V. 1 N. 2 (2022): infermieristica journal: we never stop
Articles

Weaning from mechanical ventilation: a narrative review

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  • Cristian Fusi,
  • Enrico Bulleri,
  • Giulia Azzini
Cristian Fusi
RN, Department of Intensive Care Unit, Ente Ospedaliero Cantonale - Civico, Lugano, Switzerland.
Enrico Bulleri
RN, Department of Intensive Care Unit, Ente Ospedaliero Cantonale - Civico, Lugano, Switzerland.
Giulia Azzini
RN, Department of Intensive Care Unit, Ente Ospedaliero Cantonale - Bellinzona, Switzerland
DOI: https://doi.org/10.36253/if-1928

Pubblicato 2022-12-15

Parole chiave

  • Mechanical ventilation,
  • Weaning,
  • ICU,
  • Spontaneous Breathing Trial
Informativa sui diritti

Abstract

The “weaning” from mechanical ventilation is a process that involves several assessments and steps to aid a patient to reach a “liberation” from the ventilator and allow for breathing autonomy.
The process of “weaning” from mechanical ventilation involves several assessments and steps to support a patient in reaching a “liberation” from the ventilator and allow for spontaneous breathing. The weaning process consists of evaluating if the patient is able to breathe with minimal or no ventilation support. This assessment is performed by a diagnostic test named spontaneous breathing trial (SBT), repeated every 24 hours to ensure extubation success. Even though many patients do not meet the eligibility criteria for starting the weaning process, they can still be weaned. For this reason, these criteria should be evaluated in order to assess a possible weaning, rather than adopting absolute standards which have to be met simultaneously. The SBT helps the healthcare professionals to understand the patient’s capacity to sustain physiological breathing once they are extubated (or on spontaneous breathing if a tracheostomy tube is maintained in place). Several patients fail to meet the weaning criteria after less than 20 minutes of the SBT. Therefore, a 30-minute trial is enough to estimate the patient’s capacity to withhold spontaneous breathing. 
Even if the SBT is currently the gold standard method to conduct the weaning trial, it does not prevent the occurrence of complications after extubation such as upper airways obstruction, increased resistance, loss of airway protective reflexes, cough efficiency, and drainage of tracheobronchial secretions. The preventive use of NIV or High Flow Nasal Cannula is strongly recommended for patients experiencing extubation failure and mechanically ventilated for more than 24 hours after an SBT. 
A well-performed SBT usually leads to definitive extubation; on the other hand, SBT failure requires a comprehensive investigation on potentially reversible conditions. Prolonged weaning is highly wasteful in terms of time and resources due to the need for a systematic and multidisciplinary approach to successfully face the weaning process.

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Riferimenti bibliografici

  1. Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from mechanical
  2. ventilation. Intensive Care Med. 2013;39(11):1885-95.
  3. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–1056.
  4. Sklar MC, Burns K, Rittayamai N, et al. Effort to Breathe with Various Spontaneous Breathing Trial
  5. Techniques. A Physiologic Meta-analysis. Am J Respir Crit Care Med. 2017;195(11):1477-1485.
  6. Pinsky MR. Breathing as exercise: the cardiovascular response to weaning from mechanical ventilation.
  7. Intensive Care Med. 2000;26(9):1164–1166.
  8. Pellegrini JA, Moraes RB, Maccari JG, et al. Spontaneous Breathing Trials With T-Piece or Pressure Support.
  9. Respir Care. 2016;61(12):1693-1703.
  10. Esteban A, Alía I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to
  11. discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med.
  12. ;159(2):512-8.
  13. Medeiros GC, Sassi FC, Lirani-Silva C, Andrade CR. Criteria for tracheostomy decannulation: literature
  14. review. Codas. 2019;31(6):e20180228.
  15. Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation-a systematic review. J Intensive
  16. Care. 2017;20;5:38.
  17. Thille AW, Richard CM, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care
  18. Med. 2013;187(12): 1294–1302.
  19. Quintard H, l’Her E, Pottecher J, et al. Intubation and extubation of the ICU patient. Anaesth Crit Care Pain
  20. Med. 2017;36(5):327-341.
  21. Fan E, Zakhary B, Amaral A, et al. Liberation From Mechanical Ventilation in Critically Ill Adults Liberation
  22. from Mechanical Ventilation in Critically Ill Adults: An Official ATS/ACCP Clinical Practice Guideline. Ann
  23. Am Thorac Soc. 2017;14(3):441-443.
  24. Thille AW, Richard JC, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care
  25. Med. 2013 Jun 15;187(12):1294-302. doi: 10.1164/rccm.201208-1523CI.
  26. Maclntyre NR, Cook DJ, Ely EW, et al. Evidence-based guidelines for weaning and discontinuing
  27. ventilatory support: a collective task force facilitated by the American College of Chest Physicians, the
  28. American Association for Respiratory Care, and the American College of Critical Care Medicine. Chest.
  29. ;120(6):375S-95S.
  30. Béduneau G, Pham T, Schortgen F, et al. Epidemiology of Weaning Outcome according to a New Definition.
  31. The WIND Study. Am J Respir Crit Care Med. 2017;195(6):772-783.