Weaning from mechanical ventilation. Weaning categories and weaning concepts

The international classification of three weaning categories (simple weaning, difficult weaning, prolonged weaning) has been modified in the German weaning guidelines: the group of prolonged weaning has been subclassified into weaning without noninvasive ventilation (NIV), weaning with NIV, if necessary with continuing NIV in the form of home mechanical ventilation, and weaning failure.Strategies to prevent prolonged weaning comprise daily interruption of sedation, daily screening of capability of spontaneous breathing by a spontaneous breathing trial (SBT) and early implementation of NIV instead of continuing invasive mechanical ventilation especially in hypercapnic patients. The comorbidity left heart failure plays a major role in weaning failure and need for re-intubation-in this case early diagnosis and if necessary modification of heart therapy are important.Specialised weaning-centres offer the option for successful weaning for about 50-60 % of patients declared as unweanable by usual intensive care units. A multimodal therapy concept with respiratory therapists, physiotherapists and speech therapy is necessary to reach this goal. In case of weaning failure a professional discharge management to invasive home mechanical ventilation is important. Competent care by physicians in the out-of-hospital area is restricted by the sectoral division of responsibility by the German health care system. Improvement in this area is urgently needed.