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Managing the apparent and hidden difficulties of weaning from mechanical ventilation

Andreas Perren| Laurent Brochard
Review
Volume 39, Issue 11 / November , 2013

Pages 1885 - 1895

Abstract

Background

In anaesthetized patients scheduled for surgery, tracheal intubation is performed with the expectation of subsequent smooth extubation. In critically ill patients, separation from the ventilator is often gradual and the time chosen for extubation may be either delayed or premature. Thus, weaning is challenging, represents a large part of the ventilation period and concerns all mechanically ventilated patients surviving their stay.

Definitions and management

Weaning may be stratified in three groups according to its difficulty and duration. In simple weaning the main issue is to detect the soonest time to start separation from the ventilator; this is frequently impeded by poor sedation management and excessive ventilator assistance. A two-step diagnostic approach is the most efficacious: screening for ascertained readiness to wean is confirmed by a diagnostic test simulating the post-extubation period, best performed by unassisted breathing (no PEEP). In case of test failure (difficult weaning), a structured and thorough diagnostic work-up regarding potentially reversible pathologies is required with a focus on cardiovascular dysfunction or fluid overload at the time of separation from the ventilator, respiratory or global muscle weakness and underlying infection. Prolonged weaning is exceptionally time- and resource-consuming, needs to properly appraise psychological problems, sleep and nutrition, and is probably best performed in specialized units.

Conclusions

Adequately managing simple and difficult weaning requires one to think about ICU policies in terms of sedation, fluid balance and having a systematic screening strategy; it also needs an individualized approach to understand and treat the failing patients. Prolonged weaning requires a holistic approach.

Keywords

References

  1. Boles J-M, Bion J, Connors A, Herridge M, Marsh B, Melote C et al (2007) Weaning from mechanical ventilation. Statement of the Sixth International Consensus Conference on Intensive Care Medicine organized jointly by the European Respiratory Society (ERS), the American Thoracic Society (ATS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Francaise (SRLF). Eur Respir J 29:1033–1056
    • View reference on PubMed
    • View reference on publisher's website
  2. Esteban A, Anzueto A, Alia I, Gordo F, Apezteguía C, Pálizas F et al (2000) How is mechanical ventilation employed in the intensive care unit? An international review. Am J Respir Crit Care Med 161:1450–1458
    • View reference on PubMed
    • View reference on publisher's website
  3. Latronico N, Bolton CF (2011) Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol 10:931–941
    • View reference on PubMed
    • View reference on publisher's website
  4. McGee D (2003) Preventing complications of central venous catheterization. N Engl J Med 348:1123–1133
    • View reference on PubMed
    • View reference on publisher's website
  5. Brochard L, Abroug F, Brenner M, Broccard AF, Danner RL, Ferrer M et al (2010) An official ATS/ERS/ESICM/SCCM/SRLF statement: prevention and management of acute renal failure in the ICU patient: an international consensus conference in intensive care medicine. Am J Respir Crit Care Med 181:1128–1155
    • View reference on PubMed
    • View reference on publisher's website
  6. Morandi A, Brummel NE, Ely EW (2011) Sedation, delirium and mechanical ventilation: the “ABCDE” approach. Curr Opin Crit Care 17:43–49
    • View reference on PubMed
    • View reference on publisher's website
  7. Lorente L, Blot S, Rello J (2010) New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 182:870–876
    • View reference on PubMed
    • View reference on publisher's website
  8. Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N et al (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150:896–903
    • View reference on PubMed
    • View reference on publisher's website
  9. Esteban A, Alía I, Ibañez J, Benito S, Tobin MJ (1994) Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. Chest 106:1188–1193
    • View reference on PubMed
    • View reference on publisher's website
  10. Esteban A, Frutos F, Tobin MJ, Alía I, Solsona JF, Valverdú I et al (1995) A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med 332:345–350
    • View reference on PubMed
    • View reference on publisher's website
  11. Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD (2000) Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 161:1530–1536
    • View reference on PubMed
    • View reference on publisher's website
  12. Epstein SK, Ciubotaru RL, Wong JB (1997) Effect of failed extubation on the outcome of mechanical ventilation. Chest 112:186–192
    • View reference on PubMed
    • View reference on publisher's website
  13. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE et al (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287:345–355
    • View reference on PubMed
    • View reference on publisher's website
  14. Funk GC, Anders S, Breyer MK, Burghuber OC, Edelmann G, Heindl W et al (2010) Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J 35:88–94
    • View reference on PubMed
    • View reference on publisher's website
  15. Sellares J, Ferrer M, Cano E, Loureiro H, Valencia M, Torres A (2011) Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU. Intensive Care Med 37:775–784
  16. Peñuelas O, Frutos-Vivar F, Fernández C, Anzueto A, Epstein SK, Apezteguía C et al (2011) Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med 184:430–437
    • View reference on PubMed
    • View reference on publisher's website
  17. Macintyre NR (2012) Chronic critical illness: the growing challenge to health care. Respir Care 2012(57):1021–1027
    • View reference on publisher's website
  18. Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN et al (2006) A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med 34:2530–2535
    • View reference on PubMed
    • View reference on publisher's website
  19. Tobin MJ, Jubran A (2006) Variable performance of weaning-predictor tests: role of Bayes’ theorem and spectrum and test-referral bias. Intensive Care Med 32:2002–2012
  20. Yang K, Tobin MJ (1991) A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 324:1445–1450
    • View reference on PubMed
    • View reference on publisher's website
  21. Thille AW, Cabello B, Galia F, Lyazidi A, Brochard L (2008) Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med 34:1477–1486
  22. Kress J, Pohlman A, O’Connor M, Hall J (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477
    • View reference on PubMed
    • View reference on publisher's website
  23. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 371:126–134
    • View reference on PubMed
    • View reference on publisher's website
  24. Thorens J-B, Kaelin RM, Jolliet P, Chevrolet JC (1995) Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. Crit Care Med 23:1807–1815
    • View reference on PubMed
    • View reference on publisher's website
  25. Krishnan JA, Moore D, Robeson C, Rand CS, Fessler HE (2004) A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med 169:673–678
    • View reference on PubMed
    • View reference on publisher's website
  26. MacIntyre N (2007) Discontinuing mechanical ventilatory support. Chest 132:1049–1056
    • View reference on PubMed
    • View reference on publisher's website
  27. Straus C, Louis B, Isabey D, Lemaire F (1998) Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 157:23–30
    • View reference on PubMed
    • View reference on publisher's website
  28. Perren A, Previsdomini M, Llamas M, Cerutti B, Györik S, Merlani G et al (2010) Patients’ prediction of extubation success. Intensive Care Med 36:2045–2052
  29. Esteban A, Alía I, Tobin MJ, Gil A, Gordo F, Vallverdú I et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med 159:512–518
    • View reference on PubMed
    • View reference on publisher's website
  30. Perren A, Domenighetti G, Mauri S, Genini F, Vizzardi N (2002) Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation. Intensive Care Med 28:1058–1063
  31. Vallverdú I, Calaf N, Subirana M, Net A, Benito S, Mancebo J (1998) Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 158:1855–1862
    • View reference on PubMed
    • View reference on publisher's website
  32. Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J (2010) Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med 36:1171–1179
  33. Reissmann HK, Ranieri VM, Goldberg P, Gottfried SB (2000) Continuous positive airway pressure facilitates spontaneous breathing in weaning chronic obstructive pulmonary disease patients by improving breathing pattern and gas exchange. Intensive Care Med 26:1764–1772
  34. Lenique F, Habis M, Lofaso F, Dubois-Randé JL, Harf A, Brochard L (1997) Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Am J Respir Crit Care Med 155:500–505
    • View reference on PubMed
    • View reference on publisher's website
  35. Ochoa ME, del Carmen Marín M, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E et al (2009) Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 35:1171–1179
  36. Thille AW, Richard JC, Brochard L (2013) The decision to extubate in the intensive care unit. Am J Respir Crit Care Med 187(12):1294–1302
  37. McCaffrey J, Farrell C, Whiting P, Dan A, Bagshaw SM, Delaney AP (2009) Corticosteroids to prevent extubation failure: a systematic review and meta-analysis. Intensive Care Med 35:977–986
  38. Tadié JM, Behm E, Lecuyer L, Benhmamed R, Hans S, Brasnu D et al (2010) Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study. Intensive Care Med 36:991–998
  39. Jaber S, Carlucci A, Boussarsar M, Fodil R, Pigeot J, Maggiore S et al (2001) Helium-oxygen in the postextubation period decreases inspiratory effort. Am J Respir Crit Care Med 164:633–637
    • View reference on PubMed
    • View reference on publisher's website
  40. Zeggwagh AA, Abouqal R, Madani N, Zekraoui A, Kerkeb O (1999) Weaning from mechanical ventilation: a model for extubation. Intensive Care Med 25:1077–1083
  41. Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L (2011) Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 39:2612–2618
    • View reference on PubMed
  42. Esteban A, Alía I, Gordo F, Fernández R, Solsona JF, Vallverdú I et al (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 156:459–465
    • View reference on PubMed
    • View reference on publisher's website
  43. Torres A, Gatell JM, Aznar E, el-Ebiary M, Puig de la Bellacasa J, González J et al (1995) Reintubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 152:137–141
    • View reference on PubMed
    • View reference on publisher's website
  44. Burns KEA, Adhikari NKJ, Keenan SP, Meade M (2009) Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ 338:b1574
    • View reference on PubMed
    • View reference on publisher's website
  45. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A et al (2005) Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 33:2465–2470
    • View reference on PubMed
    • View reference on publisher's website
  46. Ferrer M, Valencia M, Nicolas J, Bernardich O, Badia JR, Torres A (2006) Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 173:164–170
    • View reference on PubMed
    • View reference on publisher's website
  47. Vaschetto R, Turucz E, Dellapiazza F, Guido S, Colombo D, Cammarota G et al (2012) Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Intensive Care Med 38:1599–1606
  48. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M et al (2004) Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 350:2452–2460
    • View reference on PubMed
    • View reference on publisher's website
  49. Keenan SP, Powers C, McCormack D, Block G (2002) Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 287:3238–3244
    • View reference on PubMed
    • View reference on publisher's website
  50. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O’Halloran P (2011) Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ 342:c7237
    • View reference on PubMed
    • View reference on publisher's website
  51. Lellouche F, Mancebo J, Jolliet P, Roeseler J, Schortgen F, Dojat M et al (2006) A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med 174:894–900
    • View reference on PubMed
    • View reference on publisher's website
  52. Rose L, Presneill JJ, Johnston L, Cade JF (2008) A randomized, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartCare/PS. Intensive Care Med 34:1788–1795
  53. Schädler DD, Engel CC, Elke GG, Pulletz SS, Haake NN, Frerichs II et al (2012) Automatic control of pressure support for ventilator weaning in surgical intensive care patients. Am J Respir Crit Care Med 185:637–644
    • View reference on PubMed
    • View reference on publisher's website
  54. Burns KEA, Meade MO, Lessard MR, Hand L, Zhou Q, Keenan SP et al (2013) Wean Earlier and Automatically with New Technology (The WEAN Study): a multicentre, pilot randomized controlled trial. Am J Respir Crit. Care Med 187(11):1203–1211
  55. Georgopoulos D, Prinianakis G, Kondili E (2005) Bedside waveforms interpretation as a tool to identify patient-ventilator asynchronies. Intensive Care Med 32:34–47
  56. Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L (2006) Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 32:1515–1522
  57. Xirouchaki N, Kondili E, Vaporidi K, Xirouchakis G, Klimathianaki M, Gavriilidis G et al (2008) Proportional assist ventilation with load-adjustable gain factors in critically ill patients: comparison with pressure support. Intensive Care Med 34:2026–2034
  58. Piquilloud L, Vignaux L, Bialais E, Roeseler J, Sottiaux T, Laterre P-F et al (2011) Neurally adjusted ventilatory assist improves patient-ventilator interaction. Intensive Care Med 37:263–271
  59. McCool FD, Tzelepis GE (2012) Dysfunction of the diaphragm. N Engl J Med 366:932–942
    • View reference on PubMed
    • View reference on publisher's website
  60. Brochard L, Thille AW (2009) What is the proper approach to liberating the weak from mechanical ventilation? Crit Care Med 37:S410–S415
    • View reference on PubMed
    • View reference on publisher's website
  61. Tobin MJ, Laghi F, Jubran A (2010) Narrative review: ventilator-induced respiratory muscle weakness. Ann Intern Med 153:240–245
    • View reference on PubMed
    • View reference on publisher's website
  62. Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P et al (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358:1327–1335
    • View reference on PubMed
    • View reference on publisher's website
  63. Sassoon CSH, Caiozzo VJ, Manka A, Sieck GC (2002) Altered diaphragm contractile properties with controlled mechanical ventilation. J Appl Physiol 92:2585–2595
    • View reference on PubMed
  64. Jung B, Constantin J, Rossel N, Le Goff C (2010) Adaptive support ventilation prevents ventilator-induced diaphragmatic dysfunction in piglet: an in vivo and in vitro study. Anesthesiology 112:1435–1443
    • View reference on PubMed
    • View reference on publisher's website
  65. Laghi F, Cattapan S, Jubran A, Parthasarathy S, Warshawsky P, Choi Y-S et al (2003) Is weaning failure caused by low-frequency fatigue of the diaphragm? Am J Respir Crit Care Med 167:120–127
    • View reference on PubMed
    • View reference on publisher's website
  66. Teboul J-L, Monnet X, Richard C (2010) Weaning failure of cardiac origin: recent advances. Crit Care 14:211
    • View reference on PubMed
    • View reference on publisher's website
  67. Pinsky MR (1997) The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 23:493–503
  68. Frutos-Vivar F, Ferguson ND, Esteban A, Epstein S, Arabi Y, Apezteguĭa C et al (2006) Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 130:1664–1671
    • View reference on PubMed
    • View reference on publisher's website
  69. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354:2564–2575
  70. Mekontso Dessap A, Roche-Campo F, Kouatchet A, Tomicic V, Beduneau G, Sonneville R et al (2012) Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med 186:1256–1263
    • View reference on PubMed
    • View reference on publisher's website
  71. Jubran A, Mathru M, Dries D, Tobin MJ (1998) Continuous recordings of mixed venous oxygen saturation during weaning from mechanical ventilation and the ramifications thereof. Am J Respir Crit Care Med 158:1763–1769
    • View reference on PubMed
    • View reference on publisher's website
  72. Lemaire F, Teboul J, Cinotti L, Giotto G, Abrouk F, Steg G et al (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69:171–179
    • View reference on PubMed
    • View reference on publisher's website
  73. Lamia B, Maizel J, Ochagavia A, Chemla D, Osman D, Richard C, Teboul JL (2009) Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med 37:1696–1701
    • View reference on PubMed
    • View reference on publisher's website
  74. Anguel N, Monnet X, Osman D, Castelain V, Richard C, Teboul JL (2008) Increase in plasma protein concentration for diagnosing weaning-induced pulmonary oedema. Intensive Care Med 34:1231–1238
  75. Mekontso-Dessap A, de Prost N, Girou E, Braconnier F, Lemaire F, Brun-Buisson C et al (2006) B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med 32:1529–1536
  76. Zapata L, Vera P, Roglan A, Gich I, Ordonez-Llanos J, Betbesé AJ (2011) B-type natriuretic peptides for prediction and diagnosis of weaning failure from cardiac origin. Intensive Care Med 37:477–485
  77. Papanikolaou J, Makris D, Saranteas T, Karakitsos D, Zintzaras E, Karabinis A, Kostopanagiotou G, Zakynthinos E (2011) New insights into weaning from mechanical ventilation: left ventricular diastolic dysfunction is a key player. Intensive Care Med 37:1976–1985
  78. Routsi C, Stanopoulos I, Zakynthinos E, Politis P, Papas V, Zervakis D et al (2010) Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study. Crit Care 14:R204
    • View reference on PubMed
    • View reference on publisher's website
  79. Demoule A, Lefort Y, Lopes ME, Lemaire F (2004) Successful weaning from mechanical ventilation after coronary angioplasty. Br J Anaesth 93:295–297
    • View reference on PubMed
    • View reference on publisher's website
  80. Jubran A, Lawm G, Kelly J, Duffner LA, Gungor G, Collins EG et al (2010) Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med 36:828–835
  81. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA (2004) Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 30:1334–1339
  82. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L et al (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703–2710
    • View reference on PubMed
    • View reference on publisher's website
  83. Parthasarathy SS, Tobin MJM (2002) Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 166:1423–1429
    • View reference on PubMed
    • View reference on publisher's website
  84. Heunks LM, van der Hoeven JG (2010) Clinical review: the ABC of weaning failure—a structured approach. Crit Care 14:245
    • View reference on PubMed
    • View reference on publisher's website
  85. Laghi F, D’Alfonso N, Tobin MJ (1995) Pattern of recovery from diaphragmatic fatigue over 24 hours. J Appl Physiol 79:539–546
    • View reference on PubMed
  86. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB (2004) A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32:1689–1694
    • View reference on PubMed
    • View reference on publisher's website
  87. Trouillet J-L, Luyt C-E, Guiguet M, Ouattara A, Vaissier E, Makri R et al (2011) Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Ann Intern Med 154:373–383
    • View reference on PubMed
    • View reference on publisher's website
  88. Polverino E, Nava S, Ferrer M, Ceriana P, Clini E, Spada E et al (2010) Patients’ characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units. Intensive Care Med 36:137–142
  89. Scheinhorn DJ, Hassenpflug MS, Votto JJ, Chao DC, Epstein SK, Doig GS et al (2007) Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest 131:85–93
    • View reference on PubMed
    • View reference on publisher's website
  90. Scheinhorn DJ, Hassenpflug MS, Votto JJ, Chao DC, Epstein SK, Doig GS et al (2007) Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation. Chest 131:76–84
    • View reference on PubMed
    • View reference on publisher's website
  91. Mauri T, Pivi S, Bigatello LM (2008) Prolonged mechanical ventilation after critical illness. Minerva Anestesiol 74:297–301
    • View reference on PubMed
  92. Bigatello LM, Stelfox HT, Berra L, Schmidt U, Gettings EM (2007) Outcome of patients undergoing prolonged mechanical ventilation after critical illness. Crit Care Med 35:2491–2497
    • View reference on PubMed
    • View reference on publisher's website
  93. Nava S, Vitacca M (2006) Chronic ventilator facilities. In: Tobin MJ (ed) Principles and practice of mechanical ventilation, 2nd edn. McGraw-Hill, New York, pp 691–704
  94. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL et al (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874–1882
    • View reference on PubMed
    • View reference on publisher's website
  95. Ceriana PP, Carlucci AA, Navalesi PP, Rampulla CC, Delmastro MM, Piaggi GG et al (2003) Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive Care Med 29:845–848
    • View reference on PubMed
  96. Jubran A, Grant BJB, Duffner LA, Collins EG, Lanuza DM, Hoffman LA et al (2013) Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA 309:671–677
    • View reference on PubMed
    • View reference on publisher's website

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