title: Discontinuation of ventilatory support: new solutions to old dilemmas.
abstract: OBJECTIVE
  Weaning from mechanical ventilation implies two separate but closely related aspects of care, the discontinuation of mechanical ventilation and removal of artificial airway, which implies routine clinical dilemmas. Extubation delay and extubation failure are associated with poor clinical outcomes. We sought to summarize recent evidence on weaning.
  
  
  RESULTS
  Tolerance to an unassisted breathing does not require routine use of weaning predictors and can be addressed using weaning protocols or by implementing automatic weaning methods. Spontaneous breathing trial can be performed on low levels of pressure support, continuous positive airway pressure, or T-piece. Echocardiographic tools may help to prevent the failure of extubation. Noninvasive ventilation can prevent respiratory failure after extubation, when used in hypercapnic patients. Recently, sedation protocols and early mobilization in ventilated critically ill patients may decrease weaning period and duration of mechanical ventilation, and prevent extubation failure and complications such as ICU-acquired weakness. New techniques have been performed to identify patients with high risk for extubation failure.
  
  
  CONCLUSIONS
  There is an interesting body of clinical research in the discontinuation of mechanical ventilation. Recent randomized controlled studies provide high-level evidence for the best approaches to weaning, especially in patients who fail the first spontaneous breathing trial or targeted populations.
authors.affiliation: aIntensve Care Unit, Hospital Universitario Infanta Cristina, Parla, Madrid bCIBER de Enfermedades Respiratorias, Spain cCHU de Poitiers, Réanimation Médicale, INSERM, Université de Poitiers, Poitiers, France dHospital Universitario de Getafe, Madrid, Spain.
authors.forename: Óscar
authors.initials: Ó
authors.lastname: Peñuelas
authors.forename: Arnaud W
authors.initials: AW
authors.lastname: Thille
authors.forename: Andrés
authors.initials: A
authors.lastname: Esteban
mesh_terms: D060666:Airway Extubation; D045422:Continuous Positive Airway Pressure; D016638:Critical Illness / Q000628:therapy; D006801:Humans; D063087:Noninvasive Ventilation; D012131:Respiratory Insufficiency; D017211:Treatment Failure; D015300:Ventilator Weaning / Q000379:methods*