Weaning from the ventilator: a modern knowledge

Effective weaning from the ventilator is the key to a patient's expectation of a good future quality of life. Failed weaning from ventilation means a significantly shorter and lower quality of life for the patient. Thus, the effectiveness of weaning from the ventilator process plays a crucial role for critical care results — differentiating survivors from non survivors. From the perspective of ventilator weaning effectiveness, critical elements include lung protection against ventilation induced lung injury and diaphragm injury risk limitation, as well as prophylactic action against muscle weakness. The application of Clinical Decisions Support Systems for physicians, or weaning protocols for technicians and nurses, can improve the success rate according to the results achieved in randomized controlled trials. The important elements of a patient's clinical situation resulting in better ventilator weaning success rates are proper qualification, analgesia and sedation optimization, reestablishing homeostasis, as well as adequate nutritional therapy. Dexmedetomidyne administration for sedation, as well as advanced enteral nutrition products supplementation (with enriched protein and lipids participation and reduced carbohydrates concentration e.g. Diason Energy HP) increases the chances for treatment success. The introduction of specific programmess dedicated for supportive therapy consolidation (e.g. awakening and breathing coordination, delirium monitoring/management, and early excercise/mobility) may additionally improve results. Especially important is delirium elimination as such disturbance may create significant disruption in patient cooperation. The use of automatic algorithms for weaning from the ventilator process, such as Smartcare/PS or adaptive support ventilation presents one with the possibility of total ventilation time reduction. Noninvasive positive pressure ventilation, when applied as additional support for the patient after extubation in cases of acute respiratory insufficiency resulting from chronic obstructive pulmonary disease or circulatory insufficiency, may improve results in comparison with traditional care. There is also the widespread practice of spontaneous breathing trial which is used for the limitation of the risk of inadequate early extubation. However, in cases of long term mechanical ventilation lasting longer than 21 days, there is still an increased risk of unsuccessful extubation, even if the weaning and spontaneous breathing trials were successful. If the subsequent weaning trials fail despite patient status improvement being achieved with a probably good prognosis, there is still a possibility of the patient being transferred to the reference centre as good clinical practice. On the other hand, the possibility of home ventilation should be carefully assessed if there are no real chances for effective weaning from the ventilator, focusing on the family environment, conditions, and dedication.

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