Chapter 16: Ventilator Liberation

In patients requiring mechanical ventilation for more than 24 h, a search for all causes that may be contributing to ventilator dependence should be undertaken. Reversing all possible ventilatory and nonventilatory issues should be an integral part of the ventilator discontinuation process.

Patients receiving mechanical ventilation for respiratory failure should undergo a formal assessment of discontinuation potential if the following criteria are satisfied: evidence for some reversal of the underlying cause for respiratory failure, adequate oxygenation and pH, hemodynamic stability, and capability to initiate an inspiratory effort.

Formal discontinuation assessments for patients receiving mechanical ventilation for respiratory failure should be done during spontaneous breathing rather than while the patient is still receiving substantial ventilatory support.

Removal of the artificial airway from a patient who has successfully been discontinued from ventilatory support should be based upon assessments of airway patency and the ability of the patient to protect the airway.

Patients receiving mechanical ventilation for respiratory failure who fail an SBT should have the cause for the failed SBT determined. Once reversible causes for failure are corrected, subsequent SBTs should be performed every 24 h.

Patients receiving mechanical ventilation for respiratory failure who fail an SBT should receive a stable, nonfatiguing, comfortable form of ventilatory support.

Anesthesia/sedation strategies and ventilator management aimed at early extubation should be used in postsurgical patients.

Weaning/discontinuation protocols designed for nonphysician health care professionals should be developed and implemented by ICUs. Protocols aimed at optimizing sedation should also be developed and implemented.

Tracheostomy should be considered after an initial period of stabilization on the ventilator when it becomes apparent that the patient will require prolonged ventilator assistance.

Unless there is evidence for clearly irreversible ...