ICU Map

Mechanical Ventilation Liberation & Weaning

From readiness screening and spontaneous breathing trials to extubation and post-extubation support.

RecognizeAssessDecideDifferentialInterveneReassess
Resolving Respiratory Failure / Weaning Candidate
Assessment StepPerform daily weaning readiness screen
Criteria: primary cause improving, PaO2/FiO2 >= 150 with PEEP <= 8 cmH2O and FiO2 <= 0.40, hemodynamic stability without escalating vasopressors, and spontaneous respiratory drive.
Clinical ActionConduct Spontaneous Awakening Trial (SAT)Explore Topic
Stop continuous sedatives and opioids (unless active pain). Patient passes if they open eyes, follow simple commands, or tolerate sedation hold without severe agitation.
Decision PointInitiate Spontaneous Breathing Trial (SBT) for 30–120 minutes
Use Low Pressure Support (PS 5–8 cmH2O / PEEP 0–5) or T-piece trial. Monitor respiratory rate, SpO2, heart rate, and patient comfort.
Differential Branches (2)
1Branch
Assessment StepSBT Passed: Assess airway patency & secretion management
Check RSBI (f/Vt < 105), strong cough on suctioning, minimal secretions (<1-2 suctions/2h), and positive cuff leak test in high-risk patients.
Clinical ActionProceed with planned extubation
Suction oropharynx and ETT, deflate cuff during inspiration, remove tube smoothly, and administer supplemental oxygen immediately.
Clinical ActionSelect post-extubation support strategy
Standard nasal cannula for low risk; proactive High-Flow Nasal Cannula (HFNC) or NIV for high-risk patients (age >65, COPD, CHF, hypercapnia at SBT end).
Reassessment / LoopStable: Monitor work of breathing & gas exchange
Reassess vitals, respiratory rate, and ABG at 1–2 hours post-extubation. Initiate early mobilization.
2Branch
Critical AlertSBT Failed: Return to resting ventilator supportExplore Topic
Identify failure mechanism: diaphragmatic fatigue, cardiac ischemia / fluid overload, bronchospasm, excessive secretions, or anxiety. Rest for 24h before re-attempting.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • New post-extubation laryngeal stridor — administer nebulized racemic epinephrine and IV dexamethasone immediately; prepare for re-intubation if work of breathing escalates.
  • Extubation failure occurring >24 hours post-extubation is associated with higher mortality — re-intubate promptly rather than prolonging rescue noninvasive trials.

Related Bedside Clinical Problems (9)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Acute Hypercapnia & Ventilatory Failure

Triaging rising PaCO2: distinguishing acute uncompensated acidemia from chronic compensation, identifying central vs pump vs dead-space failure, and titrating noninvasive ventilation.

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Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

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Linked Deep-Dive Topics (3)

Reference Knowledge
Invasive Mechanical Ventilationrespiratory

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

Explore Topic →
Acute Respiratory Distress Syndromerespiratory

Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.

Explore Topic →
Respiratory Failure: Basic Principlesrespiratory

Core taxonomy (Types I–IV), alveolar gas exchange physiology, work-of-breathing mechanics, and escalation thresholds in acute respiratory failure.

Explore Topic →

Evidence status

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