Weaning and Extubation Protocol

Introduction to Weaning

The American Thoracic Society recommends that the weaning protocol include a spontaneous breathing trial (SBT) before any extubation in ventilated patients for more than 48 hours, followed by an evaluation of specific risk factors for extubation failure such as ineffective cough, excessive tracheobronchial secretions, swallowing disorders, and altered consciousness 1, 2

The evaluation of readiness for weaning should be performed daily using standardized protocols, although the specific guideline society is not mentioned in this context 3

The SBT is the primary diagnostic test to determine if patients can be extubated successfully, with initial SBT lasting 30 minutes and criteria for success including respiratory frequency = 10-30 breaths/minute, SpO2 > 92%, and absence of exhaustion, agitation, hypertension, and tachycardia 1

The British Thoracic Society notes that SBT is insufficient as the sole means to detect all patients at risk of extubation failure, and specific risk factors to evaluate include ineffective cough, excessive tracheobronchial secretions, swallowing disorders, altered consciousness, and others 1, 2
The European Respiratory Society identifies additional risk factors such as imbalance between capacity and load, bulbar dysfunction, and non-respiratory problems like myocardial ischemia or severe abdominal distension 4

The American College of Chest Physicians recommends that extubation should be performed after a successful SBT, and for patients at high risk of extubation failure, consideration should be given to prophylactic non-invasive ventilation (NIV) immediately after extubation, evaluation by a physiotherapist before and after extubation, and presence of a physiotherapist during extubation 5

The use of prophylactic NIV in patients at high risk of extubation failure reduces the risk of acute respiratory failure significantly, according to the American Thoracic Society 5
For patients at high risk of pulmonary collapse, direct extubation from CPAP levels ≥10 cmH2O has been used successfully, as noted by the Society of Critical Care Medicine 6

The definition of extubation failure is generally the need for reintubation within 48-72 hours after planned extubation, with a target goal to maintain the extubation failure rate between 5-10%, considered potentially acceptable in ICU patients, as recommended by the American College of Critical Care Medicine 1, 2

PEEP in the range of 5-10 cmH₂O is commonly required to increase residual volume and reduce oxygen dependency in patients with neuromuscular disease and chest wall deformity, and this does not contraindicate extubation, as recommended by the European Respiratory Society 7, 8
When lung volume is reduced with radiological evidence of lobar collapse or unexplained hypoxia, PEEP settings may need to be increased up to or above 10 cmH₂O, with adjustments individualized according to ventilatory parameters and patient comfort, as suggested by the British Thoracic Society 7, 8

Supplemental oxygen can be delivered via facemask, nasal cannula, or CPAP mask after extubation, according to the American Thoracic Society 9

Do not assume that PEEP 10 cmH₂O automatically indicates severe respiratory failure requiring continued intubation—the PEEP level must be interpreted in the context of the underlying pathophysiology, as stated by the European Respiratory Society 7, 8