Consequences of Failure to Identify Patients Eligible for Weaning

Clinicians face a delicate balance when evaluating weaning readiness. Failure to recognize ventilator withdrawal potential may result in increased time on mechanical ventilation, length of stay, risk of complications such as ventilator associated pneumonia (VAP), mortality, and costs.([FOOTNOTE=Blackwood, B., Burns, K. E., Cardwell, C. R., & O'Halloran, P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014(11):CD006904.],[ANCHOR=],[LINK=]),([FOOTNOTE=Ely, E. W., Baker, A. M., Dunagan, D. P., et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med>. 1996;335(25):1864-1869.],[ANCHOR=],[LINK=]),([FOOTNOTE=Marelich, G. P., Murin, S., Battistella, F., Inciardi, J., Vierra, T., & Roby, M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118(2):459-467.],[ANCHOR=],[LINK=]) Alternatively, overly aggressive weaning attempts place patients at risk as well. For example, a failed extubation is associated with an approximately 7-fold higher risk for VAP and an approximately 3-fold higher mortality risk.([FOOTNOTE=Gao, F., Yang, L. H., He, H. R., et al. The effect of reintubation on ventilator-associated pneumonia and mortality among mechanically ventilated patients with intubation: A systematic review and meta-analysis. Heart Lung. 2016;45(4):363-371.],[ANCHOR=],[LINK=])

Discover below different consequences caused by not identifying patients in time for weaning.

Consequences of Overly Aggressive Attempts at Ventilator Discontinuation

Premature ventilator withdrawal can lead to airway loss, compromised gas exchange, aspiration, and inspiratory muscle fatigue.([FOOTNOTE=Gilstrap, D., & MacIntyre, N. Patient-ventilator interactions. Implications for clinical management. Am J Respir Crit Care Med. 2013;188(9):1058-1068.],[ANCHOR=],[LINK=]) Reintubation carries an approximately 7-fold higher risk for ventilator-associated pneumonia and an approximately 3-fold increased mortality risk.4

The impact of ineffective weaning management

The Influence of Sedation and Asynchrony on Patients’ Weaning Readiness

Achieving adequate gas exchange is a primary criterion for weaning eligibility. Gas exchange is optimal when respiratory muscles are not overloaded and can complement the work of the mechanical ventilator to pull gases deep into the lungs.12 Multiple patient-specific factors, such as metabolic derangement, airway obstruction, or resistive or obstructive physiology, are responsible for the majority of respiratory muscle loading.12 However, clinicians should also consider other factors such as sedation and patient ventilator asynchrony that contribute to respiratory muscle weakness and therefore contribute to ventilator dependence.12

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  • 18. Akoumianaki, E., Prinianakis, G., Kondili, E., Malliotakis, P., & Georgopoulos, D. Physiologic comparison of neurally adjusted ventilator assist, proportional assist and pressure support ventilation in critically ill patients. Respir Physiol Neurobiol. 2014;203:82-89.

  • 19. Esteban, A., Alia, I., Tobin, M. J., et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1999;159(2):512-518.

  • 20. Esteban, A., Frutos, F., Tobin, M. J., et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995;332(6):345-350.

  • 21. Thille, A. W., Harrois, A., Schortgen, F., Brun-Buisson, C., & Brochard, L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39(12):2612-2618.

  • 22. Torres, A., Serra-Batlles, J., Ros, E., et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116(7):540-543.

  • 23. Grasso, S., Puntillo, F., Mascia, L., et al. Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. Am J Respir Crit Care Med. 2000;161(3 Pt 1):819-826.

  • 24. Kondili, E., Prinianakis, G., Alexopoulou, C., Vakouti, E., Klimathianaki, M., & Georgopoulos, D. Respiratory load compensation during mechanical ventilation--proportional assist ventilation with load-adjustable gain factors versus pressure support. Intensive Care Med. 2006;32(5):692-699.