Assessment and technique of weaning

Oxford Textbook of Critical Care (2 ed.)

Edited by Andrew Webb, Derek Angus, Simon Finfer,
Luciano Gattinoni, and Mervyn Singer

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Critical Care.

Publisher: Oxford University Press Print Publication Date: Apr 2016

Print ISBN-13: 9780199600830 Published online: Apr 2016
DOI: 10.1093/med/
9780199600830.001.0001

Assessment and technique of weaning  

Chapter: Assessment and technique of weaning

Author(s): Martin J. Tobin

DOI: 10.1093/med/9780199600830.003.0102

Key points

◆ Several studies suggest that most patients weaned successfully

could have tolerated the weaning attempts had they been initiated
a day or more earlier. Such data emphasize the need for the early
use of screening tests.
◆ A screening test should have a high sensitivity. The ratio of
respiratory frequency to tidal volume (f/VT) has been evaluated in
more than 25 studies—its average sensitivity is 0.89.
◆ Weaning involves undertaking three diagnostic tests in sequence,
measurement of predictors, a weaning trial, and a trial of
extubation.

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Assessment and technique of weaning

◆ Of the techniques used for a weaning trial, IMV has been

repeatedly shown to be inferior to the use of T-tube trials or
pressure support.
◆ Six randomized trials have evaluated the usefulness of protocols
in the management of weaning. Three revealed no benefit, two had
major methodological problems, leaving only one supporting the
use of protocols.

Introduction

Although mechanical ventilation is often lifesaving, the high risk of

complications makes it imperative to disconnect patients from the
ventilator at the earliest possible time [1]. This process is usually referred
to as weaning, an unfortunate term because the word means a gradual
reduction in a process [2]. Most patients move quite abruptly from a
period of high-level support to unassisted breathing.

The timing of this process is critical. Several randomized controlled trials

(RCTs) have revealed most patients who received mechanical ventilation
for a week or longer were able to tolerate ventilator discontinuation on
the first day that weaning-predictor tests were measured [3,4]. Many of
these patients may have tolerated extubation a day or so earlier.

Many physicians view weaning predictors as something to perform at the

point they think a patient might be able to tolerate disconnection from the
ventilator. However, weaning predictors have the greatest potential for
enhancing clinical management if performed at a time when physicians
have considerable doubt as to whether or not a patient is ready for
ventilator disconnection.

One of the main sources of weaning delay is the failure to think the
patient just might come off the ventilator. Psychological research
suggests much of this delay in ventilator weaning results from clinicians
being overconfident in their intuition that a patient is not ready for a
weaning trial [2]. Another source of error is the failure to pay close
attention to pretest probability, i.e. failure to recognize the importance of
Bayesian principles in clinical-decision making.

Assessment of patient readiness for weaning

By alerting physicians to a patient’s readiness to tolerate

unassisted ventilation—hours or days before he or she would otherwise
order a spontaneous breathing trial—weaning-predictor tests circumvent
the cognitive errors inherent in clinical decision-making [2].

Weaning-predictor tests function solely as a screening test. The goal of a

screening test is not to miss anybody with the condition under
consideration. It should have a low false-negative rate and a higher false-

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Assessment and technique of weaning

positive rate is acceptable [5]. An ideal screening test has a high

sensitivity [2,5].

Weaning uses three diagnostic tests in sequence—measurement of

predictors, a weaning trial, and a trial of extubation [2]. The sequential
nature of the testing leads to particular problems in studies undertaken
to investigate the reliability of a predictor test. One is spectrum bias
where a new study population contains fewer (or more) sick patients than
the population in which a diagnostic test was originally developed [5,6]. A
second is test-referral bias, where the results of a test under evaluation
are used to select patients for a reference-standard test, e.g. passing a
weaning trial that leads to extubation [5,6]. A third factor is base-rate
fallacy [6,7]. Consider a diagnostic test for a disease that has a false-
positive rate of 5% and false-negative rate of 0%, and the incidence of the
disorder (under consideration) is 1 per 1000 persons. A randomly
selected person undergoes diagnostic testing. The result comes back
positive. What is the chance this person has the disease? Most physicians
answer 95%. The correct answer is 1.96% [7]. Physicians who answer
95% are failing to take into account the pretest probability of the
disorder. Thus, they fall into the trap of base-rate fallacy.

Pretest probability is the estimate of the likelihood of a particular

condition (weaning outcome) before a diagnostic test is undertaken [2].
Post-test probability (typically expressed as positive- or negative-
predictive value) is the new likelihood after the test results are obtained.
A good diagnostic test achieves a marked increase (or decrease) in the
post-test probability (over pretest probability) (Fig. 102.1). For every test
the change between pre- and post-test probability is determined by Bayes’
theorem [6]. Three factors determine the magnitude of the pre- to post-
test change—sensitivity, specificity, and pre-test probability. Sensitivity
and specificity are commonly assumed to remain constant for a test. In
truth, test-referral bias, a common occurrence in studies of weaning tests,
leads to major changes in sensitivity and specificity [5]. Likewise, major
changes in pre-test probability arise as a consequence of spectrum bias
[5].

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Assessment and technique of weaning

Fig. 102.1
Relationship between pre- and post-test probability for a good weaning-
predictor test, sensitivity of 0.9 and specificity of 0.9, is characterized by
the red curve. If pretest probability of weaning success is 0.40, Bayes’
theorem dictates that a positive result on the weaning-predictor test will
yield a post-test probability of 0.86. If pretest probability is 0.80, post-test
probability will be 0.97. The increase between pretest and post-test
probability in the second instance (21%, 0.17/.80) is only a fraction of that
in the first instance (115%, 0.46/0.40) despite the sensitivity and
specificity being identical. Thus, a high pretest probability markedly
decreases the apparent reliability of a weaning-predictor test.

Frequency-to-tidal volume ratio

Weaning-failure involves several different physiological abnormalities [8].

The combination of a low tidal volume and elevated respiratory frequency
is recognized as the physiological hallmark of weaning failure (Fig.
102.2) [9]. Patients who fail a weaning trial typically demonstrate rapid
shallow breathing in the first few minutes after they are disconnected
from the ventilator [10] quantified as the ratio of respiratory frequency to
tidal volume (f/VT) [11]. The higher the f/VT, the more severe the rapid,
shallow breathing and the greater the likelihood of unsuccessful weaning.
An f/VT of 100 best discriminates between successful and unsuccessful
attempts at weaning [11]. The measurement should be obtained during
spontaneous breathing because measurements of f/VT in the presence of
pressure support or CPAP will result in inaccurate predictions of weaning
outcome [2].

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Assessment and technique of weaning

Fig. 102.2
A time-series, breath-by-breath plot of respiratory frequency and tidal
volume in a patient who failed a weaning trial. The arrow indicates the
point of resuming spontaneous breathing. Rapid, shallow breathing
developed almost immediately after discontinuation of the ventilator.

Reprinted with permission of the American Thoracic Society. Copyright ©

2015 American Thoracic Society. Tobin MJ, 1986, ‘The pattern of
breathing during successful and unsuccessful trials of weaning from
mechanical ventilation’, American Review of Respiratory Disease, 134,
pp. 1111–18. The American Journal of Respiratory and Critical Care
Medicine is an official journal of the American Thoracic Society.

The initial evaluation of f/VT was reported in 1991 [11]. Since then, this
test has been evaluated in more than 25 studies. Sensitivity ranges from
0.35 to 1 [6]. Specificity ranges from 0 to 0.89 [6]. At first glance, this
wide scatter suggests that f/VT is an unreliable predictor of weaning
outcome. This was also the viewpoint of an Evidence-Based Medicine Task
Force that undertook a meta-analysis of the studies [12,13]. The Task
Force, however, failed to take account of test-referral bias and spectrum
bias [2,5]. When data from the studies (included in the meta-analysis)
were compared with the test characteristics in the original 1991 report,
taking into account Bayesian pretest probability, the weighted Pearson
correlation coefficient was 0.86 (P < 0.0001) for positive-predictive value
and 0.82 (P < 0.0001) for negative-predictive value (Figs. 102.3 and
102.4) [6]. The average sensitivity in all of the studies on f/VT was 0.89,
and 85% of the studies reveal sensitivities higher than 0.90 [6]. This
sensitivity compares well with commonly used diagnostic tests [2].

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Assessment and technique of weaning

Fig. 102.3
Positive-predictive value (post-test probability of successful outcome) for
f/VT plotted against pretest probability of successful outcome. Studies
included in EBM Task Force meta-analysis are indicated by blue symbols;
additional studies are indicated by red symbols. The curve is based on the
sensitivity and specificity originally reported by Yang and Tobin2411 and
Bayes’ formula for 0.01-unit increments in pretest probability between
0.00 and 1.00.226 The lines represent the upper and lower 95%
confidence intervals for the predicted relationship of the positive
predictive values against pretest probability. The observed positive-
predictive value in each study (indicated a separate number) is plotted
against the pretest probability of weaning success (prevalence of
successful outcome).

Reproduced from Intensive Care Medicine, 32, 2006, pp. 2002–12,

‘Variable performance of weaning-predictor tests: Role of Baye’s theorem
and spectrum and test-referral bias’, Tobin MJ and Jubran A, © European
Society of Intensive Care Medicine and the European Society of
Paediatric and Neonatal Intensive Care. With kind permission from
Springer Science and Business Media.

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Assessment and technique of weaning

Fig. 102.4
Negative-predictive value (post-test probability of unsuccessful outcome)
for f/VT. The curve, its 95% confidence intervals, and placement of a study
on the plot are described in the legend of Fig. 102.3. The observed
negative-predictive value in each study (indicated a separate number) is
plotted against the pretest probability of weaning success (prevalence of
successful outcome).

Reproduced from Intensive Care Medicine, 32, 2006, pp. 2002–12,

‘Variable performance of weaning-predictor tests: Role of Bayes’ theorem
and spectrum and test-referral bias’, Tobin MJ and Jubran A, © European
Society of Intensive Care Medicine and the European Society of
Paediatric and Neonatal Intensive Care. With kind permission from
Springer Science and Business Media.

Diagnostic screening requires a simple test performed at a time when

pre-test probability is low (less than 50%) [2]. A screening test should be
cheap, easy to perform, pose minimal risk to patients, and provide a quick
answer. A spontaneous breathing trial that involves 30–120 minutes of
monitored performance is the antithesis of a screening test.

Techniques of weaning

When a screening test is positive, the clinician proceeds to a

confirmatory test [5]. The goal of a positive result on a confirmatory test
is to rule in a condition, i.e. the likelihood of a patient tolerating a trial of
extubation is high. An ideal confirmatory test has a low rate of false-
positive results (i.e. a high specificity) [5]. Unfortunately, the specificity of
a spontaneous breathing trial is not known. Indeed, its specificity will
never be known because its determination would require an unethical
experiment—extubating all patients who fail a weaning trial and counting
how many require reintubation [2].

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Assessment and technique of weaning

T-tube trials

During a T-tube trial, the patient is completely disconnected from the

ventilator and required to breathe spontaneously, while receiving an
enriched supply of oxygen through a T-tube circuit. If the trial is
successful, the patient is extubated. If the trial is unsuccessful, the
patient is typically given at least 24 hours of respiratory muscle rest with
full ventilator support before another T-tube trial is performed [2].

Intermittent mandatory ventilation

Intermittent mandatory ventilation (IMV) was the most popular method of

weaning for many years [14]. With IMV, the mandatory rate from the
ventilator is reduced in steps of 1–3 breaths per minute, and an arterial
blood gas is obtained about 30 minutes after each rate change. Titrating
the number of ventilator-supported breaths in accordance with the results
of arterial blood gases provides no information regarding a patient’s work
of breathing (which may be excessive) [9].

Pressure support

When pressure support is used for weaning, the level of pressure is

reduced gradually (decrements of 3–6 cm H2O) and titrated on the basis
of the patient’s respiratory frequency [3]. When the patient tolerates a
minimal level of pressure support, he or she is extubated. What exactly
constitutes a ‘minimal level of pressure support’ has never been defined
[9].

Comparison of weaning methods

Two RCTs revealed weaning time was three times longer with IMV than
with the use of T-tube trials [3,4]. In a study involving patients with
respiratory difficulties on attempted weaning, T-tube trials halved the
weaning time compared with pressure support [4]. In another study, the
weaning time was similar with the two methods [3]. Performing trials of
spontaneous breathing once a day is as effective as performing such trials
several times a day, but much simpler [4]. In patients not expecting to
pose any particular difficulty with weaning, a half-hour trial of
spontaneous breathing is as effective as a 2-hour trial [15]. In a recent
study of patients requiring prolonged mechanical ventilation, the rate of
successful weaning was more than 40% higher with trials involving
unassisted breathing through a tracheostomy than with pressure support
[16].

Weaning by protocol versus usual care

Six RCTs compared the use of protocols with usual care in the
management of weaning [2]. Three found protocolized weaning was
without benefit. Data from two of the other studies, although sometimes
viewed as evidence of the benefit of protocolized weaning, contain
internal validity problems of such magnitude that the data cannot be

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Assessment and technique of weaning

accepted as supportive. This leaves only one of the six studies supportive
of the use of protocols [2].

In a RCT to determine whether the inclusion of f/VT in a weaning protocol

influenced weaning time Tanios et al. [17] found weaning duration was
longer in the f/VT protocol group than in the non-protocol group. In this
study, patients who had a f/Vt of 105 or less progressed to a weaning trial,
whereas patients with a f/VT of 106 or higher were returned to the
ventilator. When conducting research, this is exactly how a protocol must
be specified and followed. No flexibility is permitted. However, it is not
clinically realistic to slavishly comply with a protocol that decides an
entire day of ventilator management on a one-unit difference in a single
measurement of f/VT. Rather, customizing knowledge of each patient
outperforms the inflexible application of a protocol.

Extubation

Decisions about weaning and decisions about extubation are

commonly combined [18]. When a patient tolerates a weaning trial
without distress, a clinician feels reasonably confident that the patient
will be able to sustain spontaneous ventilation after extubation. Before
removing the endotracheal tube, however, the clinician must also judge
whether or not the patient will be able to maintain a patent upper airway
after extubation.

Of patients who are expected to tolerate extubation without difficulty,

approximately 10–20% fail and require reintubation [3,4]. Mortality
among patients who require re-intubation is more than six times higher
than patients who can tolerate extubation [15]. The reason for the higher
mortality is unknown. It might be related to the development of new
problems after extubation or to complications associated with reinsertion
of a new tube. A more likely explanation is that the need for re-intubation
reflects greater severity of the underlying illness [18].

Many find it convenient to extubate a patient once he or she can breathe

comfortably on a pressure support of about 7 cmH2O and PEEP 5 cmH2O
based on the belief that such ‘minimal ventilator settings’ are simply
overcoming the resistance engendered by an endotracheal tube [19]. This
ignores the inflammation and oedema that develops in the upper airways
after an endotracheal tube has been in place for a day or more. On
removal of the tube, the mucosal swelling produces an increase in upper
airway resistance. Straus et al. [20] demonstrated the respiratory work
dissipated against the supraglottic airway after extubation is almost
identical to the work dissipated against an endotracheal tube before
extubation. Thus, applying any level of pressure support causes
underestimation of the respiratory resistance a patient will encounter
after extubation. The addition of a small amount of pressure support
produces surprisingly large reductions in inspiratory work in ventilated
patients: 5 cmH2O decreases inspiratory work by 31–38% and 10 cmH2O
decreases work by 46–60% [19]. Independently, addition of 5 cmH2O of

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Assessment and technique of weaning

PEEP can decrease work of breathing by as much as 40% in ventilated

patients [19]. In the case of a patient who might experience
cardiorespiratory difficulties after extubation, it is sensible to ensure that
the patient is able to breathe comfortably for about 30 minutes in the
complete absence of pressure support or PEEP before removal of the
endotracheal tube.

Conclusion

In conclusion, to minimize the likelihood of either delayed weaning

or premature extubation, a two-step diagnostic strategy is recommended
—measurement of weaning predictors followed by a weaning trial.
Because each step constitutes a diagnostic test, clinicians must be
mindful of the scientific principles of diagnostic testing when interpreting
the information generated by each step. The critical step is to
contemplate the possibility that a patient just might be able to tolerate
weaning. Such diagnostic triggering is assisted through use of a
screening test, which is the rationale for measurement of weaning-
predictor tests. Importantly, one should not postpone this first step by
waiting for a more complex diagnostic test, such as a T-tube trial.
Because of the many complex facets of pulmonary pathophysiology that
impinge on ventilator disconnection, weaning requires individualized care
at a high level of sophistication.

References
1. Tobin MJ. (2001). Advances in mechanical ventilation. New England
Journal of Medicine, 344, 1986–96.

2. Tobin MJ and Jubran A (2012). Weaning from mechanical ventilation. In

Tobin MJ. (ed.) Principles and Practice of Mechanical Ventilation, 3rd edn,
pp. 1185–220. New York, NY: McGraw-Hill, Inc.

3. Brochard L, Rauss A, Benito S, et al. (1994). Comparison of three

methods of gradual withdrawal from ventilatory support during weaning
from mechanical ventilation. American Journal of Respiratory and Critical
Care Medicine, 150, 896–903.

4. Esteban A, Frutos F, Tobin MJ, et al. (1995). A comparison of four

methods of weaning patients from mechanical ventilation. Spanish Lung
Failure Collaborative Group. New England Journal of Medicine, 332, 345–
50.

5. Feinstein AR (1985). Clinical Epidemiology: The Architecture of Clinical

Research. Philadelphia, PA: Saunders.

6. Tobin MJ and Jubran A. (2006). Variable performance of weaning-

predictor tests: Role of Bayes’ theorem and spectrum and test-referral
bias. Intensive Care Medicine, 32, 2002–12.

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Assessment and technique of weaning

7. Casscells W, Schoenberger A, and Graboys TB. (1978). Interpretation

by physicians of clinical laboratory results. New England Journal of
Medicine, 299, 999–1001.

8. Laghi F, Cattapan SE, Jubran A, et al. (2003). Is weaning failure caused

by low-frequency fatigue of the diaphragm? American Journal of
Respiratory and Critical Care Medicine, 167, 120–7.

9. Tobin MJ, Laghi F, and Jubran A. (2012). Ventilatory failure, ventilator

support, and ventilator weaning. Comprehensive Physiology, 2, 1–51.

10. Tobin MJ, Perez W, Guenther SM, et al. (1986). The pattern of
breathing during successful and unsuccessful trials of weaning from
mechanical ventilation. American Reviews of Respiratory Disease, 134,
1111–18.

11. Yang KL and Tobin MJ. (1991). A prospective study of indexes

predicting the outcome of trials of weaning from mechanical ventilation.
New England Journal of Medicine, 324, 1445–50.

12. MacIntyre NR, Cook DJ, Ely EW Jr, et al. (2001). 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. Chest, 120(Suppl. 6), 375S–95S.

13. Meade M, Guyatt G, Cook D, et al. (2001). Predicting success in

weaning from mechanical ventilation. Chest, 120, 400S–24S.

14. Sassoon CS (2012). Intermittent mechanical ventilation. In: Tobin MJ

(ed.) Principles and Practice of Mechanical Ventilation, 3rd edn, pp. 17–
98. New York, NY: McGraw-Hill.

15. Esteban A, Alia I, Tobin MJ, et al. (1999). Effect of spontaneous

breathing trial duration on outcome of attempts to discontinue
mechanical ventilation. Spanish Lung Failure Collaborative Group.
American Journal of Respiratory and Critical Care Medicine, 159, 512–18.

16. Jubran A, Grant BJB, Duffner LA, et al. (2013). Weaning from
prolonged mechanical ventilation. Effect of pressure support vs
unassisted breathing through a tracheostomy collar on weaning duration
in patients requiring prolonged mechanical ventilation: a randomized
trial. Journal of the American Medical Association, 309, 671–7.

17. Tanios MA, Nevins ML, Hendra KP, et al. (2006). A randomized,
controlled trial of the role of weaning predictors in clinical decision
making. Critical Care Medicine, 34(10), 2530–5.

18. Tobin MJ and Laghi F. (2012). Extubation. In: Tobin MJ (ed.) Principles
and Practice of Mechanical Ventilation, 3rd edn, pp. 1221–36. New |York,
NY: McGraw-Hill Inc.

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19. Tobin MJ. (2012). Extubation and the myth of ‘minimal ventilator
settings’. American Journal of Respiratory and Critical Care Medicine,
185(4), 349–50.

20. Straus C, Louis B, Isabey D, et al. (1998). Contribution of the

endotracheal tube and the upper airway to breathing workload. American
Journal of Respiratory and Critical Care Medicine, 157, 23–30.

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