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. 2002 Nov;57(11):986–991. doi: 10.1136/thorax.57.11.986

The pulmonary physician in critical care • 10: Difficult weaning

J Goldstone 1
PMCID: PMC1746211  PMID: 12403884

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Selected References

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  1. Abalos A., Leibowitz A. B., Distefano D., Halpern N., Iberti T. J. Myocardial ischemia during the weaning period. Am J Crit Care. 1992 Nov;1(3):32–36. [PubMed] [Google Scholar]
  2. Alberti A., Gallo F., Fongaro A., Valenti S., Rossi A. P0.1 is a useful parameter in setting the level of pressure support ventilation. Intensive Care Med. 1995 Jul;21(7):547–553. doi: 10.1007/BF01700158. [DOI] [PubMed] [Google Scholar]
  3. Anzueto A., Peters J. I., Tobin M. J., de los Santos R., Seidenfeld J. J., Moore G., Cox W. J., Coalson J. J. Effects of prolonged controlled mechanical ventilation on diaphragmatic function in healthy adult baboons. Crit Care Med. 1997 Jul;25(7):1187–1190. doi: 10.1097/00003246-199707000-00021. [DOI] [PubMed] [Google Scholar]
  4. Barnard M., Shukla A., Lovell T., Goldstone J. Esophageal-directed pressure support ventilation in normal volunteers. Chest. 1999 Feb;115(2):482–489. doi: 10.1378/chest.115.2.482. [DOI] [PubMed] [Google Scholar]
  5. Black L. F., Hyatt R. E. Maximal respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis. 1969 May;99(5):696–702. doi: 10.1164/arrd.1969.99.5.696. [DOI] [PubMed] [Google Scholar]
  6. Bolton C. F. Neuromuscular complications of sepsis. Intensive Care Med. 1993;19 (Suppl 2):S58–S63. doi: 10.1007/BF01708802. [DOI] [PubMed] [Google Scholar]
  7. Brochard L., Harf A., Lorino H., Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis. 1989 Feb;139(2):513–521. doi: 10.1164/ajrccm/139.2.513. [DOI] [PubMed] [Google Scholar]
  8. Brochard L., Rauss A., Benito S., Conti G., Mancebo J., Rekik N., Gasparetto A., Lemaire F. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994 Oct;150(4):896–903. doi: 10.1164/ajrccm.150.4.7921460. [DOI] [PubMed] [Google Scholar]
  9. Coakley J. H., Nagendran K., Yarwood G. D., Honavar M., Hinds C. J. Patterns of neurophysiological abnormality in prolonged critical illness. Intensive Care Med. 1998 Aug;24(8):801–807. doi: 10.1007/s001340050669. [DOI] [PubMed] [Google Scholar]
  10. Cohen C. A., Zagelbaum G., Gross D., Roussos C., Macklem P. T. Clinical manifestations of inspiratory muscle fatigue. Am J Med. 1982 Sep;73(3):308–316. [PubMed] [Google Scholar]
  11. Dasgupta A., Rice R., Mascha E., Litaker D., Stoller J. K. Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation. Chest. 1999 Aug;116(2):447–455. doi: 10.1378/chest.116.2.447. [DOI] [PubMed] [Google Scholar]
  12. Demling R. H., Read T., Lind L. J., Flanagan H. L. Incidence and morbidity of extubation failure in surgical intensive care patients. Crit Care Med. 1988 Jun;16(6):573–577. doi: 10.1097/00003246-198806000-00001. [DOI] [PubMed] [Google Scholar]
  13. Derenne J. P. P0.1--about the relevance of 100 milliseconds. Intensive Care Med. 1995 Jul;21(7):545–546. doi: 10.1007/BF01700157. [DOI] [PubMed] [Google Scholar]
  14. Ely E. W., Baker A. M., Evans G. W., Haponik E. F. The prognostic significance of passing a daily screen of weaning parameters. Intensive Care Med. 1999 Jun;25(6):581–587. doi: 10.1007/s001340050906. [DOI] [PubMed] [Google Scholar]
  15. Engström C. P., Persson L. O., Larsson S., Sullivan M. Health-related quality of life in COPD: why both disease-specific and generic measures should be used. Eur Respir J. 2001 Jul;18(1):69–76. doi: 10.1183/09031936.01.00044901. [DOI] [PubMed] [Google Scholar]
  16. Esteban A., Frutos F., Tobin M. J., Alía I., Solsona J. F., Valverdú I., Fernández R., de la Cal M. A., Benito S., Tomás R. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995 Feb 9;332(6):345–350. doi: 10.1056/NEJM199502093320601. [DOI] [PubMed] [Google Scholar]
  17. Fabry B., Haberthür C., Zappe D., Guttmann J., Kuhlen R., Stocker R. Breathing pattern and additional work of breathing in spontaneously breathing patients with different ventilatory demands during inspiratory pressure support and automatic tube compensation. Intensive Care Med. 1997 May;23(5):545–552. doi: 10.1007/s001340050371. [DOI] [PubMed] [Google Scholar]
  18. Fiastro J. F., Habib M. P., Shon B. Y., Campbell S. C. Comparison of standard weaning parameters and the mechanical work of breathing in mechanically ventilated patients. Chest. 1988 Aug;94(2):232–238. doi: 10.1378/chest.94.2.232. [DOI] [PubMed] [Google Scholar]
  19. Goldstone J. C., Green M., Moxham J. Maximum relaxation rate of the diaphragm during weaning from mechanical ventilation. Thorax. 1994 Jan;49(1):54–60. doi: 10.1136/thx.49.1.54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Grasso S., Puntillo F., Mascia L., Ancona G., Fiore T., Bruno F., Slutsky A. S., Ranieri V. M. Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. Am J Respir Crit Care Med. 2000 Mar;161(3 Pt 1):819–826. doi: 10.1164/ajrccm.161.3.9902065. [DOI] [PubMed] [Google Scholar]
  21. Henneman E., Dracup K., Ganz T., Molayeme O., Cooper C. Effect of a collaborative weaning plan on patient outcome in the critical care setting. Crit Care Med. 2001 Feb;29(2):297–303. doi: 10.1097/00003246-200102000-00013. [DOI] [PubMed] [Google Scholar]
  22. Hurtado F. J., Berón M., Olivera W., Garrido R., Silva J., Caragna E., Rivara D. Gastric intramucosal pH and intraluminal PCO2 during weaning from mechanical ventilation. Crit Care Med. 2001 Jan;29(1):70–76. doi: 10.1097/00003246-200101000-00017. [DOI] [PubMed] [Google Scholar]
  23. Jabour E. R., Rabil D. M., Truwit J. D., Rochester D. F. Evaluation of a new weaning index based on ventilatory endurance and the efficiency of gas exchange. Am Rev Respir Dis. 1991 Sep;144(3 Pt 1):531–537. doi: 10.1164/ajrccm/144.3_Pt_1.531. [DOI] [PubMed] [Google Scholar]
  24. Jubran A., Tobin M. J. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med. 1997 Mar;155(3):906–915. doi: 10.1164/ajrccm.155.3.9117025. [DOI] [PubMed] [Google Scholar]
  25. Kennedy D. D., Fletcher S. N., Ghosh I. R., Coakley J. H., Monson J. P., Hinds C. J. Reversible tetraplegia due to polyneuropathy in a diabetic patient with hyperosmolar non-ketotic coma. Intensive Care Med. 1999 Dec;25(12):1437–1439. doi: 10.1007/s001340051095. [DOI] [PubMed] [Google Scholar]
  26. Kim M. J., Druz W. S., Danon J., Machnach W., Sharp J. T. Mechanics of the canine diaphragm. J Appl Physiol. 1976 Sep;41(3):369–382. doi: 10.1152/jappl.1976.41.3.369. [DOI] [PubMed] [Google Scholar]
  27. Laghi F., D'Alfonso N., Tobin M. J. Pattern of recovery from diaphragmatic fatigue over 24 hours. J Appl Physiol (1985) 1995 Aug;79(2):539–546. doi: 10.1152/jappl.1995.79.2.539. [DOI] [PubMed] [Google Scholar]
  28. Leith D. E., Bradley M. Ventilatory muscle strength and endurance training. J Appl Physiol. 1976 Oct;41(4):508–516. doi: 10.1152/jappl.1976.41.4.508. [DOI] [PubMed] [Google Scholar]
  29. Lemaire F., Teboul J. L., Cinotti L., Giotto G., Abrouk F., Steg G., Macquin-Mavier I., Zapol W. M. Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology. 1988 Aug;69(2):171–179. doi: 10.1097/00000542-198808000-00004. [DOI] [PubMed] [Google Scholar]
  30. Maldonado A., Bauer T. T., Ferrer M., Hernandez C., Arancibia F., Rodriguez-Roisin R., Torres A. Capnometric recirculation gas tonometry and weaning from mechanical ventilation. Am J Respir Crit Care Med. 2000 Jan;161(1):171–176. doi: 10.1164/ajrccm.161.1.9904080. [DOI] [PubMed] [Google Scholar]
  31. Mancebo J., Albaladejo P., Touchard D., Bak E., Subirana M., Lemaire F., Harf A., Brochard L. Airway occlusion pressure to titrate positive end-expiratory pressure in patients with dynamic hyperinflation. Anesthesiology. 2000 Jul;93(1):81–90. doi: 10.1097/00000542-200007000-00016. [DOI] [PubMed] [Google Scholar]
  32. Marelich G. P., Murin S., Battistella F., Inciardi J., Vierra T., Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000 Aug;118(2):459–467. doi: 10.1378/chest.118.2.459. [DOI] [PubMed] [Google Scholar]
  33. Miller J. F. Hope-inspiring strategies of the critically ill. Appl Nurs Res. 1989 Feb;2(1):23–29. doi: 10.1016/s0897-1897(89)80021-7. [DOI] [PubMed] [Google Scholar]
  34. Montgomery A. B., Holle R. H., Neagley S. R., Pierson D. J., Schoene R. B. Prediction of successful ventilator weaning using airway occlusion pressure and hypercapnic challenge. Chest. 1987 Apr;91(4):496–499. doi: 10.1378/chest.91.4.496. [DOI] [PubMed] [Google Scholar]
  35. Moody L. E., Lowry L., Yarandi H., Voss A. Psychophysiologic predictors of weaning from mechanical ventilation in chronic bronchitis and emphysema. Clin Nurs Res. 1997 Nov;6(4):311–333. doi: 10.1177/105477389700600402. [DOI] [PubMed] [Google Scholar]
  36. Moxham J., Goldstone J. Assessment of respiratory muscle strength in the intensive care unit. Eur Respir J. 1994 Nov;7(11):2057–2061. [PubMed] [Google Scholar]
  37. Multz A. S., Aldrich T. K., Prezant D. J., Karpel J. P., Hendler J. M. Maximal inspiratory pressure is not a reliable test of inspiratory muscle strength in mechanically ventilated patients. Am Rev Respir Dis. 1990 Sep;142(3):529–532. doi: 10.1164/ajrccm/142.3.529. [DOI] [PubMed] [Google Scholar]
  38. Murciano D., Boczkowski J., Lecocguic Y., Emili J. M., Pariente R., Aubier M. Tracheal occlusion pressure: a simple index to monitor respiratory muscle fatigue during acute respiratory failure in patients with chronic obstructive pulmonary disease. Ann Intern Med. 1988 Jun;108(6):800–805. doi: 10.7326/0003-4819-108-6-800. [DOI] [PubMed] [Google Scholar]
  39. Pepe P. E., Marini J. J. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. Am Rev Respir Dis. 1982 Jul;126(1):166–170. doi: 10.1164/arrd.1982.126.1.166. [DOI] [PubMed] [Google Scholar]
  40. Polese G., Massara A., Poggi R., Brandolese R., Brandi G., Rossi A. Flow-triggering reduces inspiratory effort during weaning from mechanical ventilation. Intensive Care Med. 1995 Aug;21(8):682–686. doi: 10.1007/BF01711550. [DOI] [PubMed] [Google Scholar]
  41. Polkey M. I., Duguet A., Luo Y., Hughes P. D., Hart N., Hamnegård C. H., Green M., Similowski T., Moxham J. Anterior magnetic phrenic nerve stimulation: laboratory and clinical evaluation. Intensive Care Med. 2000 Aug;26(8):1065–1075. doi: 10.1007/s001340051319. [DOI] [PubMed] [Google Scholar]
  42. Purro A., Appendini L., De Gaetano A., Gudjonsdottir M., Donner C. F., Rossi A. Physiologic determinants of ventilator dependence in long-term mechanically ventilated patients. Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 1):1115–1123. doi: 10.1164/ajrccm.161.4.9812160. [DOI] [PubMed] [Google Scholar]
  43. Ranieri V. M., Giuliani R., Mascia L., Grasso S., Petruzzelli V., Puntillo N., Perchiazzi G., Fiore T., Brienza A. Patient-ventilator interaction during acute hypercapnia: pressure-support vs. proportional-assist ventilation. J Appl Physiol (1985) 1996 Jul;81(1):426–436. doi: 10.1152/jappl.1996.81.1.426. [DOI] [PubMed] [Google Scholar]
  44. Rochester D. F., Arora N. S. Respiratory muscle failure. Med Clin North Am. 1983 May;67(3):573–597. doi: 10.1016/s0025-7125(16)31190-7. [DOI] [PubMed] [Google Scholar]
  45. Rothenhäusler H. B., Ehrentraut S., von Degenfeld G., Weis M., Tichy M., Kilger E., Stoll C., Schelling G., Kapfhammer H. P. Treatment of depression with methylphenidate in patients difficult to wean from mechanical ventilation in the intensive care unit. J Clin Psychiatry. 2000 Oct;61(10):750–755. doi: 10.4088/jcp.v61n1007. [DOI] [PubMed] [Google Scholar]
  46. Sahn S. A., Lakshminarayan S. Bedside criteria for discontinuation of mechanical ventilation. Chest. 1973 Jun;63(6):1002–1005. doi: 10.1378/chest.63.6.1002. [DOI] [PubMed] [Google Scholar]
  47. Sassoon C. S., Mahutte C. K. Airway occlusion pressure and breathing pattern as predictors of weaning outcome. Am Rev Respir Dis. 1993 Oct;148(4 Pt 1):860–866. doi: 10.1164/ajrccm/148.4_Pt_1.860. [DOI] [PubMed] [Google Scholar]
  48. Sassoon C. S., Te T. T., Mahutte C. K., Light R. W. Airway occlusion pressure. An important indicator for successful weaning in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. 1987 Jan;135(1):107–113. doi: 10.1164/arrd.1987.135.1.107. [DOI] [PubMed] [Google Scholar]
  49. Seneff M. G., Wagner D., Thompson D., Honeycutt C., Silver M. R. The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation. Crit Care Med. 2000 Feb;28(2):342–350. doi: 10.1097/00003246-200002000-00009. [DOI] [PubMed] [Google Scholar]
  50. Shikora S. A., Bistrian B. R., Borlase B. C., Blackburn G. L., Stone M. D., Benotti P. N. Work of breathing: reliable predictor of weaning and extubation. Crit Care Med. 1990 Feb;18(2):157–162. [PubMed] [Google Scholar]
  51. Similowski T., Fleury B., Launois S., Cathala H. P., Bouche P., Derenne J. P. Cervical magnetic stimulation: a new painless method for bilateral phrenic nerve stimulation in conscious humans. J Appl Physiol (1985) 1989 Oct;67(4):1311–1318. doi: 10.1152/jappl.1989.67.4.1311. [DOI] [PubMed] [Google Scholar]
  52. Similowski T. The diaphragm, the magnet, and the critically ill: stimulating perspectives. Crit Care Med. 2001 Jul;29(7):1476–1478. doi: 10.1097/00003246-200107000-00031. [DOI] [PubMed] [Google Scholar]
  53. Srivastava S., Chatila W., Amoateng-Adjepong Y., Kanagasegar S., Jacob B., Zarich S., Manthous C. A. Myocardial ischemia and weaning failure in patients with coronary artery disease: an update. Crit Care Med. 1999 Oct;27(10):2109–2112. doi: 10.1097/00003246-199910000-00005. [DOI] [PubMed] [Google Scholar]
  54. Tahvanainen J., Salmenperä M., Nikki P. Extubation criteria after weaning from intermittent mandatory ventilation and continuous positive airway pressure. Crit Care Med. 1983 Sep;11(9):702–707. doi: 10.1097/00003246-198309000-00006. [DOI] [PubMed] [Google Scholar]
  55. Tobin M. J., Lodato R. F. PEEP, auto-PEEP, and waterfalls. Chest. 1989 Sep;96(3):449–451. doi: 10.1378/chest.96.3.449. [DOI] [PubMed] [Google Scholar]
  56. Tobin M. J., Perez W., Guenther S. M., Semmes B. J., Mador M. J., Allen S. J., Lodato R. F., Dantzker D. R. The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation. Am Rev Respir Dis. 1986 Dec;134(6):1111–1118. doi: 10.1164/arrd.1986.134.5.1111. [DOI] [PubMed] [Google Scholar]
  57. Udwadia Z. F., Santis G. K., Steven M. H., Simonds A. K. Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency. Thorax. 1992 Sep;47(9):715–718. doi: 10.1136/thx.47.9.715. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Whitelaw W. A., Derenne J. P., Milic-Emili J. Occlusion pressure as a measure of respiratory center output in conscious man. Respir Physiol. 1975 Mar;23(2):181–199. doi: 10.1016/0034-5687(75)90059-6. [DOI] [PubMed] [Google Scholar]
  59. Williams A. G., Rayson M. P., Jubb M., World M., Woods D. R., Hayward M., Martin J., Humphries S. E., Montgomery H. E. The ACE gene and muscle performance. Nature. 2000 Feb 10;403(6770):614–614. doi: 10.1038/35001141. [DOI] [PubMed] [Google Scholar]
  60. Woods D. R., Humphries S. E., Montgomery H. E. The ACE I/D polymorphism and human physical performance. Trends Endocrinol Metab. 2000 Dec;11(10):416–420. doi: 10.1016/s1043-2760(00)00310-6. [DOI] [PubMed] [Google Scholar]
  61. Yang K. L. Reproducibility of weaning parameters. A need for standardization. Chest. 1992 Dec;102(6):1829–1832. doi: 10.1378/chest.102.6.1829. [DOI] [PubMed] [Google Scholar]
  62. Yang K. L., Tobin M. J. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991 May 23;324(21):1445–1450. doi: 10.1056/NEJM199105233242101. [DOI] [PubMed] [Google Scholar]
  63. Yang K. L., Tobin M. J. Measurement of minute ventilation in ventilator-dependent patients: need for standardization. Crit Care Med. 1991 Jan;19(1):49–53. doi: 10.1097/00003246-199101000-00014. [DOI] [PubMed] [Google Scholar]

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