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comparison of four methods of weaning patients from ´ mechanical ventilation. N Engl J Med. 1995;332:345-350. 6. Brochard L, Rauss A, Benito S, Conti G, Mancebo J, Rekik N et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994;150:896-903. 7. Esteban A, Alıa I, Gordo F, Ferna ´ ´ndez R, Solsona JF, Vallverdu I et al. Extubation outcome after spontaneous breathing ´ trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med. 1997;156:459-465. 8. Esteban A, Alıa I, Tobin MJ, Gil A, Gordo F, Vallverd ´ u I et al. Effect of spontaneous breathing trial duration on outcome of ´ attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med. 1999;159:512-518. 9. Schadler D, Engel C, Elke G, Pulletz S, Haake N, Frerichs I et al. Automatic control of pressure: Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support A Collective Task Force Facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine Introduction Pathophysiology of Ventilator Dependence Criteria to Assess Ventilator Dependence Managing the Patient Who Has Failed a Spontaneous Breathing Test Role of Tracheotomy in Ventilator-Dependent Patients The Role of Long-Term Facilities [Respir Care 2002;47(1):69–90] Introduction The discontinuation or withdrawal process from mechanical ventilation is an important clinical issue.1,2 Patients are generally intubated and placed on mechanical ventilators when their own ventilatory and/or gas exchange capabilities are outstripped by the demands placed on them from a variety of diseases. Mechanical ventilation also is required when the respiratory drive is incapable of initiating ventilatory activity, either because of disease processes or drugs. As the conditions that warranted placing the patient on the ventilator stabilize and begin to resolve, attention should be placed on removing the ventilator as quickly as possible. Although this process often is termed “ventilator weaning” (implying a gradual process), we prefer the more encompassing term “discontinuation.” SEE THE RELATED EDITORIAL ON PAGE 29 Unnecessary delays in this discontinuation process increase the complication rate from mechanical ventilation (eg, pneumonia, airway trauma) as well as the cost. Aggressiveness in removing the ventilator, however, must be balanced against the possibility that premature discontinuation may occur. Premature discontinuation carries its own set of problems, including difficulty in reestablishing artificial airways and compromised gas exchange. It has been estimated that as much as 42% of the time that a medical patient spends on a mechanical ventilator is during the discontinuation process.3 This percent is likely to be much higher in patients with more slowly resolving lung disease processes. There are a number of important issues involved in the management of a mechanically ventilated patient whose disease process has begun to stabilize and/or reverse such that the discontinuation of mechanical ventilation becomes a consideration. First, an understanding of all the reasons that a given patient required a mechanical ventilator is needed. Only with this understanding can medical management be optimized. Second, assessment techniques to identify patients who are capable of ventilator discontinuation need to be utilized. Ideal assessment techniques should be able to easily and safely distinguish which paThe Writing Committee, on behalf of the Panel, includes Neil R MacIntyre MD FAARC (Chairman), Deborah J Cook MD, E Wesley Ely Jr MD MPH, Scott K Epstein MD, James B Fink MSc RRT FAARC, John E Heffner MD, Dean R Hess PhD RRT FAARC, Rolf D Hubmayr MD, and David J Scheinhorn MD. Other members of the panel include Suzanne Burns RN MSN CCRN RRN, David Chao MD, Andres Esteban MD, Douglas R Gracey MD, Jesse B Hall MD, Edward F Haponik MD, Marin H Kollef MD, Jordi Mancebo MD, Constantine A Manthous MD, Arthur S Slutsky MD, Meg A Stearn-Hassenpflug MS RD, and James K Stoller MD MSc
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