. (See 'Identify
and correct the cause' above.)

● Once the potential causes have been identified and treated, weaning trials may resume. SBTs are
similar to those undergoing first time weaning except special attention should be paid to
comfortable posture, airway management, and appropriate ventilation in between trials; in
addition trials are typically longer (up to two hours) and T-piece trials may be preferred in those
with cardiac dysfunction. (See 'Resuming weaning trials' above.)

● Early mobilization/physical therapy in mechanically ventilated patients should be used as a

preventive measure to promote liberation from mechanical ventilation. However, specific
therapeutic strategies for difficult-to-wean patients have not been studied. Inspiratory muscle
training is of unclear benefit and therefore, not typically used. (See 'Investigational strategies
(respiratory muscle training)' above and 'Improving respiratory muscle strength' above.)

● Some patients remain difficult-to-wean even though their acute illness and factors contributing to
failure to wean have been resolved. In such patients, a tracheostomy is frequently placed and the
patient transferred to a long term acute care facility/hospital where further weaning efforts can
be undertaken (ie, prolonged weaning). (See 'Transfer to long-term acute care' above and
'Refractory patients' above.)

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2 . Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med 2003;
168:10.

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Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from
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Topic 1646 Version 15.0

GRAPHICS

Etiologies of the difficult-to-wean patient

Etiologies Investigations Treatment

Respiratory/ventilatory

Increased Hypoxemia (eg, atelectasis, morbid obesity, abdominal Clinical examination Treat underlying
ventilator distension, lung disease, sepsis), elevated dead space (eg, including neurological etiology (eg,
demand hyperinflation, pulmonary embolism, dehydration), excess examination, chest bronchodilation,
carbon dioxide production (eg, fever, infection, overfeeding radiograph, arterial blood antibiotics,
[refer to nutritional, below], metabolic acidosis, or gases, routine pulmonary toilet,
neuropsychiatric factors [eg, delirium, anxiety, pain]). chemistries, thyroid fluids, diuresis).
Increased Bronchoconstriction (eg, COPD, asthma), airway edema (eg, function tests, nutrition Administer oxygen.
resistive load lower respiratory infection), secretions (eg, assessment, and Adjust mechanical
tracheobronchitis, pneumonia), equipment issues (refer to occasionally CT chest ventilator settings,
ventilator circuit below). and/or abdomen or CT when indicated (eg,
angiography. Rarely, for auto-PEEP).
Increased Dynamic hyperinflation (eg, COPD, asthma, increased nerve conduction Correct feeding or
elastic load minute ventilation), alveolar filling (eg, pulmonary edema), studies or metabolic
atelectasis, pleural disease (eg, pleural effusion, bronchoscopy. disturbances.
pneumothorax), chest wall disease, or abdominal distension
Optimize sedative
(eg, morbid obesity, ileus, ascites).
analgesics.
Reduced Electrolyte abnormalities (eg, hypophosphatemia, Rarely, ETT change,
neuromuscular hypomagnesemia, hypocalcemia, hypokalemia), physical therapy,
capacity medications (eg, steroids, neuromuscular blocking agents), thoracocentesis.
malnutrition (refer to nutritional below), hypothyroidism,
systemic inflammation (eg, sepsis), neuropathy (eg, Guillain-
Barré syndrome, critical illness polyneuropathy), and
myopathy (eg, critical illness myopathy).

Decreased Excess sedation, metabolic alkalosis (eg, nasogastric

ventilatory suctioning, volume depletion, diuretics and other causes of
drive chloride depletion), central nervous system disease (eg,
stroke, encephalopathy), central sleep apnea, or obesity
hypoventilation syndrome.

Cardiac

  Weaning may induce myocardial ischemia in susceptible A continuous multi-lead Maximize cardiac
patients. EKG during spontaneous medications (eg, beta
breathing trials or EKG blockade, diuresis,
pre-and post-weaning ACE inhibition, or
  Pulmonary edema may develop in patients with cardiac trial. BNP or N-terminal vasodilators before
dysfunction or ischemia. pro-BNP pre-and post- or during SBT).
weaning trial. Rarely, coronary re-
Transthoracic perfusion
  Fluid overload may present similarly in patients with normal
echocardiography. interventions or
cardiac function.
Rarely, cardiac inotropic agents.
catheterization.

Psychological

  Psychologic issues (eg, depression, anxiety, delirium, pain) Clinical history and Patients education,
and oversedation may limit ventilation and impede examination including optimize sedative
cooperation with a SBT. pain assessment. analgesia
medications, which
may involve
increasing, adjusting,
or weaning
 psychoactive
medications.

Ventilator circuit

  Equipment dead space, circuit compliance, gas Examine waveforms (eg, Equipment
compression volume, exhalation valve dysfunction, and ventilator asynchrony), modifications (eg,
increased resistance (eg, endotracheal tube luminal ventilator pressures (eg, change tubing,
narrowing due to inspissated secretions and debris or peak inspiratory ventilator,
small-sized ETT). pressure, plateau endotracheal tube,
pressure), and etc), pulmonary toilet.
equipment (eg, blocked
exhalation valve, excess
condensation).

Nutritional

  Protein catabolism and underfeeding leading to respiratory Calculate nutrition Administer adequate
muscle weakness. Overfeeding leading to increased carbon needs. nutrition.
dioxide production and increased ventilatory load.

COPD: chronic obstructive pulmonary disease; CT: computed tomography; PEEP: positive end-expiratory pressure; ETT: endotracheal tube; EKG:
electrocardiogram; BNP: brain natriuretic peptide; ACE: angiotensin converting enzyme; SBT: spontaneous breathing trial.

Graphic 115677 Version 1.0

Clinical criteria used to determine readiness for trials of spontaneous breathing

Required criteria
1. The cause of the respiratory failure has improved

2. PaO 2 /FiO 2 ≥150* or SpO 2 ≥90 percent on FiO 2 ≤40 percent and positive end-expiratory pressure (PEEP) ≤5 cmH 2 O

3. pH >7.25

4. Hemodynamic stability (no or low dose vasopressor medications)

5. Able to initiate an inspiratory effort

Additional criteria (optional criteria)

1. Hemoglobin ≥7 mg/dL

2. Core temperature ≤38 to 38.5°Centigrade

3. Mental status awake and alert or easily arousable

* A threshold of PaO 2 /FiO 2 ≥120 can be used for patients with chronic hypoxemia. Some patients require higher levels of PEEP to avoid
atelectasis during mechanical ventilation.

Adapted from: MacIntyre, NR, Cook, DJ, Ely, EW, 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; 120:375S.

Graphic 62377 Version 3.0

Contributor Disclosures
Scott K Epstein, MD Nothing to disclose Martin F Joyce-Brady, MD Nothing to disclose Polly E Parsons,
MD Nothing to disclose Geraldine Finlay, MD Consultant/Advisory Boards: LAM Board of directors, LAM
scientific grant review committee for The LAM Foundation.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
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