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these should clearly involve the wider interdisciplinary team; the patient, where possible; and the patient’s family. Input from a palliative care team may add significant value for the patient and their family. Continuing the weaning process in an alternative environment may become appropriate depending upon the individual patient’s physiological needs. There are advantages to providing ongoing weaning and ventilatory support in other environments, not only for the patient, in terms of the special expertise and access to medical and nonmedical therapies that may not be universally available, but also for the demands on the critical care unit where the patient may be moved from. WHAT IS THE ROLE OF TRACHEOSTOMY IN WEANING? Neither the performance of a tracheostomy nor its timing have been shown conclusively to lead to reductions in patient mortality, the incidence of ventilator-associated pneumonia, or the duration of mechanical ventilation. Subscribe to ATOTW tutorials by visiting www.wfsahq.org/resources/anaesthesia-tutorial-of-the-week ATOTW 372 — Evidence-Based Practice of Weaning from Ventilator: A Review (6 February 2018) Page 4 of 6 The TracMan study in the United Kingdom demonstrated no improvement in ICU mortality and many other secondary outcomes with an early (,4 days) versus a late (.10 days) tracheostomy. In addition, the ability of clinicians to identify patients that would require prolonged ventilation was limited. The study concluded that early tracheostomy could result in more tracheostomies being performed with the potential for more procedural complications and no improvement in mortality of ICU length of stay.20 Tracheostomy may, however, be advantageous for an individual patient. Mechanically ventilated patients may no longer require any sedation after insertion of a tracheostomy and thus may avoid some of the complications and disadvantages of long-term sedation and may be weaned more rapidly. Patients with marginal respiratory mechanics may be weaned quickly after tracheostomy because of lower airway resistance, especially if respiratory rates are high. The ability to eat orally, the ability to communicate, and the enhanced mobility after tracheostomy can provide psychological well-being and help weaning in prolonged mechanical ventilation. In addition, the ability to receive physical therapy and use mobility aids can aid the recovery of respiratory and skeletal muscle strength. CONCLUSION Although weaning over the years has become more objective and evidence based, there are still questions relating to predictive models of weaning, newer weaning modes, and the role of tracheostomy. Technologies such as ultrasound, echocardiography, and biomarkers have been trialled in the trouble-shooting algorithm for weaning failure. In COPD patients, there seems to be a benefit in transitioning to NIV following extubation. Finally, failure to wean may result in prolonged ventilation in specialised respiratory care units outside an ICU. Weaning from mechanical ventilation remains an evolving domain of intensive care where more research is required to clarify unsettled terrains. In the meantime, as with many aspects of healthcare, there appears to be a role for a protocol-based, multidisciplinary approach with an emphasis on getting the basics right by minimising sedation, using daily sedation holds, and maximising early nutrition and mobility. REFERENCES 1. Ely EW. The utility of weaning protocols to expedite liberation from mechanical ventilation. Respir Care Clin N Am. 2000;6:303-319. 2. Smyrnios NA, Connolly A, Wilson MM, Curley FJ, French CT, Heard SO et al. Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation. Crit Care Med. 2002;30:1224-1230. 3. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324:1445-1450. 4. Chatila W, Jacob B, Guaglionone D, Manthous CA. The unassisted respiratory rate-tidal volume ratio accurately predicts weaning outcome. Am J Med. 1996;101:61-67. 5. Esteban A, Frutos F, Tobin MJ, Alıa I, Solsona JF, Valverd ´ u I et al. A
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