Routine Weaning

Standard weaning should be employed early in the ICU stay. Once the need for muscle paralysis, deep sedation, prone positioning, and other complex respiratory interventions is no longer needed, active weaning should commence.

Generally, once the underlying condition is reversed, the majority of patients can be weaned by simple sequential cessation of neuromuscular blocking agents, sedation, and respiratory support, with wakefulness, spontaneous breathing, and extuba- tion following without significant delay. However, a smaller number, dependent on case mix but usually about one third of patient number, require a more complex process. The truly “difficult-to-wean patient” represents one in six of all MV patients in the ICU [3, 22, 23].

Respiratory failure is due to ARDS that may be solely due to community-, hospital-, or ICU-acquired ARDS, or it can be contributed to by coexisting respiratory conditions, such as chronic lung disease (CLD) [23]. These coexisting conditions all carry different morbidities and associated mortalities, and influence the duration of support required, difficulty of weaning, and outcomes achieved [23]. Unfortunately, ARDS, particularly severe ARDS, while not exclusively confined to one group, makes up a significant portion of “difficult-to-wean” patients. Of this difficult-to- wean group, about one third of patients require more than 3 weeks of weaning makeup representing about one a patient in 20 of all ICU MV patients [10, 24, 25]