Weaning in a Pandemic Situation - A Position Paper

DEVELOPMENT AND VALIDATION OF A CLINICAL DECISION-SUPPORT TOOL FOR PREDICTION OF WEANING OUTCOME ON ADMISSION TO THE ICU

To explore the diagnostic and therapeutic methods for perioperative children with congenital heart disease (CHD) with airway stenosis in pediatric intensive care unit (PICU). Fiberoptic bronchoscopy was used for the diagnosis of 100 CHD cases in PICU who were clinically considered to have possible airway malformation because of complicated difficult-to-control lung infection, atelectasis and failure with the ventilator after surgery from January 2010 to October 2011. Cases who were confirmed to have severe airway stenosis by bronchoscopy and weaning from the ventilator after surgery were treated with balloon expandable stents into the desired position in the bronchoscopy. There were 73 cases (73%) of CHD patients with airway abnormalities, including 31 cases of severe stenosis (31%), moderate stenosis in 29 cases (29%), mild stenosis in 13 cases (13%). Nine of the 10 children in whom the mechanical ventilation was hard to be stopped after surgery because of severe airway stenosis were weaned from mechanical ventilation successfully by fiberoptic bronchoscopy, while one case died from primary disease with severe sepsis after the placement of bronchial stents. CHD children with difficult-to-control lung infection, atelectasis and failure with ventilator after surgery are often complicated with airway abnormalities. The therapeutic bronchoscopy with airway stent can be used for cases with weaning from the ventilator because of severe airway stenosis.

Early weaning from mechanical ventilation in children will lead to an extubation failure, however, prolonging mechanical ventilation will increase the risk of ventilator associated complication and the economical burden of disease. Nowadays there is no unified and objective ventilator weaning indexes in pediatrics, so it is significant to searching for appropriate and feasible ventilator weaning indexes. This article detailed the current progress on the condition and predictors of ventilator weaning in children, and comparing the predictability and accuracy of ventilator weaning indexes in children, also looking forward to the possibility of higher accuracy or scheme in ventilator weaning that used for clinical purposes. Key words: Mechanical ventilation; Ventilator weaning predictor; Children

High mortality rates are often observed among patients with liver cirrhosis admitted to an intensive care unit (ICU). Thus, the decision to treat such patients with aggressive life-support methods such as mechanical ventilation, vasopressors, and renal replacement therapy (RRT) is frequently questioned. A 77-year-old woman with hepatitis C-related cirrhosis, Child-Pugh category C, was admitted to the ICU because of respiratory failure. Ventilator weaning was difficult because of pulmonary compression by massive intractable ascites. The patient also presented with acute kidney injury (AKI), and thus, RRT was indicated. Six days after emergency peritoneal dialysis (PD), she was extubated. The mortality rate among ventilated patients with liver cirrhosis and AKI is extremely high. Ventilator weaning and extubation is often very difficult in these patients because of intractable ascites. Once RRT is indicated, emergency PD may be an effective strategy to relieve the patient of discomfort caused by massive ascites, eliminate uremic toxins, and facilitate smooth extubation of the patient.

Weaning from invasive mechanical ventilation represents a critical transition in intensive care, accounting for a substantial proportion of total ventilation time in successfully extubated patients. Inadequate assessment may lead either to prolonged ventilation with associated complications or to premature extubation attempts with an increased risk of reintubation. To systematically describe weaning processes, several classification models have been proposed. The established International Concensus Classification (ICC) weaning classification ("Budapest classification") categorized weaning courses into three groups (simple, difficult and prolonged) but showed major limitations, including restricted applicability, limited prognostic value, and an overly short observation period. The WIND (Weaning accordIng to a New Definition) classification, introduced in 2017, provides the first time-based and internationally applicable system that allows nearly complete categorization of ventilated patients and demonstrates consistent associations with patient-relevant outcomes. Validation studies across large international cohorts confirmed significantly improved classification rates and prognostic discrimination of WIND compared with the ICC system. In German-speaking countries, however, a more granular differentiation of prolonged weaning remains clinically important. The S2k guideline "Prolonged Weaning" addresses this heterogeneity through six specific subgroups, which are essential for prognosis, resource planning, and long-term care. The 2025 revised "Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation" therefore recommends a hybrid approach, combining the international standardization of the WIND classification with the detailed subgrouping of prolonged weaning from the German S2k guideline. This model enables both international comparability and the level of detail required in clinical practice within German-speaking countries, thus representing a pragmatic consensus.

Muscle weakness, defined by the Medical Research Council scale, has been associated with delay in mechanical ventilation weaning. In this study, we evaluated handgrip strength as a prediction tool in weaning outcome. This was a 1-y prospective study in 2 ICUs in 2 university hospitals. Adult patients who were on mechanical ventilation for at least 48 h and eligible for mechanical ventilation weaning were screened for inclusion. Handgrip strength was evaluated using a handheld dynamometer before each spontaneous breathing trial (SBT). Attending physicians were unaware of handgrip strength and decided on extubation according to guidelines. Eighty-four subjects were included (median age 66 [53-79] y, with a median Simplified Acute Physiology Score II of 49 [37-63]). At the first evaluation, median handgrip strength was significantly associated with weaning outcome as defined by international guidelines: simple (20 [12-26] kg), difficult (12 [6-21] kg), or prolonged (6 [3-11] kg) weaning (P = .008). Time to liberation from mechanical ventilation and ICU stay were significantly longer for subjects classified as having muscle weakness according to the handgrip strength-derived definition (P = .02 and P = .03, respectively). In multivariate analysis, known history of COPD (odds ratio [OR] 5.48, 95% CI 1.44-20.86, P = .01), sex (OR 6.16, 95% CI 1.64-23.16, P = .007), and handgrip strength at the first SBT (OR 0.89, 95% CI 0.85-0.97, P = .004) were significantly associated with difficult or prolonged weaning. Extubation failure, as defined by re-intubation or unscheduled noninvasive ventilation within 48 h after extubation, occurred 14 times after 92 attempts, leading to an extubation failure rate of 15%. No association was found between handgrip strength and extubation outcome. Muscle weakness, assessed by handgrip strength, is associated with difficult or prolonged mechanical ventilation weaning and ICU stay, but not with extubation outcome.

Background: The Rapid Shallow Breathing Index (RSBI) is widely used in weaning assessment. The threshold value of the RSBI is dependent on the patient cohort and the method used to measure it. The aims of this study were to establish a protocol for measuring the RSBI through mechanical ventilator monitoring and to simplify weaning assessment. Patients and methods: The study was conducted prospectively at Taichung Veterans General Hospital. Patients intending to discontinue mechanical ventilator use were enrolled. The RSBI was measured using 2 methods for each patient: 1) a conventional hand-held calibrated spirometry (C-RSBI), and 2) the RSBI calculated through mechanical ventilator monitoring (V-RSBI) under CPAP 5 cmH2O and a flow trigger. In addition, the ability to cough was scored semi-quantitatively. The performance of these parameters in predicting weaning failure and re-intubation within 72 hours was evaluated. Results: One hundred and eight patients (age: 66±17 years; M/F: 75/33; intubation days: 8.8±9.8) were enrolled. The C-RSBI (70±42) and V-RSBI (69±35) showed significantly good correlation (r=0.759, p＜0.001). The values of the RSBI were higher in the medical patients than in the surgical patients, but were not related to weaning failure. A poor ability to cough was a significant predictor of weaning failure. The rate of weaning failure was up to 18.2% in the patients with an ability to cough ≤3 and V-RSBI ≥60. Conclusions: The V-RSBI was measured accurately through the readout of the mechanical ventilator and its value was nearly equal to that of the C-RSBI. In combination with a non-invasive assessment of the ability to cough, V-RSBI was a simple method to assess patients with the intent to wean from the ventilator.

Weaning from mechanical ventilation has become an important challenge.It contains weaning from breathing machine and pulling out the tracheal intubation.Prolonging the time of mechanical ventilation could cause the dependence on mechanical ventilation and increasing complications associated with ventilator.Up to now,there are many methods to wean and some new techniques of weaning is developing,but it lacks all-sided knowledge for weaning from mechanical ventilation.There are many different ideas about that which method is benificial most to wean.This review is focused on all kinds of techniques for weaning. Key words: Mechanical ventilation; Weaning; Spontaneous breathing trial

The closed loop ventilation mode has been applied in the clinic for many years, it can maintain patients' breath effectively in the conventional ventilation stage, reduce the labor intensity of the staff and the frequency of blood gas analysis. Smartcare is the most intellectualization mode applied in the clinic at the present. Not only because it can automatically decide the time of weaning from mechanical ventilation early so that patients wean safely as soon as possible, but also it is available in difficult-weaning patients (eg. the acute exacerbation of chronic obstructive pulmonary diseases). Totally, it is worth recommending in the clinic. Key words: Mechanical ventilation; Ventilator weaning; Closed-loop ventilation; Adaptive support ventilation; Knowledge-based system

BackgroundOlder age has been identified in many studies as a predictor of poor outcomes in intensive care, including weaning failure. Age is a risk factor for prolonged weaning, resulting in an increased number of geriatric patients being referred to specialist weaning centres. The aim of our analysis was to investigate weaning outcomes in different age groups.MethodsWe analysed patients in prolonged weaning at Thoraxklinik Heidelberg from 1 December 2008 to 31 December 2023. We classified three groups: ≤64, 65–79 and ≥80 years of age. The patients’ characteristics and weaning success, as well as weaning failure (continued invasive mechanical ventilation (IMV) and death), were analysed using group comparisons and logistic regression analyses.ResultsDuring the study period, 915 patients (64.9±13.7 years, 39.3% female) underwent prolonged weaning. 73.3% were successfully weaned, 20.2% were discharged with IMV and 6.6% died. 40.5% of the patients were ≤64 years, 49.7% were 65–79 years and 9.7% were ≥80 years old. There was a significant difference in weaning success: in the group ≤64 years the success rate was 79.0%, 65–79 years 70.3% and ≥80 years 64.0%, p=0002. The patients’ characteristics differ in the age groups, with more postoperative patients, delirium and cardiovascular comorbidities and less neuromuscular disease and malignancy in ≥80 years old patients.Conclusions64% of carefully selected patients ≥80 years of age could be successfully weaned in a specialised centre instead of being discharged from a general intensive care unit with continuing IMV in an outpatient intensive care setting.

Objective To evaluate the predictive performance of diaphragm thickening fraction (DTF) assessed by ultrasound in the feasibility of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD). Methods Forty-three patients with COPD were enrolled for prospective study.All patients were ventilated mechanically for more than 48 hours and were expected to be weaned when they met clinical criteria in the intensive care unit from February 2015 to August 2015.Patients received a spontaneous breathing trial under pressure support for 1 h. At the end of spontaneous breathing trial, the right hemi-diaphragm was visualized in the zone of apposition using a 6-13 MHz linear ultrasound probe. Diaphragm thickness was recorded at end-inspiration(DTei) and end-expiration(DTee), and the DTF was calculated as percentage from the following formula: (DTei - DTee) / DTee. Also the rapid shallow breathing index (RSBI) was calculated. Patients meeting weaning criteria were extubated. Weaning successfully was defined as spontaneous breathing for >48 h without any form of ventilation support. Results Twenty-five patients were weaned successfully and failure of weaning was found in 18 patients. A significant differences in DTF(39.66±13.22)%vs.(23.84±8.85)%, P<0.05 and RSBI(62.74±26.05)vs.(98.89±35.44), P<0.05 were observed between patients with successful weaning and patients with failure. The sensitivity and specificity of DTF≥30 % for successful weaning were 84% and 83.88 %, respectively. The area under the receiver operating characteristic curve was 0.872(95 % CI: 0.759-0.985)for DTF. By comparison, when RSBI was ≤105, there was a sensitivity of 92 %, and a specificity of 38.89 % for determining successful weaning. The area under the receiver operating characteristic curve was 0.804(95 % CI: 0.669-0.940)for RSBI. Conclusions This study shows that in a cohort of COPD patients, the assessment of DTF using diaphragm ultrasound may be useful to predict success weaning or failure during spontaneous breathing trial. Key words: Ultrasound; Diaphragm; Chronic obstructive pulmonary disease; Mechanical ventilation; Weaning; Bedside; Critical ill; Predictive value

Objective. To ascertain the outcome, benefits, and complications of patients using home care ventilation. Methods. We reviewed the hospital charts and clinical records of all patients who had been admitted to our hospital and used a mechanical ventilator at home from 1991 through 1998. The starting point for data collection on survival was the date of discharge from the hospital. The end point was either the patient's death or the time when support using a mechanical ventilator was discontinued. The mortality rate was calculated. The cost data for the different types of ventilators were obtained from two local vendors. The cost of disposable respiratory care items (suction catheters; sterile water) was obtained by averaging the expenses from five patients. Nursing charges were surveyed for our community. Medications varied widely among patients and were not included in the estimated costs of care using a ventilator at home. Results. Twenty-six adult and five children with chronic respiratory failure are enrolled; 18 (58%) of them had neuromuscular diseases (including central nervous system disorders), and four had injuries to the spinal cord. Three of the patients used non-invasive bi-level positive pressure ventilators and two used negative pressure ventilators. Among the 31 patients, four were eventually weaned from the ventilator, and 11 (36%) died at home or in the hospital due to disconnection from the ventilator other complications. The mortality rate was greater for adults than for children. For the majority of the patients, the cost of management at home was significantly less than the cost of management in the hospital, depending largely on the level of nursing care required. Conclusions. We suggest that mechanical ventilation at home is a reasonable alternative to prolonged hospitalization on for medically stable ventilator-dependent patients, and non-invasivemechanical ventilation may be useful for some patients. ”

Objective To investigate the effect of enteral microecopharmaceutics nutrition supplement (EMN) on incidence of ventilator associated pneumonia complications, inflammatory responses, and prognoses in patients with severe traumatic brain injury (sTBI) undergoing ventilator therapy. Methods From January 2016 to September 2017, 70 patients with sTBI were randomly divided into an experimental group (EMN supplement, n=35) and a control group (n=35). Early enteral nutrition was given to patients from both groups, and bifidobacterium viable capsule was given to patients from the experimental group. Glasgow Coma Scale (GCS) scores, acute physiological and chronic health evaluation (APACHE) II scores, number of white blood cells (WBC), proportion of neutrophil (N), and serum levels of procalcitonin (PCT) and C-reactive protein (CRP) were compared between the two groups on admission and 14 d after treatment. The incidence of VAP and clinical pulmonary infection scale (CPIS) scores, pulmonary function, mechanical ventilation time and hospital stays were compared 14 d after treatment. Results The incidence of VAP in the experimental group (n=17, 51%) 14 d after EMN supplement was significantly lower as compared with that in the control group (n=22, 63%, P<0.05). Meanwhile, VAP patients from the experimental group had significantly lower CPIS scores as compared with patients from control group (P<0.05). Ventilator weaning was achieved in 29 patients from experimental group (83%) and 24 patients from control group (69%), with significant difference (P<0.05); ventilator weaning patients from the experimental group had significantly improved lung function as compared with ventilator weaning patients from control group (P<0.05). WBC number, N proportion, and serum PCT and CRP levels in the experimental group were significantly smaller/decreased as compared with those in the control group (P<0.05). As compared with patients from control group, patients from the experimental group had significantly higher GCS scores (8.35±0.51 vs. 9.48±0.48, P<0.05) and significantly lower APACHE II scores (12.58±0.78 vs. 14.68±0.97, P<0.05). Conclusion EMN supplement can effectively reduce the VAP incidence, alleviate the degree of infection and inflammatory response in patients with sTBI undergoing ventilator therapy, therefore, improve the prognosis; this method is worth of promotion. Key words: Traumatic brain injury; Enteral microecopharmaceutics nutrition; Ventilator associated pneumonia; Inflammatory response

Objective To investigate the value of Neurally adjusted ventilatory assist mode (NAVA) in difficult weaning. Methods Discussed the value of NAVA in the difficult weaning by analyzing the weaning process using the NAVA model in one case, and then reviewed related literatures. Results The patient underwent a long-term mechanical ventilation and failure of weaning after intracerebral hemorrhage.The diaphragm function was evaluated by measuring diaphragm electrical action potential and gradually exercised after switching to NAVA mode.Finally weaning successed. Conclusions NAVA is an idealventilation mode close to physiologicaland at the same time to evaluate the function of diaphragm.It has a good application prospect in difficult weaning. Key words: Neurally adjusted ventilatory assist; Electrical activity of diaphragm; Difficult weaning

The prevalence of difficult or prolonged weaning from the ventilator is increasing due to a growing number of multi-morbid, elderly and pulmonary deficient patients being mechanically ventilated. Intensive care units (ICU) tend to refer difficult to wean patients to specialised weaning facilities. A survey of 38 centres - performed in 2006 - included a total number of 2718 patients with difficult or prolonged weaning. Almost three quarters of the patients were transferred to a weaning centre from an external ICU. The weaning success rate was 66.3 %. After weaning in 31.9 % of the patients, home mechanical ventilation was started. The overall hospital mortality rate was 20.8 %. Recently the task force "WeanNet" - a network of weaning units - was founded under the auspices of the German Thoracic Society. The main aim of WeanNet is to improve cooperation among the weaning centres and the quality of patient management. Important tools of WeanNet are (i) the register of weaning patients and (ii) accreditation of the weaning centres. To develop the register an intensive cooperation between the task force and the Institute for Lung Research (ILF) was necessary. The finished register is now logistically run by ILF. In less than 1 year after the official start, already 70 weaning units with ca. 3000 patients are registered. In future "WeanNet", in particular in terms of the register and the accreditation, will stand for the quality of weaning centres in Germany.