Weaning Protocols for COPD and ARDS Patients

Introduction to Weaning Protocols

The American Thoracic Society and American College of Chest Physicians establish traditional thresholds for general ICU populations, including an RSBI <105 breaths/min/L to predict weaning success 1
The European Respiratory Society recommends systematic screening including PaO₂/FiO₂ ratio ≥200, PEEP ≤5 cmH₂O, and RSBI ≤105 breaths/min/L (or ≤85 for COPD with hypercapnia) 1, 3

RSBI should never be used in isolation, and the European Respiratory Society recommends assessing PaO₂/FiO₂ ratio ≥200, PEEP ≤5 cmH₂O, RSBI ≤105 breaths/min/L, intact cough on suctioning, and absence of sedative or vasopressor infusions 1, 3
Do not attempt weaning if PaO₂ <55 mmHg on FiO₂ ≥0.40, as recommended by the American College of Chest Physicians 4, 1

Measure RSBI after 30-60 minutes of spontaneous breathing, as recommended by the American Thoracic Society 1
Use pressure support ventilation (5-8 cmH₂O) rather than T-piece for the spontaneous breathing trial, which has higher success rates (84.6% vs 76.7%) 2, 3
Terminate the SBT immediately if respiratory rate >35 breaths/min, SpO₂ <90%, heart rate >140 bpm, or systolic blood pressure >180 mmHg or <90 mmHg, as recommended by the European Respiratory Society 3

Consider systematic extubation directly to NIV starting with IPAP 10-12 cmH₂O and EPAP 5-10 cmH₂O for COPD patients with chronic hypercapnia, as recommended by the American College of Chest Physicians 3
NIV facilitates weaning in hypercapnic patients with decreased mortality (RR 0.54) and reduced weaning failure (RR 0.61), according to the European Respiratory Society 3
Target SpO₂ 88-92% to avoid suppressing respiratory drive, as recommended by the American Thoracic Society 3

Daily spontaneous breathing trials should be central to the weaning protocol once FiO₂ and PEEP can be reduced, as recommended by the European Respiratory Society 5
Consider prophylactic non-invasive ventilation immediately after extubation for high-risk patients, which reduces mortality (RR 0.54) and weaning failure (RR 0.61), according to the American College of Chest Physicians 2, 3