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Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist–control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure. Weaning from mechanical ventilation is an essential and universal element in the care of critically ill intubated patients receiving mechanical ventilation. Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube, including relevant aspects of terminal care. There is uncertainty about the best methods for conducting this process, which will generally require the cooperation of the patient during the phase of recovery from critical illness. This makes weaning an important clinical issue for patients and clinicians. Immediate, uncomplicated postoperative extubation is excluded from the scope of the current statement. In April 2005, a two-day International Consensus Conference in Intensive Care Medicine sponsored by five scientific societies was held in Budapest, Hungary, on the subject of weaning from mechanical ventilation. International Consensus Conferences in Intensive Care Medicine were first introduced in Europe in the early 1990s and were extended to North America in the mid-1990s. The methods of such conferences were specified by the National Institutes of Health. The organizational process was as follows. The International Consensus Liaison Group (ICLG) representing the five sponsoring societies designated the two chairs of the International Consensus Committee (ICC) in charge of the conference. They proposed, in turn, two recognised experts in the field to serve as scientific advisors. All four were responsible for: 1) establishing the five questions to be answered by the jury; 2) selecting the topics and the international experts who were asked to deliver lectures at the conference itself; and 3) selecting the chair and the 10-member international jury. The ICLG ultimately approved the whole process. The experts delivered their presentations during the 2- day conference, which was attended by the jury and ,130 participants. Debate and discussion followed each presentation. The names of the ICC chairs, the scientific advisors and the scientific experts are listed in the Acknowledgements. CONSENSUS DEVELOPMENT The jury held sessions during the 2 days following the Conference, developing and writing a draft of their consensus statement, which was also partially discussed with one of the scientific advisors. The process of consensus formation involved informal discussions during the 2-day sessions. One inconclusive discussion regarding classification of weaning groups required resolution via a formal vote. The jury had unrestricted access to Medline for consulting the literature during its deliberations. Accordingly, the consensus statement presented hereafter represents the jury’s analysis of the experts’ oral and written presentations and the relevant literature. Although the jury did not apply a formal evidence-based review of the material available, it followed the general methods of this extensively used consensus process. Subsequently, the consensus statement was finalised through e-mail discussions among members of the jury. The consensus statement includes the jury’s opinion on ongoing debates, uncertainties and recommendations for clinical practice and further research. The consensus statement was approved by the board of administrators of the five organising societies and submitted for peer review by the lead organisation’s journal. THE JURY ANSWERED THE FOLLOWING FIVE SPECIFIC QUESTIONS 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? QUESTION 1: WHAT IS KNOWN ABOUT THE EPIDEMIOLOGY OF WEANING PROBLEMS? Weaning process As illustrated in figure 1, TOBIN proposed at this conference a series of stages in the process of care, from intubation and initiation of mechanical ventilation through initiation of the weaning effort to the ultimate liberation from mechanical ventilation and successful extubation.
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