The difficult-to-wean patient represents 6% of the intensive care population, but consumes a third of resources. Such patients experience increased morbidity and mortality. Given the changing demographics of intensive care practice, this patient group is likely to grow. Hitherto management of the difficult wean is rarely debated, though there exists a clear demand for further exploration. Here we present often overlooked, modifiable patient factors to optimise the chance of weaning success. The mechanism of weaning, trouble-shooting, continuing and limiting treatment are subsequently explored.
BolesJMBionJConnorsA. Weaning from mechanical ventilation. Eur Respir J2007;29: 1033–56.
2.
NHS Modernisation Agency. Critical Care Programme: Weaning and Long-term Ventilation.London; NHS Modernisation Agency: 2002.
3.
PeñuelasOFrutos-VivarFFernándezC. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med2011;184: 430–37.
4.
WagnerDP. Economics of prolonged mechanical ventilation. Am Rev Respir Dis1989;140: S14–18.
5.
RadyMYRyanT. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med1999;27: 340–47.
6.
WebsterNRKulkarniV. Metabolic alkalosis in the critically ill. Crit Rev Clin Lab Sci1999;36: 497–510.
7.
PochetJMLaterrePFJadoulMDevuystO. Metabolic alkalosis in the intensive care unit. Acta Clin Belgica2001;56: 2–9.
8.
GuerinCNesmePLerayV. Quantitative analysis of acid-base disorders in patients with chronic respiratory failure in stable or unstable respiratory condition. Resp Care2010;55: 1453–63.
9.
JonesPWGreenstoneM. Carbonic anhydrase inhibitors for hypercapnic ventilatory failure in chronic obstructive pulmonary disease. Cochrane Database Syst Rev2001;(1):CD002881.
10.
BrignallKADavidsonAC. Weaning from mechanical ventilation: art or science?Care Crit Ill2009;25: 22–28.
11.
GeerseDABindelsAJKuiperMA. Treatment of hypophosphatemia in the intensive care unit: A review. Crit Care2010;14: R147.
12.
AlsumrainMHJawadSAImranNB. Association of hypophosphatemia with failure-to-wean from mechanical ventilation. Ann Clin Lab Sci2010;40: 144–48.
13.
CharronTBernardFSkrobikY. Intravenous phosphate in the intensive care unit: More aggressive repletion regimens for moderate and severe hypophosphatemia. Intensive Care Med2003;29: 1273–78.
14.
BuggNCJonesJA. Hypophosphataemia. Pathophysiology, effects and management on the intensive care unit. Anaesthesia1998;53: 895–902.
15.
GoligherECLeisJAFowlerRA. Utility and safety of draining pleural effusions in mechanically ventilated patients: A systematic review and meta-analysis. Crit Care2011;15: R46.
16.
ChiumelloDBertoVMiettoC. Effects of pleural effusion on respiratory mechanics in acute lung injury/acute respiratory distress syndrome patients. Intensive Care Med2010;36.
17.
AzoulayE. Pleural effusions in the intensive care unit. Curr Opinion Pulm Med2003;9: 291–97.
18.
National Institute for Health and Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care.London: NICE; 2010. http://www.nice.org.uk/nicemedia/live/13099/50517/50517.pdf accessed 21 August 2011.
19.
OgawaSTakeuchiKMoriT. Spironolactone further reduces urinary albumin excretion and plasma B-type natriuretic peptide levels in hypertensive type II diabetes treated with angiotensin-converting enzyme inhibitor. Clin Exp Pharm Phys2006;33: 477–79.
20.
SterbaMBanerjeeAMudaliarY. Prospective observational study of levosimendan and weaning of difficult-to-wean ventilator dependent intensive care patients. Crit Care Resusc2008;10: 182–86.
21.
De VecchisRCiccarelliAPucciarelliA. Unloading therapy by intravenous diuretic in chronic heart failure: A double-edged weapon?J Cardiovasc Med (Hagerstown)2010;11: 571–74.
22.
UpadyaATilluckdharryLMuralidharanV. Fluid balance and weaning outcomes. Intensive Care Med2005;31: 1643–47.
23.
Cartin-CebaRAfessaBGajicO. Low baseline serum creatinine concentration predicts mortality in critically ill patients independent of body mass index. Crit Care Med2007;35: 2420–23.
24.
WiedemannHPWheelerAPBernardGR. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med2006;354: 2564–75.
25.
MorrisCPlumbJ. Mobilising oedema in the oedematous critically ill patient with ARDS: do we seek natriuresis not diuresis?JICS2011;12: 92–97.
26.
FoleyEFBorlaseBCDzikWH. Albumin supplementation in the critically ill. A prospective, randomized trial. Arch Surg1990;125: 739–42.
27.
MartinGSMangialardiRJWheelerAP. Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury. Crit Care Med2002;30: 2175–82.
28.
DahnMSMitchellRALangeMP. Hepatic metabolic response to injury and sepsis. Surgery1995;117: 520–30.
29.
WoodcockTEWoodcockTM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth2012;108: 384–94.
30.
JubranALawmGKellyJ. Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med2010;36: 828–35.
31.
RothenhauslerHBEhrentrautSvon DegenfeldG. Treatment of depression with methylphenidate in patients difficult to wean from mechanical ventilation in the intensive care unit. J Clin Psychiatry2000;61: 750–55.
32.
SalamATilluckdharryLAmoateng-AdjepongYManthousCA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med2004;30: 1334–39.
33.
van den BoogaardMPickkersPSlooterAJ. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ2012;344: e420.
34.
MorandiABrummelNEElyEW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care2011;17: 43–49.
35.
MartinezFJBermudez-GomezMCelliBR. Hypothyroidism. A reversible cause of diaphragmatic dysfunction. Chest1989;96: 1059–63.
36.
SchandlPHeilSLenhart-OratorAGustorffB. A multidisciplinary weaning and extubation regime leads to relevant reduction of weaning and ventilation time. Eur J Anaesthesiol2011;170–71.
37.
BocciMToddSRHargettK. A team approach to mechanically ventilated patients with tracheostomy in a surgical icu reduces length of stay and mortality?Crit Care Med2009; 37 (Suppl): A440.
38.
BlackwoodBAlderdiceFBurnsK. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ2011;342: c7327.
39.
RumbakMJWalshFWAndersonWM. Significant tracheal obstruction causing failure to wean in patients requiring prolonged mechanical ventilation: a forgotten complication of long-term mechanical ventilation. Chest1999;115: 1092–95.
40.
NoppenMStratakosGAmjadiK. Stenting allows weaning and extubation in ventilator- or tracheostomy dependency secondary to benign airway disease. Resp Med2007;101: 139–45.
41.
SnowNBerginKTHorriganTP. Thoracic CT scanning in critically ill patients. Information obtained frequently alters management. Chest1990;97: 1467–70.
42.
MillerWTTinoGFriedburgJS. Thoracic CT in the intensive care unit: assessment of clinical usefulness. Radiology1998;209: 491–98.
43.
PerisATutinoLZagliG. The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. Anesth Analg2010;111: 687–92.
44.
EliasSSviriSOrenbuch-HarrochE. Sildenafil to facilitate weaning from inhaled nitric oxide (iNO) and mechanical ventilation in a patient with severe secondary pulmonary hypertension and a patent foramen ovale. Respir Care2011;56: 1611–13.
45.
AdamopoulosCTsagouriasMArvanitiK. Weaning failure from mechanical ventilation due to hypertrophic obstructive cardiomyopathy. Intensive Care Med2005;31: 734–37.
46.
TangASWellsGATalajicM. Cardiac-resynchronization therapy for mild-to-moderate heart failure. N Engl J Med2010;363: 2385–95.
47.
HøibyNCiofuOBjarnsholtT. Pseudomonas aeruginosa biofilms in cystic fibrosis. Future Microbiol2010;5: 1663–74.
48.
Bream-RouwenhorstHRBeltzEARossMBMooresKG. Recent developments in the management of acute respiratory distress syndrome in adults. Am J Health-System Pharm2008;65: 29–36.
49.
PourriatJLBaudMLambertoC. Effects of doxapram on hypercapnic response during weaning from mechanical ventilation in COPD patients. Chest1992;101: 1639–43.
50.
LandsbergKFVaughanLMHeffnerJE. The effect of theophylline on respiratory muscle contractility and fatigue. Pharmacotherapy1990;10: 271–79.
WildmanMJSandersonCGrovesJ. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ2007;335: 1132.
