The use of invasive mechanical ventilation in critically ill patients can be lifesaving. Most patients admitted to adult intensive care units (ICUs) require invasive ventilation. Weaning is the process during which the work of breathing is transferred from the ventilator back to the patient. Almost 40% of the time spent on invasive mechanical ventilation is spent weaning. Although invasive ventilation is effective, it is associated with the development of numerous complications including respiratory muscle weakness, ventilator associated pneumonia (VAP) and sinusitis. VAP is associated with increased morbidity and a trend toward increased mortality. At the same time, premature or failed attempts at extubation necessitating reintubation are also associated with important complications including an increased risk of developing VAP, prolonged ventilation and ICU stay and increased mortality Consequently, in their efforts to minimize the duration of invasive ventilation, clinicians are challenged by a ‘trade-off’ between the complications associated with protracted invasive ventilation and the risks associated with a premature failed attempt at extubation.
More than two decades of research support the use of specific strategies to limit the duration of invasive ventilation including the (i) use of multidisciplinary screening protocols to identify candidates for a spontaneous breathing trial (SBT), (ii) conduct of SBTs in patients who meet screening criteria, and (iii) use of specific modes and techniques [reductions in Pressure Support (PS) and once daily SBTs [PS ± positive end expiratory pressure (PEEP) or T-piece] to discontinue support in patients who fail an initial SBT.