Patients with respiratory muscle weakness should never be forced into rapid weaning maneuvers or confidence in the attendant staff will be lost. Extreme patience is often required and it must be understood that the patient will breathe when he or she is ready and not before. Patients who are recovering from respiratory muscle weakness are often acutely aware of subtle changes in ventilator settings such as respiratory rate, tidal volume, and pressure support. Therefore it is important to inform the patient prior to altering ventilator settings. If the patient is totally dependent upon ventilator-generated breaths, it is prudent to reduce these gradually while simultaneously delivering a degree of pressure support to spontaneously generated breaths sufficient to allow an acceptable tidal volume. Once mandatory ventilator breaths have been removed and the patient is breathing solely with pressure support, the level of pressure support may be gradually reduced. However, it is often necessary to increase the pressure support delivered to the patient overnight to allow adequate sleep. A patient who has been totally removed from ventilatory support should be observed breathing unaided for approximately 24 to 48 h prior to discharge to a general ward. In some cases it is prudent to observe the patient on a high-dependency unit, although many hospitals in the United Kingdom do not have such a facility. The tracheostomy should be removed when the patient has fully recovered the ability to swallow, breathe, and cough adequately.
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