Discontinuation of ventilation is estimated to take up to 40% of the total duration of ventilatory support, and around 3–6% of patients admitted to the intensive care unit (ICU) require a prolonged course of mechanical ventilation (MV).¹ Patients being liberated from ventilatory support therefore occupy a significant number of ICU beds and have a major impact on healthcare resources. There have been several recent key developments in the field of weaning—the use of weaning protocols, ventilatory strategies to reduce the need for invasive ventilation and facilitate successful extubation, and the creation of regional long term ventilator units. All have the potential to affect weaning outcome, but how valuable are they in practice?

WEANING PROTOCOLS

In 1996 Ely and colleagues² showed that the implementation of a standardised protocol of daily trials of spontaneous breathing performed by nursing staff reduced the total duration of MV from 6 to 4.5 days, and complications such as need for reintubation, tracheostomy, and duration of MV >21 days were also decreased, resulting in a reduction in ICU costs. Similar protocols have reduced the duration of MV, although not necessarily ICU stay.³ Smyrnios et al⁴ implemented a hospital-wide weaning protocol and found a decrease in the need for tracheostomy by a third and a reduction in mean hospital stay from 37.5 to 24.7 days, resulting in a 30% fall in cost per case.

Despite these findings, weaning protocols have not been taken up universally. For example, in a survey of ICUs in England commissioned by the Department of Health, protocol directed weaning was reported in less than one in five units.⁵ This may be due to a variety of reasons including differences in healthcare practice and cultures, …