title: Evidence-based assessments in the ventilator discontinuation process.
abstract: The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous  gas exchange impairment, loss of airway protection, and also a higher mortality. An evidence-based task force has recommended a daily discontinuation assessment and management process for most ICU patients requiring at least 24 hours of mechanical ventilator support. This process focuses on  assessments on the causes for ventilator dependence, assessments for evidence of disease stability/reversal, use of regular spontaneous breathing trials (SBTs) as the primary assessment tool for ventilator discontinuation potential, use of separate assessments to evaluate the need for an artificial  airway in patients tolerating the SBT, and the use of comfortable, interactive ventilator modes (that do not need to be "weaned") in between regular SBTs. More recent developments have focused on the utility of computer decision support to guide these processes and the importance  of linking sedation reduction protocols to ventilator discontinuation protocols. These guidelines are standing the test of time, and practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement and need for further clinical studies, especially in  the patient requiring prolonged mechanical ventilation.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA. neil.macintyre@duke.edu
authors.forename: Neil R
authors.initials: NR
authors.lastname: Macintyre
mesh_terms: D003422:Critical Care; D019317:Evidence-Based Medicine; D017408:Guidelines as Topic; D006801:Humans; D015300:Ventilator Weaning / Q000379:methods*