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Weaning from the ventilator: readiness, the spontaneous breathing trial, extubation and the hours after

  • Safe practice

Each day the team checks readiness and pairs a sedation break with a breathing trial; the nurse watches closely before and after extubation.

Updated

What it is

Liberation from the ventilator should happen as soon as the patient can breathe without it, because every extra day adds risk of pneumonia, lung injury and weakness. The WHO toolkit describes seven steps: assess readiness daily, run the spontaneous breathing trial (SBT) safely, judge how the patient did, check that extubation is safe, extubate, monitor and respond, and deliver it all within the ABCDEF bundle. The SBT is done with a T-piece, CPAP or low pressure support. A patient who fails the trial goes back to rest settings, the team looks for the reason and the trial is repeated the next day. Passing the trial is not enough: the patient must also protect the airway and clear secretions.

What it requires

  • A weaning protocol agreed by the team, with daily screening.
  • A sedation plan that allows the patient to wake.
  • Staff at the bedside during the trial and in the hours after extubation.
  • Oxygen device, suction, bag-mask and intubation equipment ready.

Components

  • Daily readiness screen.
  • Spontaneous awakening trial (sedation break).
  • Spontaneous breathing trial with T-piece, CPAP or low pressure support.
  • Extubation readiness: airway protection, cough, secretions, cuff leak test when the risk is high.
  • Extubation and close monitoring, with high-flow oxygen or noninvasive ventilation in selected patients.

How it is applied (and why)

  1. Each morning screen readiness with the team: cause improving, stable without vasopressor infusion, reflexes, oxygenation within protocol.
  2. Lighten or pause sedation as the protocol says and assess pain and delirium — the patient must be awake enough to breathe and cough.
  3. Start the trial as ordered (T-piece, CPAP or low pressure support) and stay close — failure often shows early.
  4. Watch RR, SpO2, heart rate, blood pressure, effort, sweating and anxiety throughout — these are the failure signs.
  5. If failure signs appear, return to the previous settings and report — pushing on exhausts the muscles and delays liberation.
  6. If passed, assess cough, secretions and consciousness, and do the cuff leak test if ordered — the airway must stay open and clear.
  7. Prepare suction, the oxygen device, bag-mask and intubation equipment, and explain the procedure — reintubation, if needed, must be fast.
  8. Suction the mouth and above the cuff before deflating it, then remove the tube as the protocol says and apply oxygen.
  9. Monitor closely in the first hours: stridor, RR, SpO2, work of breathing and consciousness.
  10. Encourage coughing, deep breathing and early mobilisation — they clear secretions and rebuild strength.

In nursing practice

  • Higher risk of post-extubation stridor: intubation for more than 6 days, traumatic intubation, a large tube, female sex, several recent intubations, prone positioning, generalised oedema.
  • Post-extubation stridor is reported in about 2–26% of patients and often leads to reintubation.
  • High-flow nasal oxygen or noninvasive ventilation after extubation may prevent reintubation in selected high-risk patients.
  • Common reasons for failure: secretions and bronchospasm, stiff lungs, auto-PEEP, heart dysfunction or ischaemia, electrolyte and nutrition problems.
  • If ventilation is expected to last long, the team considers a tracheostomy (see the tracheostomy care page).

Common mistakes

  • Running the breathing trial while the patient is still deeply sedated.
  • Continuing a failing trial to see whether it improves.
  • Extubating after a passed trial without checking cough and secretions.
  • Leaving the newly extubated patient without close observation.

Test yourself

Think of the answer, then tap the question to see it.

Which two daily trials are paired in the liberation protocol?

The spontaneous awakening trial (a sedation break) and the spontaneous breathing trial.

Which four signs mean the spontaneous breathing trial should be stopped?

RR above 35/min, SpO2 below 90% or a fall of more than 5%, a rise in heart rate or blood pressure of more than 20–25%, and anxiety, sweating or accessory muscle use.

What should happen after a failed breathing trial?

Return to the previous settings, look for and treat the reason for failure, and try again the next day.

What does a positive cuff leak test suggest before extubation?

That the airway is unlikely to be very swollen, so stridor is less likely. It does not guarantee the airway will stay open.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), chapter 11 (World Health Organization, 2022); Clinical review: liberation from mechanical ventilation (Critical Care (open access, PMC), 2008); Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update (Infection Control & Hospital Epidemiology, SHEA/IDSA/APIC (open access, PMC), 2022); Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis (Critical Care (open access, PMC), 2020).

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Representative model, for educational purposes only.