Weaning protocols and difficult weaning
AARC (2002) Clinical Practice Guideline: evidence-based guidelines for weaning and discontinuing ventilatory support. Respir Care, 47, 1, 69-90
www.rcjournal.com/cpgs/ebgwdvscpg.html

AARC (2007) Clinical Practice Guideline: Removal of the endotracheal tube. Respir Care; 52(1):81-93
www.rcjournal.com/cpgs/pdf/removal_of_endotracheal_tube.pdf


Azeredo LM, Leandro M, Nemer SN et al (2017) The integrative weaning index in elderly ICU subjects. Respir Care; 62(3): 333-339
• spontaneous breathing trial presents a positive weaning predictive value of 85%

Bach JR, Saporito LR, Shah HR et al (2014) Decanulation of patients with severe respiratory muscle insufficiency: efficacy of mechanical insufflation-exsufflation. J Rehabil Med; 46(10):1037-41. doi: 10.2340/16501977-1874

Bach JR, Sinquee DM, Saporito LR et al (2015) Efficacy of mechanical insufflation-exsufflation in extubating unweanable subjects with restrictive pulmonary disorders. Respir Care; 60(4):477-483

Beigmohammadi MT, Hussain Khan Z et al (2016) Role of hematocrit concentration on successful extubation in critically ill patients in the intensive care units. Anesth Pain Med; 6(1):e32904. doi: 10.5812/aapm.32904
www.ncbi.nlm.nih.gov/pmc/articles/PMC4834742/

Bell L (2015) Safe weaning from mechanical ventilation. Am J Crit Care; 24:130; doi:10.4037/ajcc2015935

Bellani G, Pesenti A (2014) Assessing effort and work of breathing. Curr Opin Crit Care; 20(3):352-8. doi: 10.1097/MCC.0000000000000089

Berg M (2013) The rapid shallow breathing index as a predictor of failure of noninvasive ventilation for patients with acute respiratory failure. Respir Care; 57(10):1548-54

Bien M-Y et al (2004) Breathing pattern variability: a weaning predictor. Int Care Med, 30, 241 - 247
www.springerlink.com/app/home/contribution.asp?wasp=62f56d83b3534a79925ee91a017a8d9a&referrer=parent&backto=issue,11,33;journal,18,126;browsepublicationsresults,950,2444;
• breathing pattern variability associated with weaning failure in postop patients recovering from SIRS, and this variability may serve as a weaning predictor

Blackwood B, Alderdice F, Burns K (2011) Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients. BMJ, 342, c7237
www.bmj.com/content/342/bmj.c7237.full
• Cochrane review recommending use of protocols for weaning

Bouley GH (1992) The experience of dyspnea during weaning, Heart Lung, 21, 471-6

Bruton A, McPherson K (2004) Impact of the introduction of a multidisciplinary weaning team in a general intensive care unit. Internat J Ther Rehab, 11, 9, 435-40
www.ijtr.co.uk/cgi-bin/go.pl/library/article.cgi?uid=19591;article=IJTR_11_9_435_440

Burns KEA, Adhikari NKJ, Keenan SP, Meade MO (2010) Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database of Systematic Reviews, Issue 8
onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004127/frame.html
• NIV shows a consistent, positive effect on mortality and ventilator associated pneumonia

Chen YH, Tsai YH, Wu YK (2004) Exercise reconditioning in the rehabilitation for prolonged ventilator dependent patients. Eur Respir J, 24: Suppl. 48, 662s
www.ersnet.org/ers/lr/browse/media.aspx?id_dossier=18513&id_fiche=124415
• exercise training improves pulmonary function, exercise capacity and hospitalization outcomes

Chiang L-L, Wang L-Y, Wu C-P (2006) Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther, 86, 1271-81
ptjournal.apta.org/content/86/9/1271.full
• a 6-week physical training program may increase ventilator-free time

Chung MS, Huang CC, Yeh SL et al (2016c) The effectiveness of pulmonary rehabilitation for critical-care ventilator patients: a systematic review. Hu Li Za Zhi; 63(3):94-104. doi: 10.6224/JN.63.3.94

Cooper RM, O'Sullivan E, Popat M et al (2013) Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia; 68:217. doi: 10.1111/anae.12139

Cottereau G, Dres M, Avenel A et al (2015) Handgrip strength predicts difficult weaning but not extubation failure in mechanically ventilated subjects. Respir Care; 60(8):1097-104. doi: 10.4187/respcare.03604

Cowan T (2001) Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes. Respir Care, 46, 460-5
www.rcjournal.com/contents/05.01/05.01.0460.asp
• in weaning a tracheostomized patient, increasing the internal diameter of the tube by removing the inner cannula may be beneficial

Credland N (2016) How to remove an endotracheal tube. Nurs Stand; 30(36):31-3. doi: 10.7748/ns.30.36.31.s43

Duan J, Shuliang G, Han X et al (2012) Dual-mode weaning strategy for difficult-weaning tracheotomy patients: a feasibility study. Anesth Analg; 115(3):597–604

Ely EW, Meade MO (2001) Mechanical ventilator weaning protocols driven by non-physician health-care professionals. Chest, 120, 454-463
www.chestjournal.org/cgi/reprint/120/6_suppl/454S

Esteban A (1995) A comparison of 4 methods of weaning. New.Eng.J.Med, 332, 345-50
• weaning by intermittent spontaneous breathing is 3 times quicker than IMV weaning, twice as quick as pressure support weaning

Ferrer M (2009) Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet, 374, 9695, 1082-9
• early NIV after extubation reduces respiratory failure and mortality in hypercapnic weaning COPD patients, so should be routine.

Figueroa-Casas JB, Connery SM, Montoya R (2015) Changes in breathing variables during a 30-minute spontaneous breathing trial. Respir Care; 60(2):155-161

Duan J, Han X, Huang S et al (2016) Noninvasive ventilation for avoidance of reintubation in patients with various cough strength. Crit Care; 20:316
ccforum.biomedcentral.com/articles/10.1186/s13054-016-1493-0

Dugernier J, Bialais E, Reychler G et al (2015) Neurally adjusted ventilatory assist during weaning from respiratory support in a case of Guillain-Barré Syndrome. Respir Care; 60(4):e68-72

Hernández G (2016) Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA; 315(13):1354-61. doi: 10.1001/jama.2016.2711.
• high-flow nasal cannula oxygen reduces the risk of reintubation

Heunks LM, Doorduin J, van der Hoeven JG (2015) Monitoring and preventing diaphragm injury. Curr Opin Crit Care; 21(1):34-41. doi: 10.1097/MCC.0000000000000168
• ‘it is surprising that respiratory muscle dysfunction largely develops without being noticed’

Holets, SR, Marini JJ (2016) Is automated weaning superior to manual spontaneous breathing trials? Respir Care; 61(6): 749-760.

Hooijman PE, Beishuizen A, Witt CC et al (2015) Diaphragm muscle fiber weakness and ubiquitin-proteasome activation in critically ill patients. Am J Respir Crit Care Med; 191(10):1126-38. doi: 10.1164/rccm.201412-2214OC

Hussain SNA, Cornachione AS, Céline Guichon C et al (2016) Prolonged controlled mechanical ventilation in humans triggers myofibrillar contractile dysfunction and myofilament protein loss in the diaphragm. Thorax; 71(5)::436-445. doi: 10.1136/thoraxjnl-2015-207559

Jeganathan N, Kaplan CA, Balk RA et al (2015) Ventilator liberation for high-risk-for-failure patients: improving value of the spontaneous breathing trial. Respir Care; 60(2):290-296

Jones K, Newhouse R, Johnson K et al (2014) Achieving quality health outcomes through the implementation of a spontaneous awakening and spontaneous breathing trial protocol. AACN Adv Crit Care; 25(1):33-42. doi: 10.1097/NCI.0000000000000011

Jubran A, Grant BJB, Duffner LA et al 2013 Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilationa randomized trial. J Am Med Ass, 309, 7, 671-677. doi:10.1001/jama.2013.159
jama.jamanetwork.com/article.aspx?articleid=1558054

Kacmarek RM, Villar J, Blanch L (2015) Why use anything but a standard spontaneous breathing trial to determine readiness for ventilator discontinuation? Respir Care; 60(11):1705-1707

Keenan SP, Sinuff T, Burns TEA (2011) Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. Can Med Ass J, 183, 3, E195–E214
www.ncbi.nlm.nih.gov/pmc/articles/PMC3042478/?tool=pmcentrez
• NIV helps prevent reintubation in acute respiratory failure

Kim JH (2016) Can a high-flow nasal cannula substitute for noninvasive positive pressure ventilation in post-extubation respiratory failure? Korean J Internal Med; 31(1):36-39. doi: 10.3904/kjim.2016.31.1.36.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4712432/

Koksal GM (2003) The effects of different weaning modes on the endocrine stress response. Crit.Care, 8, R31-R34
• weaning by T-piece causes greater stress response than weaning by PS or CPAP

Kollef MH (1998) We should listen to the patient when it comes to timing extubation. Crit Care Med, 26, 1148-9

Loik PS (2015) The spontaneous breathing trial: separating fact from fiction.
Respir Care; 60(2):306-306

Lu X, Li J, Li T et al (2016) Clinical study of midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in intensive care unit. Chin J Traumatol; 19(2):94-6. doi: 10.1016/j.cjtee.2015.09.007

Macht M, Wimbish T, Brendan J, Clark BJ (2011) Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care; 15:R231 doi:10.1186/cc10472
• after extubation, dysphagia is present in 84% of patients, leading to aspiration and a worse outcome

MacIntyre N (2009) Discontinuing mechanical ventilatory support. Chest, 132, 3, 1049-1056
www.chestjournal.org/content/132/3/1049.abstract
• early tracheostomy may facilitate weaning in patients requiring prolonged ventilatory support.

Martin D, Smith BK, Davenport PD (2011) Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial. Crit Care, 15, 2, R84

Martin AD, Barbara K. Smith, Andrea Gabrielli (2013) Mechanical ventilation, diaphragm weakness and weaning: A rehabilitation perspective. Resp Physiol Neurobiol; 189(2):377-383
• the proportion of patients experiencing difficulty weaning is 25% and rising

MacIntyre NR (2013) The ventilator discontinuation process: an expanding evidence base. Respir Care, 58, 6, 1074-82

McConnell RA, Kerlin MP, Schweickert WD et al (2016) Using a post-intubation checklist and time out to expedite mechanical ventilation monitoring: observational study of a quality improvement intervention. Respir Care; 61(7):902-912

McKim D, Rose L (2015) Efficacy of mechanical insufflation-exsufflation in extubating unweanable subjects with restrictive pulmonary disorders. Respir Care; 60(4):621-2. doi: 10.4187/respcare.04051

Mifsud BD, Sanctuary T, Warren A et al (2016) Prospective observational cohort study of patients with weaning failure admitted to a specialist weaning, rehabilitation and home mechanical ventilation centre. BMJ Open; 6(3):e010025. doi: 10.1136/bmjopen-2015-010025K
www.ncbi.nlm.nih.gov/pmc/articles/PMC4785284/

Mokhlesi B (2007) Predicting extubation failure after successful completion of a spontaneous breathing trial. Resp Care, 52 (12):1710-7
• protocol for extubation - include mental status, bronchial secretions, and pre-extubation PaCO2:

Moodie L, Reeve J, Elkins M (2011) Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: a systematic review.
J Physiother, 57, 4, 213–221

Nava S (2011) Inspiratory muscle training in difficult to wean patients: work it harder, make it better, do it faster, makes us stronger. Crit Care, 15, 2, 153. doi: 10.1186/cc10125

Ornico SRP, Lobo SMA, Sanches HS et al (2013) Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial. Crit Care, 17, 1, R39 doi:10.1186/cc12549
• noninvasive ventilation can prevent reintubation.

Piriyapatsom A, Williams EC, Waak K et al (2016) Prospective observational study of predictors of re-intubation following extubation in the surgical ICU. Respir Care; 61(3):306-315. doi: 10.4187/respcare.04269
• muscle weakness is a risk factor for re-intubation
• extubation failure varies from 6 to 40%.

Pryor LN, Baldwin CE, Ward EC et al (2016) Tracheostomy tube type and inner cannula selection impact pressure and resistance to air flow. Respir Care; 61(5):607-614

Pu XX, Wang J, Yan XB et al (2015) Sequential invasive-noninvasive mechanical ventilation weaning strategy for patients after tracheostomy. World J Emerg Med; 6(3):196-200. doi: 10.5847/wjem.j.1920-8642.2015.03.006

Rosario ND, Sassoon CSH, Chetty KG, Gruer SE (1997) Breathing pattern during acute respiratory failure and recovery. Eur Resp J, 10, 2560-5
• failure to wean is presaged by a breathing pattern similar to acute respiratory failure

Scheel R, Pisegna JM, McNally E et al (2016) Endoscopic assessment of swallowing after prolonged intubation in the ICU setting. Ann Otol Rhinol Laryngol; 125(1):43-52
• 22% of patients aspirate after prolonged intubation

Schmidt GA, Girard TD, Kress JP et al (2017) Liberation from mechanical ventilation in critically ill adults: executive summary of an official American College Of Chest Physicians/American Thoracic Society clinical practice guideline. Chest; 151(1):160-165.
doi:10.1016/j.chest.2016.10.037
• CPAP and T-piece weaning are no longer recommended

Shehabi Y (2010) The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients. Anaesth Int Care, 38, 82-90
xa.yimg.com/kq/groups/16749867/2013815741/name/The+effect+of+dexmedetomidine+on+agitation+during+weaning+of+mechanical+ventilation+in+critically+ill+patients-+Anesth+Intensiv
• anxiety, fear and agitation are common non-pulmonary causes of failure to wean.

Siegel MD (2009) Technique and the rapid shallow breathing index. Respir Care, 54, 11, 1462-6

Smith BK, Gabrielli A, Davenport PW et al (2014) Effect of training on inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients. Respir Care; 59(1):22–31

Smyrnios NA (2002) Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning. Crit Care Med, 30, 1224-30

Spiva L, Hart PL, Gallagher E et al (2015) The effects of guided imagery on patients being weaned from mechanical ventilation. Evid Based Complement Alternat Med; 2015:802865. doi: 10.1155/2015/802865
• guided imagery can shorten weaning time and improve oxygenation

Subira C, Fernandez R (2015) Weakness and fluid overload hinder weaning. or do they? Respir Care; 60(8):1213-1214

Taniguchi C, Victor ES, Pieri T et al (2015) Smart Care versus respiratory physiotherapy driven manual weaning for critically ill adult patients: a randomized and controlled trial. Critical Care, 19:246. doi: 10.1186/s13054-015-0978-6
• physiotherapy weaning reduces weaning time compared to automatic system

Teixeira SN, Osaku EF, Costa CRLM et al (2015) Comparison of proportional assist ventilation plus, T-tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care; 60(11):1527-1535

Thille A, Boissier F, Ben-Ghezala H et al 2016) Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study. Crit Care; 20:48. doi: 10.1186/s13054-016-1228-2

Twibell R et al (2003) Subjective perceptions and physiological variables during weaning from mechanical ventilation. Am J Crit Care, 12, 2
• patients’ perceptions of dyspnea, fatigue, and self-efficacy

Uchiyama A, Yoshida T, Yamanaka H et al (2013) Estimation of tracheal pressure and imposed expiratory work of breathing by the endotracheal tube, heat and moisture exchanger, and ventilator during mechanical ventilation. Respir Care; 58(7):1157-69. doi: 10.4187/respcare.01698
• hot-water humidifier should be used because heat moisture exchanger causes significant airflow resistance

Vassilakopoulos T (2016) Respiratory muscle wasting in the ICU: is it time to protect the diaphragm? Thorax; 71:397-398 doi:10.1136/thoraxjnl-2016-208354

Vitacca M, Scalvini S, Volterrani M et al (2014) In COPD patients on prolonged mechanical ventilation heart rate variability during the T-piece trial is better after pressure support plus PEEP: a pilot physiological study. Heart Lung; 43(5):420-6. doi: 10.1016/j.hrtlng.2014.04.003

Yoo J-W, Synn A, Huh JW et al (2016) Clinical efficacy of high-flow nasal cannula compared to noninvasive ventilation in patients with post-extubation respiratory failure. Korean J Internal Med; 31(1):82-88. doi: 10.3904/kjim.2016.31.1.82.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4712438/

Zein H, Baratloo A, Negida A et al (2016) Ventilator weaning and spontaneous breathing trials; an educational review. Emergency; 4(2):65-71
www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/


AARC = American Association for Respiratory Care
CPAP = continuous positive airways pressure