Evidence-based assessments in the ventilator discontinuation process

The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. An evidence-based task force has recommended a daily discontinuation assessment and management process for most ICU patients requiring at least 24 hours of mechanical ventilator support. This process focuses on assessments on the causes for ventilator dependence, assessments for evidence of disease stability/reversal, use of regular spontaneous breathing trials (SBTs) as the primary assessment tool for ventilator discontinuation potential, use of separate assessments to evaluate the need for an artificial airway in patients tolerating the SBT, and the use of comfortable, interactive ventilator modes (that do not need to be "weaned") in between regular SBTs. More recent developments have focused on the utility of computer decision support to guide these processes and the importance of linking sedation reduction protocols to ventilator discontinuation protocols. These guidelines are standing the test of time, and practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement and need for further clinical studies, especially in the patient requiring prolonged mechanical ventilation.