Hallmarks of Weaning from Mechanical Ventilation: A 3S Framework for Ventilator Liberation - A Narrative Review

Safe and long-lasting separation from invasive mechanical ventilation (MV) is a critical aspect of care provision in the intensive care unit (ICU), yet it remains a complex and heterogeneously applied process. Current weaning strategies often rely on fragmented assessments, personal judgment, and poorly integrated decision milestones that individually and collectively may contribute to delayed attempts, weaning and extubation failure. In this How I Do It article, we propose a comprehensive framework based on seven hallmarks, organized into three sequential and interrelated phases (3S framework): screening, separating, and securing. The screening phase includes sedation management, the facilitation phase (maintaining limb and respiratory muscles strength and functionality, as well as cardiac function) and the transition phase (which involves switching from controlled to partial support mode and the stepwise reduction of ventilatory support). The separating phase includes the assessment of readiness for spontaneous breathing trial (SBT), SBT conduct, and extubation risk assessment and decision-making. The securing phase focuses on post-extubation management and includes strategies to prevent respiratory failure. Rather than focusing on isolated physiological parameters or scores, this framework highlights the dynamic, staged, and integrative nature of the weaning process. By structuring current evidence around these hallmarks, we aim to provide both a patient-centered approach to ventilator liberation and a conceptual foundation for future research, protocol development, and clinical decision-making.