Weaning the patient with CAL

• An early trial of extubation may be worthwhile before the patient becomes ventilator-dependent.

• Weaning may be a lengthy procedure. Daily trials of spontaneous breathing may reveal faster-than-anticipated progress.

• Provide plentiful encouragement and psychological support. Setting daily targets and early mobilisation may be advantageous.

• Do not tire by prolonged spontaneous breathing. Consider gradually increasing periods of spontaneous breathing interspersed by periods of rest. Ensure a good night's sleep.

• Use patient appearance and lack of symptoms (e.g. tachypnoea, fatigue) rather than specific blood gas values to judge the duration of spontaneous breathing.

• Early tracheostomy may benefit when difficulty in weaning is expected.

• The patient may cope better with a tracheostomy mask than CPAP.

• Addition of extrinsic PEEP or CPAP may prevent early airways closure and thus reduce the work of breathing. However, this should be done with caution because of the risk of increased air trapping.

• Consider heart failure as a cause of difficulty in weaning.

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