Strategies for weaning from mechanical ventilation: a state of the art review

Identification and adoption of strategies to promote timely and successful weaning from mechanical ventilation remain a research and quality improvement priority. The most important steps in the weaning process to prevent unnecessary prolongation of mechanical ventilation are timely recognition of both readiness to wean and readiness to extubate. Strategies shown to be effective in promoting timely weaning include weaning protocols and use of spontaneous breathing trials. This review explores various other strategies that also may promote timely and successful weaning including bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility, the use of automated weaning systems and modes that improve patient-ventilator interaction, mechanical insufflation-exsufflation as a weaning adjunct, early extubation to non-invasive ventilation and high flow humidified oxygen. As most critically ill patients requiring mechanical ventilation will tolerate extubation with minimal weaning, identification of strategies to improve management of those patients experiencing difficult and prolonged weaning should be a priority for clinical practice, quality improvement initiatives and weaning research.