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Review A r tic le

Weaning from mechanical ventilation in chronic

obstructive pulmonary disease: Keys to success
Deepak Talwar, Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
Vikas Dogra
Address for correspondence:
Dr. Deepak Talwar, Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida,
Uttar Pradesh, India. E‑mail: dtlung@gmail.com

Abstract
Invasive mechanical ventilation (IMV) for management of chronic obstructive pulmonary disease (COPD) associated respiratory
failure is increasing in Intensive Care Units. However, IMV is not without its own complications. Hence, aim of managing such
patients is to get them off the ventilator as early as possible. This bridging process from IMV to extubation is called weaning in
which mechanical ventilation is gradually withdrawn and the patient resumes spontaneous breathing. Many objective parameters
have been defined for weaning success. Many of these patients are difficult‑to‑wean because of various pathophysiologic
mechanisms that are of particular relevance to patients of COPD. The following review focuses on these mechanisms and how
to troubleshoot patients who are difficult‑to‑wean.

Key words: Chronic obstructive pulmonary disease, ventilation, weaning

INTRODUCTION in this subgroup of patients, as longer MV duration leads

Prolonged mechanical ventilation (MV) leads to high
resource utilization and poor outcomes. Increasing use of
MV for the management of chronic obstructive pulmonary
disease (COPD) associated respiratory failure has in turn
increased the burden of patients with difficult weaning
in Intensive Care Units (ICUs) worldwide. Weaning
from MV is a process where MV is gradually withdrawn
and the patient resumes spontaneous breathing, [1]
thereby meaning liberation or freedom from ventilator.
Difficult‑to‑wean patients are defined as those who require
more than 7  days of weaning after first spontaneous
breathing trial (SBT).[2] Data collected from studies in
various ICUs have estimated that approximately 20–30%
of mechanically ventilated patients fulfill this criteria.[3]
In patients with COPD on MV, almost 50% meet this
criteria,[4] highlighting the importance of delayed weaning
to increased complications and in‑hospital mortality.
Mortality is around 2.6% in successfully weaned patients
whereas it is significantly higher at 27% in those requiring
re‑intubation.[5] Invasive ventilation leads to considerable
reduction in respiratory muscle strength and increase in
the incidence of ventilator‑associated pneumonia. If the
weaning procedure is started early, it can often lead to
cardiorespiratory failure. On the other hand, if it is started
too late, it can be unsuccessful because of respiratory
muscle weakness caused by deconditioning and disrupted
breathing regulation,[6] so optimal time of decision to wean
is of utmost importance in modern ICUs.
Liberating a COPD patient from ventilator is a continuous
process as with any other disease condition which starts
with recognition of patient being ready to be weaned from
ventilator by letting the patient breathe on T‑piece and,

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DOI: How to cite this article: Talwar D, Dogra V. Weaning from

10.4103/2320-8775.183839 mechanical ventilation in chronic obstructive pulmonary disease:
Keys to success. J Assoc Chest Physicians 2016;4:43-9.

43 © 2016 The Journal of Association of Chest Physicians | Published by Wolters Kluwer ‑ Medknow

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Talwar and Dogra: Weaning in COPD

if successful, proceeding to SBT followed by extubation, • Adequate neurological response – awake or arousable

if it is tolerated well (simple weaning), else letting the
patient on ventilator till next such trial till being successful.
Before the next trial, patient needs to be evaluated for the
possible causes of weaning failure and its correction in
an individual patient  (difficult weaning  –33%). Repeated
failures of SBT >3 times or longer than 7 days on
ventilator make patients more dependent on ventilator
(prolonged weaning –20%). Such patients are more
challenging and need interventions to prevent such patients
from becoming permanent weaning failures where either
transfer to dedicated weaning centers or home ventilation
are the options left for them [Figure 1].
Patients after successful extubation may require re‑intubation
due to “extubation failure,” which carries high mortality
and morbidity and needs to prevented using accurate
predicting indices prior to extubation using various clinical
and laboratory parameters, while patient is being put on
SBT and bridging with noninvasive ventilation (NIV) in
high risk for failures.
FIRST KEY TO SUCCESS: RECOGNITION OF
READINESS TO WEAN
• Cough and secretions – good cough on endotracheal
tube suction with manageable secretions
• Respiratory response  –  rapid shallow breathing
index (RSBI) <100 after 2 min of SBT.
RSBI has a sensitivity of 87  ±  14% with a specificity of
52 ± 26% and is by far most widely used index for readiness to
wean predicting high chances of passing SBT trial. However,
it is to be followed by SBT trial in all patients who are ready
to wean, which has been shown to occur in 60% only.
SECOND KEY TO SUCCESS: CLOSELY
MONITORED AND PROTOCOLIZED
SPONTANEOUS BREATHING TRIAL
The SBT simulates the conditions after extubation and
should therefore, be performed without PEEP and
pressure support. Once patient is considered ready to wean,
patient is given SBT for 2 h and proposed criteria for failure
during 2 h on T‑piece are listed in Table 1. However, some
of these criteria singly may not be an indication to abandon
and label it a “SBT failure” as readiness to wean does not
predict the success of SBT trial [Figure 2].

COPD patients are put on MV on account of giving rest

and are invariably needed for 48–72 h. Readiness to wean
THIRD KEY TO SUCCESS: EVALUATE THE
is the first step to recognize as soon as possible for every CAUSE OF SPONTANEOUS BREATHING
patient on ventilator. This is assessed by the following TRIAL FAILURE, RECTIFY, AND REPEAT
criteria: SPONTANEOUS BREATHING TRIAL NEXT DAY
• Acceptable oxygenation – PaO2/FiO2 >200 on positive
end expiratory pressure (PEEP) <4 cm of H2O Failure of first SBT trial makes patient difficult‑to‑wean
• Hemodynamic stability – no vasopressors infusions and its cause in an individual patient needs to be evaluated.

On MV

Facilitative NIV
Readiness
to Wean
7 Days
TIME

1st SBT 2nd SBT 3rd SBT >3 SBT’s Permanent WF

Extubation Extubation Extubation Extubation Transfer to

Weaning Center
Difficult weaning Home
Simple Prolonged
Weaning MV
Weaning

Prophylactic
NIV
Extubation Failure
Curative
NIV

Figure 1: Scheme of weaning and interventions recommended

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Talwar and Dogra: Weaning in COPD

Table 1: Criteria for weaning failure

Clinical criteria
Diaphoresis
Nasal flaring
Increasing respiratory effort
Tachycardia (increase in
heart rate >40 bpm)
Cardiac arrhythmias
Hypotension
Apnea
Laboratory criteria
Increase of PETCO2 >10 mm Hg
Decrease of arterial pH <7.32
Decline in arterial pH>0.07
PaO2 <60 mm Hg with an
FiO2 >0.40 (PaO2/FiO2 ratio <150)
Fall in SpO2 >5%

Figure 2: Signs of SBT failure Table 2: Causes of difficult weaning

Pulmonary Electrolyte abnormalities
Common causes of weaning difficulty are enumerated in Increased airway resistance Hypokalemia
Table 2. Multiple pathophysiologic mechanisms may exist Decreased lung compliance Hypophosphatemia
in COPD patients in and each has to be evaluated and Patient‑ventilator dyssynchrony Hypomagnesemia
Pre‑existing cardiac disease Ventilator induced
managed individually for next SBT trial. diaphragmatic dysfunction
Steroid induced myopathy
Critical illnes myopathy
FOURTH KEY TO SUCCESS: SUSPECT, Depressed central drive Anemia
Metabolic alkalosis Malnutrition/overweight
DIAGNOSE, AND TREAT SPECIAL Sedative‑hypnotic medications Adrenal insufficiency
CONDITIONS PERTAING TO CHRONIC
OBSTRUCTIVE PULMONARY DISEASE have been published for optimizing delivery of inhaled
PATIENTS WITH WEANING FAILURE medications in ventilated patients.[10]

Approximately, 60% COPD patients fail the first SBT
trial with 40% experiencing difficulties in weaning.[7]
Six common conditions peculiar to COPD patient’s failing
to wean, needs special attention are given below.
Tracheal obstruction
According to a study by Rumbak et al., tracheal injury
leads to weaning failure in patients on invasive mechanical
ventilation (IMV) for more than 4 weeks.[8] Tracheal injury
includes tracheal stenosis, tracheomalacia, and granulation
tissue formation. Secretions in the endotracheal tube
also increase resistance. Paradoxical increase in upper
airway resistance postextubation due to edema of upper
airways needs to be suspected when patient develops
laryngospasm immediately after extubation.[9] Flexible
fiberoptic bronchoscopy of computerized tomography
scans with three‑dimensional reconstruction images are
used to diagnose tracheal stenosis or tracheomalacia.
Increased airway resistance
Airway resistance has been found to be significantly
greater in patients who failed weaning trial as compared to
successful trial in same patients. Expiratory flow limitation
along with high respiratory drive can lead to respiratory
muscle fatigue, which is a contributing factor for prolonged
ventilation. Cornerstone in the management of ventilated
COPD patients is to reduce bronchoconstriction using
bronchodilators and anti‑inflammatory drugs. Guidelines
Inspiratory muscle fatigue
Dynamic hyperinflation in COPD patients leads to
flattening of diaphragm. Its contraction requires more
work of breathing being at flat part of length-tension
relationship. Levine et al.[11] found significant diaphragmatic
muscle atrophy in patients mechanically ventilated for
18–96 h. Isolated measurement of Maximal Inspiratory
Pressure does not take into account inspiratory muscle
endurance; hence, its role as a weaning predictor is
controversial.[5] Absence of hypercapnia in a weaning‑failure
patient virtually excludes inspiratory muscle fatigue.
Rehabilitation and muscle retraining with inspiratory
muscle training has an important role in successful weaning
in patients unable to wean. Antioxidant supplementation
with N acetylcysteine may attenuate low‑frequency
human diaphragm fatigue and has been shown to reduce
ventilator‑dependent days.[12]
Acute cardiac dysfunction
Acute cardiac dysfunction can contribute in weaning
failure. Airway obstruction and dynamic hyperinflation
in mechanically ventilated COPD patients can increase
preload by increasing venous return. Patients with
occult cardiac dysfunction cannot tolerate this additional
load and can lead to the development of cardiogenic
pulmonary edema during weaning of difficult‑to‑wean
COPD patients.[13] Weaning also results in increase in
afterload, which is more prominent in patients with

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Talwar and Dogra: Weaning in COPD
systemic hypertension and in a study by Routsi et al., they
showed beneficial effect of vasodilatory therapy using
nitroglycerine in difficult‑to‑wean COPD patients with
hypertension.[14]
Nonthyroidal illness syndrome
Nonthyroidal illness syndrome (NTIS) is a variable
condition of abnormal thyroid hormone concentrations
that can rise in the serum following any acute or chronic
illness that is not due to an intrinsic abnormality in thyroid
function.[15] The prevalence of NTIS is about 60–70% in
patients admitted to the ICU.[16] The proposed pathogenesis
is imbalance between the activities of Types I and II
deiodinase, decreased sensitivity of the hypothalamus and
pituitary gland to thyroid hormones, and reduced T4 protein
binding and cellular uptake.[17] NTIS has been seen in MV in
ICU patients.[18] COPD is associated with hypoxemia, which
can cause abnormal thyroid hormones. Yasar et al. proposed
NTIS to be an independent predictor of prolonged weaning
in intubated COPD patients.[19] Whether thyroid hormones
substitution is helpful in weaning is unknown.
Critical illness neuromyopathy
Critical illness neuromyopathy (CINM) includes critical
illness neuropathy and critical illness myopathy, which
often co‑exist, but usually myopathy predominates. It is
common in the mechanically ventilated (25–60% patients
ventilated for >7 days) patients. Multiple pathogenic
factors are involved in its causation including axonopathy,
mitochondrial dysfunction, microvascular ischemia,
sodium channelopathy, catabolism, and immobility.
CINM is associated with sepsis, systemic inflammation,
poor glycemic control, steroids, neuromuscular blocking
agents, immobility, and malnutrition.[20] CINM presents as
flaccid quadriparesis with hypo or areflexia and confirmed
by nerve conduction and electromyography studies.[11,21]
Optimal therapy for this condition is unknown. Treatment
is usually supportive therapy with intensive glycemic control,
minimizing the use of corticosteroids and neuromuscular
blockade, early mobilization, neuromuscular stimulation,
electrolyte replacement, and optimizing nutrition. Nearly,
70% of survivors recover completely over 4–5 months.[22]
Low body mass index and wasting in COPD patients
predisposes to CINM and prevention and treatment need
early extubation with the use of NIV. Physiotherapy with
early mobilization of critically ill patients is a relatively new
management strategy advocated to address and to reduce
the disability associated with ICU‑acquired weakness.[23] This
therapeutic approach has been reported in clinical studies
and is recommended by the European Respiratory Society.[24]
Nutritional abnormalities
Weaning from artificial nutritional intake with the
subsequent possibility to eat is an essential rehabilitative
The Journal of Association of Chest Physicians| Jul-Dec 2016 | Vol 4 | Issue 2
outcome in tracheostomized difficult‑to‑wean COPD
patients. In these COPD patients, meals may induce an
increase in respiratory rate, end‑tidal carbon dioxide, and
dyspnea. Inspiratory pressure support ventilation (PSV)
during meals may prevent worsening of dyspnea.[25]
Percutaneous endoscopic gastrostomy (PEG) as a measure
of enteral tube feeding has gained wide acceptance, and
it is currently the preferred method for providing enteral
nutrition in long‑term settings with the aim to prevent
the most serious complications. Short‑term studies have
demonstrated the advantages of PEG as compared with
the nasogastric tube feeding in patients with dysphagia
due to chronic neurological diseases. PEG insertion is a
quick procedure that is generally well tolerated by patients,
and a relatively low complication rate in the outcome has
been described.[26] Obese individuals with COPD may have
associated obstructive sleep apnea. These patients may
be more difficult to wean and require early use of NIV
post-extubation.
FIFTH KEY TO SUCCESS: RECOGNIZE
AND CORRECT PATIENT– VENTILATOR
ASYNCHRONY DURING WEANING
Intrinsic (PEEPi) is a common problem in patients with
COPD leading to asynchrony and needs to recognized
and treated as is associated with weaning failure. PEEPi
has been reportedly higher in COPD patients with
weaning failure as compared to those being successfully
weaned. [27] Multiple mechanisms are responsible for
the development of PEEPi in mechanically ventilated
COPD patients, for example, insufficient expiratory
time for complete emptying of lungs due to increased
airflow resistance with expiratory airflow limitation
and high breathing frequency and promotes patient–
ventilator asynchrony. This leads to ineffective breaths
being triggered, a significant factor for difficult weaning.
A study by de Wit et al. demonstrated significantly
longer duration of MV in patients with more than 10%
ineffective trigger breaths.[28]
SIXTH KEY TO SUCCESS: CHOOSE
NONINVASIVE VENTILATION TO FACILITATE
WEANING
Gradual weaning methods
• Synchronized intermittent mechanical ventilation
(SIMV)
• PSV
• SIMV + PSV
• Extubation + NIV.
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Talwar and Dogra: Weaning in COPD
A study by Matic et al. tried to compare T‑tube weaning with
PSV in mechanically ventilated COPD patients in whom
extubation failed after a 2‑h SBT.[29] They found PSV to
be more suitable than T‑tube for difficult‑to‑wean patients
with COPD based on shorter time needed for weaning
from MV, total MV duration, and median time spent in ICU.
A prospective randomized controlled study, which included
fifty COPD patients with Type II respiratory failure requiring
initial invasive MV found statistically significant difference
between groups weaned by noninvasive positive pressure
ventilation (NIPPV) and those weaned by conventional
PSV.[30] Randomization of patient groups was done after
failing a T‑piece trial. Statistically significant difference
was found between the two groups in terms of duration
of MV, weaning duration, length of ICU stay, occurrence
of nosocomial pneumonia, and outcome, each favoring
NIPPV. Authors concluded that NIPPV is a promising
weaning modality for mechanically ventilated patients and
be tried in resource‑limited settings in developing countries.
Use of NIV has been shown to be more safe with lesser
complications. It preserves the cough reflex and reduces the
risk for ventilator‑associated pneumonia.[31] With NIV, oral
intake and speech can be maintained along with no requirement
of sedation. In a recent Cochrane systematic review on NIV
as a weaning strategy for MV in adults with respiratory failure,
which included 16 trials, suggested that noninvasive weaning
reduces mortality and pneumonia without increasing the risk
of weaning failure or re‑intubation [Figure 3].[32]
In subgroup analysis, the authors found significantly
reduced mortality in noninvasive weaning in patients with
COPD compared involving mixed populations. This recent
meta‑analysis again confirmed the importance of NIV in
weaning of COPD patients. NIV application immediately
postextubation of COPD patients can reduce SBT time to
Figure 3: Effect of noninvasive weaning on weaning failures
47 The Journal of Association of Chest Physicians | Jul-Dec 2016 | Vol 4 | Issue 2
30 min or 1 h and can lead to successful extubation even
after failure of SBT trial.
SEVENTH KEY TO SUCCESS: RECOGNITION
AND PREVENTION OF EXTUBATION
FAILURES
Extubation failure is defined by the need of re‑intubation
within the 48 or 72 h of extubation and is associated with
significant deterioration in patients’ clinical condition. This
occurs in 10–20% of patients and needs to be avoided
as carries up to 50% mortality and is highest for late
re‑intubations partly due to different severity of disease
and of underlying comorbidities at the time of extubation,
but also contributed by clinical deterioration directly
generated by extubation failure and respiratory distress
of re‑intubation, and later by the issues of prolongation
of MV. As organ failures have been shown to worsen
after re‑intubation with increase in mortality, it is prudent
to prevent it as far as possible by refining decisions to
extubate and postextubation management. Hence, to
make extubation in COPD a success, there is a need to
optimize preextubation strategies as well as postextubation
interventions so as to prevent re‑intubation.
Management prior to extubation
Preventing extubation failure needs to optimize patient
prior to extubation so as to address the causes of
extubation failure which are similar to the causes of
weaning failure mentioned earlier with fluid balance and
cardiac dysfunction being of more significance in COPD.
Left ventricular heart failure and/or fluid overload is the
recognized cause for extubation failure as and biomarkers
such as BNP or NT‑proBNP may play a role in optimizing
fluid therapy prior to extubation. [33] Patient’s own
confidence predicts success in 90% versus 45% in patients
not confident about their own extubation.[34]
Management after extubation
Hypercapnia is more than a good predictor of extubation
failure in COPD during SBT and is a marker for the need
of prophylactic NIV after extubation.[35] Prophylactic
NIV after extubation may prevent acute respiratory
failure (ARF) and has been shown to reduce mortality
in selected high risk population of patients, for example,
COPD.[35‑37] At‑risk patients include at least one weaning
trial failure, PCO2 >45 mmHg during the T‑piece trial, and
chronic heart failure.[36] Using these various criteria, the use
of NIV resulted in a reduction of risk of ICU mortality.[36]
Preventive NIV should probably be systematically applied
immediately after extubation of hypercapnic patients. The
excellent clinical tolerance of this technique could facilitate
its systematic application.
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Talwar and Dogra: Weaning in COPD
EIGHTH KEY TO SUCCESS: REMEMBER
WHEN NOT TO USE NONINVASIVE
VENTILATION
When patient has established weaning failure, there is
no clear role of using NIV with curative intent to treat
extubation failure. Although its feasibility has been
suggested by Meduri et al.,[38] subsequently, a multicenter
study involving 221 patients (20% postoperative ARF)
was later stopped on the basis of intermediate analysis
which showed significantly increased ICU mortality in
NIV group (25 vs. 14%).[39] Current results should prompt
clinicians to be cautious in using “curative NIV” routinely
in the management of postextubation ARF in medical
ICU patients, not to delay re‑intubation. There is no study
that addressed the issue of use of NIV in patients who
get self extubated.[40]
NINTH KEY TO SUCCESS: JUDICIOUS USE OF
TRACHEOSTOMY
The use of tracheostomy is increasing in patients requiring
prolonged MV,[41] although the advantage of this strategy on
outcome is still debatable. In some studies, tracheostomy
did not favorably influence ICU survival,[42] whereas it
has been reported that tracheostomy performed in ICU
for long‑term MV patients was associated with lower
ICU and in‑hospital mortality rates.[43] Efforts should
be made to identify patients who might clearly benefit
from this technique to avoid unnecessary and unwanted
prolonged MV. A recent survey on 719 patients from 22
Italian respiratory ICUs shows that tracheostomy was
maintained in a substantial proportion of patients without
any need for home MV.[44] Consequently, the decision to
perform tracheostomy is more of an experience driven,
rather ‑ than an evidence‑based decision and should be
made with caution.
TENTH KEY TO SUCCESS: AVOID INVASIVE
MECHANICAL VENTILATION
The most important decision at the time of intubation
in a patient of COPD with respiratory failure is to
intubate or use NIV. Unless clearly contraindicated,
such patients should be tried on NIV first and to
intubate only if it fails. Unconsciousness, hemodynamic
instability, severe acidosis (pH<7.20) and hypercapnia
(>80 mmHg) are contraindications for use of NIV. Severe
encephalopathy is also considered a contraindication to
NPPV due to the concern that a depressed sensorium
would predispose the patient to aspiration. In a prospective
case–control multicenter study of patients with acute
The Journal of Association of Chest Physicians| Jul-Dec 2016 | Vol 4 | Issue 2
exacerbation COPD and moderate to severe hypercapnic
encephalopathy, the use of NIV versus IMV was associated
with similar short‑ and long‑term survivals with fewer
nosocomial infections and shorter durations of ventilation
and hospitalization. In a single‑center study in patients of
COPD with respiratory failure and do not intubate (DNI)
orders showed 45% survival, which was much less than the
group with full resuscitation orders, but encouraging to use
NIV in such situations.[45]
CONCLUSION
Successful liberation of COPD patients from MV needs
all patients with COPD be assessed on a daily basis for
their readiness to wean, followed by SBT, which may be
abbreviated to be followed by extubation and use of NIV
to facilitate weaning and preventing extubation failure.
Optimization of ventilatory strategy, bronchial hygiene,
relief of bronchospasm, and reversal of underlying
disease form cornerstones to successful weaning. Special
emphasis of physiotherapy, nutrition and systemic illness,
and comorbidities associated with COPD needs proactive
management. Given the data supporting the use of NIPPV
postextubation in COPD patients, its use for this indication
should be increased, especially in resource‑limited settings
and extending to situations such as DNI. However,
meticulous monitoring and technically skilled staff make
an integral component of good dedicated NIV unit to
cater to patients with COPD and difficult weaning and
should be established in each tertiary care unit to achieve
best outcomes in such patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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