Synopsis
Separate liberation from ventilatory support from airway safety, use a structured weaning pathway, and respond safely to secretion burden or tracheostomy emergencies.
- Weaning succeeds when respiratory capacity can meet load after reversible problems, sedation, fluid excess, metabolic disturbance and excessive support have been addressed.
- A spontaneous breathing trial tests ventilatory independence, but successful extubation also requires airway protection, cough, manageable secretions and a credible reintubation plan.
- Repeated weaning failure should trigger a diagnosis-focused review rather than progressively exhausting trials; cardiac dysfunction, diaphragm weakness, delirium and critical-illness weakness are common contributors.
Key red flags
Acute distress with a tracheostomy, absent airflow or inability to pass a suction catheter is an airway emergency: call for expert help and follow the bedside emergency algorithm immediately.
Investigation priorities
Identify when a spontaneous breathing trial is safe and potentially informative.
Management branches
The acute illness is improving and the patient is initiating breaths with acceptable physiological stability.
- Perform a daily readiness review covering illness trajectory, oxygenation, haemodynamics, consciousness, sedation, fluid balance, electrolytes, pain and neuromuscular function.
- Conduct a supervised spontaneous breathing trial using the unit protocol, stopping safely if distress, gas exchange or haemodynamic instability develops.
Key medicines
Humidification and nebulised salineDelivered according to secretion consistency, airway device and local respiratory protocol.
Sedation minimisationDaily individualised review with the lowest effective agent exposure and explicit targets.