Key messages

• The decision to start weaning is made on subjective clinical assessments rather than on outcome predictors.

• Conditions such as adequate recovery from the precipitating illness and hemodynamic stability must be met before weaning is started. Potential causes of weaning failure must be excluded.

• An organized approach should be planned for each patient.

• Common ventilatory modes used for weaning are T-tube breathing, intermittent mandatory ventilation, and pressure support ventilation. Use of low levels of continuous positive airways pressure is recommended.

• The clinician chooses the most appropriate mode. If used properly, there is no evidence to show that one mode is superior to the others. Ventilatory modes can be used in combination; if the patient is unsettled, another mode may be tried on an empirical basis.

• The pace of weaning and time to resume ventilatory support are decided on clinical grounds.

• Close observation, pulmonary care, and psychological reassurance are vital. Attention must be paid to pain relief, cardiac failure, anemia, electrolyte imbalance, and acid-base disorders.

• Appropriate nutrition avoids a high carbohydrate intake.

• The patient must be allowed sufficient rest and sleep. Overnight ventilation will help fatigued respiratory muscles to recover.

• Close observation extends beyond extubation or separation from the ventilator. Non-invasive ventilatory support can be useful in this period.

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