Ventilator Weaning Strategies

Evidence-Based Approaches to Ventilator Weaning

The European Respiratory Society recommends NIV to aid weaning from invasive mechanical ventilation (IMV) in patients with acute hypercapnic respiratory failure (AHRF) secondary to COPD 1, 2
NIV has been shown to accelerate weaning from IMV in COPD patients who fail a spontaneous breathing trial (SBT) 1, 2
Use of NIV for weaning in patients with hypercapnic respiratory failure is associated with decreased mortality (RR 0.54, 95% CI 0.41-0.70) 2, 3
Use of NIV for weaning in patients with hypercapnic respiratory failure is associated with reduced weaning failure (RR 0.61, 95% CI 0.48-0.79) 2, 4
Use of NIV for weaning in patients with hypercapnic respiratory failure is associated with lower incidence of ventilator-associated pneumonia (RR 0.22, 95% CI 0.15-0.32) 2, 3

An organized and systematic approach to weaning is desirable, but protocols should be used with caution in patients with AHRF 1, 5
Weaning protocols may reduce the duration of IMV and ventilator-associated pneumonia, though evidence is mixed 1, 6
Computer-automated weaning cannot be recommended in AHRF due to conflicting evidence 1, 5
In non-COPD causes of AHRF, NIV may have a role in shortening IMV duration when local expertise exists 1, 6

Care is needed to identify factors that increase the risk of extubation failure so that additional support can be provided 7, 5
Risk factors for extubation failure include capacity-load imbalance (severe airflow obstruction or neuromuscular weakness) 5, 6
Risk factors for extubation failure include impaired bulbar function 5, 6
Risk factors for extubation failure include ineffective cough 5, 6
Risk factors for extubation failure include non-respiratory issues (cardiac dysfunction, encephalopathy, abdominal distension) 5, 6
Prophylactic use of NIV should be considered for post-extubation support in patients with identified risk factors for extubation failure 1, 6

NIV is not recommended for established post-extubation respiratory failure, as evidence suggests it may be harmful by potentially delaying re-intubation 8, 2
This recommendation may not apply to COPD patients with post-extubation respiratory failure, who may still benefit from NIV 8, 2

For patients with high levels of intrinsic PEEP, external PEEP should be applied to improve triggering sensitivity 9
Flow triggering in conjunction with NIV may be beneficial for patients with hypercapnic respiratory failure during weaning 9

Centers must have adequate experience using NIV for weaning before considering its implementation 2, 3