What is the best way to wean and liberate patients from mechanical ventilation?

“Weaning” refers to the transition from full mechanical ventilatory support to spontaneous ventilation with minimal support. “Liberation” refers to discontinuation of mechanical ventilation. This chapter focuses on clinical assessment of readiness to wean, the technique for conducting a spontaneous breathing trial (SBT), and the assessment of readiness of extubation. In addition, we review the evidence supporting various ventilator strategies in the difficult-to-wean patients. We discuss several implications for clinical care. We recommend sedation reduction and use of short-acting, titratable, sedative infusions as essential to enable early and appropriate clinical assessments. Assessment of readiness to wean and reductions in sedative infusions should be considered early and frequently in critically ill patients receiving mechanical ventilation. We recommend that once the acute insult has resolved, clinicians should have a low threshold for conducting an SBT in all critically ill patients, the SBT should last more than 30 minutes, and that current data support pressure support ventilation as the simplest and most effective technique. In patients who fail an SBT, the clinician should do the following: address all contributory causes of failure to wean, not perform a repeat SBT for 24 hours, support the patient with a nonfatiguing mode of ventilation (most commonly pressure support ventilation [PSV]), and consider tracheostomy or whether extubation to noninvasive ventilation (NIV) might be appropriate. In patients who are extubated but at high risk of reintubation, clinicians should consider the utility of NIV or high-flow nasal oxygen to reduce risk of reintubation. Weaning protocols should be considered in intensive care units (ICUs).