Liberation from Mechanical Ventilation: Established and New Insights

Abstract

A substantial proportion of critically ill patients require ventilator support with the majority requiring invasive mechanical ventilation. Timely and safe liberation from invasive mechanical ventilation is a critical aspect of patient care in the intensive care unit (ICU) and is a top research priority for patients and clinicians. In this article, we discuss how to (1) identify candidates for liberation from mechanical ventilation, (2) conduct spontaneous breathing trials (SBTs), and (3) optimize patients for liberation from mechanical ventilation. We also discuss the roles for (4) extubation to noninvasive ventilation and (5) newer modes of mechanical ventilation during liberation from mechanical ventilation. We conclude that, though substantial progress has been made in identifying patients who are likely to be liberated (e.g., through the use of SBTs) and management strategies that speed liberation from the ventilator (e.g., protocolized SBTs, lighter sedation, and early mobilization), many important questions regarding liberation from mechanical ventilation in clinical practice remain unanswered.

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

“…Moreover, our strict inclusion criteria might have introduced a selection bias in the study with a high pretest probability of successful weaning and, therefore, could not detect a clinically important treatment effect for the comparison of highflow oxygen SBT versus T-piece SBT. Although this could mitigate the risk of premature extubation, it could potentially lead to delayed extubation which might contribute to a worse outcome [31]. However, our RCT cohort had similar clinical characteristics, such as age and sequential organ failure assessment (SOFA) score, compared to previous studies, whereas the median duration of mechanical ventilation before the SBT in our RCT cohort was similar to or shorter than that of previous studies [5,18].…”

“…On the other hand, these attempts can potentially lead to premature extubation which may require reintubation. There are several risk factors associated with SBT and/or extubation failure, including advanced age, hypoxemia, hypercapnia, chronic cardiovascular disease, reason for intubation, and duration of mechanical ventilation [31]. Extubation strategies (reconnection to ventilator and prophylactic HFNC and/or NIV) may significantly lower the rates of reintubation [11][12][13]21].…”