Characteristics and Outcomes of Ventilated Patients

According to Time to Liberation from

Mechanical Ventilation
Oscar Peñuelas1,2, Fernando Frutos-Vivar1,2, Cristina Fernández3, Antonio Anzueto4, Scott K. Epstein6,
Carlos Apezteguı́a7, Marco González8, Nicolas Nin1,2, Konstantinos Raymondos9, Vinko Tomicic10,
Pablo Desmery11, Yaseen Arabi12, Paolo Pelosi13, Michael Kuiper14, Manuel Jibaja15, Dimitros Matamis16,
Niall D. Ferguson5, and Andrés Esteban1,2 for the Ventila Group*
1
Hospital Universitario de Getafe, Madrid, Spain; 2CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; 3Department of
Preventive Medicine and Clinical Epidemiology, Hospital Clı́nico San Carlos, Madrid, Spain; 4South Texas Veterans Health Care System and
University of Texas Health Science Center, San Antonio, Texas; 5Interdepartmental Division of Critical Care Medicine and Department of Medicine,
Division of Respirology, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Canada; 6Office of Educational Affairs,
Tufts University School of Medicine, Boston, Massachusetts; 7Hospital Profesor A. Posadas, El Palomar, Buenos Aires, Argentina; 8Clı́nica Medellı́n
and Universidad Pontificia Bolivariana, Medellı́n, Colombia; 9Medizinische Hochschule, Hannover, Germany; 10Clı́nica Las Lilas, Santiago, Chile;
11
Sanatorio Mitre, Buenos Aires, Argentina; 12King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 13Dipartimento di
Scienze Chirurgiche e Diagnostiche Integrate, Universita’ degli Studi di Genova, Genova, Italy; 14Medical Center Leeuwarden, Leeuwarden, The
Netherlands; 15Hospital Militar de Quito, Quito, Ecuador; and 16Papageorgiou General Hospital, Thessaloniki, Greece

Rationale: A new classification of patients based on the duration of

liberation of mechanical ventilation has been proposed. AT A GLANCE COMMENTARY
Objectives: To analyze outcomes based on the new weaning classifi-
cation in a cohort of mechanically ventilated patients. Scientific Knowledge on the Subject
Methods: Secondary analysis included 2,714 patients who were It has been estimated that 40% of the time that a patient
weaned and underwent scheduled extubation from a cohort of spends on mechanical ventilation is devoted to the with-
4,968 adult patients mechanically ventilated for more than 12 hours. drawal from mechanical ventilation. However, there is little
Measurements and Main Results: Patients were classified according to information about the relationship between duration of
a new weaning classification: 1,502 patients (55%) as simple wean- weaning and outcome.
ing, 1,058 patients (39%) as difficult weaning, and 154 (6%) as pro-
longed weaning. Variables associated with prolonged weaning (.7 d)
were: severity at admission (odds ratio [OR] per unit of Simplified What This Study Adds to the Field
Acute Physiology Score II, 1.01; 95% confidence interval [CI], 1.001–
1.02), duration of mechanical ventilation before first attempt of
Among patients who begin weaning, a weaning duration
weaning (OR per day, 1.10; 95% CI, 1.06–1.13), chronic pulmonary longer than 7 days identifies a subgroup of patients at in-
disease other than chronic obstructive pulmonary disease (OR, creased risk for death.
13.23; 95% CI, 3.44–51.05), pneumonia as the reason to start me-
chanical ventilation (OR, 1.82; 95% CI, 1.07–3.08), and level of pos-
itive end-expiratory pressure applied before weaning (OR per unit,
1.09; 95% CI, 1.04–1.14). The prolonged weaning group had a non-
significant trend toward a higher rate of reintubation (P ¼ 0.08), Conclusions: Only patients who need more than 7 days for weaning
tracheostomy (P ¼ 0.15), and significantly longer length of stay have an increased mortality.
and higher mortality in the intensive care unit (OR for death, 1.97;
95% CI, 1.17–3.31). The adjusted probability of death remained con- Keywords: mechanical ventilation; weaning; outcome; extubation
stant until Day 7, at which point it increased to 12.1%.
The discontinuation of mechanical ventilation can be defined as
the process of abruptly or gradually withdrawing ventilatory sup-
port and represents one of the most important issues in intensive
care. It has been estimated that 40% of the time that a patient
(Received in original form November 23, 2010; accepted in final form April 25, 2011)
spends on mechanical ventilation is devoted to the withdrawal
*A complete list of members may be found before the beginning of the REFERENCES.
from mechanical ventilation (1). The understanding of the clin-
Supported by CIBER Enfermedades Respiratorias from Instituto de Salud Carlos III, ical reason for mechanical ventilation, the techniques used to
Spain. N.D.F. is supported by a Canadian Institutes of Health Research New In-
vestigator Award (Ottawa, Canada). A.E. is supported by the Best Spanish Clinical
identify patients capable of ventilator discontinuation, managing
Researcher, Lilly Award (Spain). the interaction between weaning and sedation, and the ventilator
Correspondence and requests for reprints should be addressed to Andrés
management strategy may help minimize both complications
Esteban, M.D., Ph.D., Intensive Care Unit, Hospital Universitario de Getafe, Car- and resource consumption during discontinuation of mechanical
retera de Toledo km, 12,500, 28905-Madrid, Spain. E-mail: aesteban@ucigetafe. ventilation (2–4).
com Weaning is a term often used to describe the ventilator discon-
Author contributions: Coordination in the acquisition of data: A.A., C.A., M.G., N.N., tinuation process by many consensus groups (3, 5) and will be
K.R., V.T., P.D., Y.A., P.P., M.K., M.J., D.M. Study concept and design: O.P., F.F.-V., a term used throughout the rest of this article. The European
A.A., N.D.F., A.E. Analysis and interpretation of data: O. P., F.F.-V., C.F., A.A., N.D.F., Respiratory Society, American Thoracic Society, European So-
S.K.E., C.A., A.E. Drafting of the manuscript: O.P., F.F.-V. Critical revision of manu- ciety of Intensive Care Medicine, Society of Critical Care Medi-
script: A.A., N.D.F., S.K.E., C.A., M.G., N.N., K.R., V.T., P.D., Y.A., P.P., M.K., M. J.,
D.M., A.E.. Statistical expertise: O.P., C.F.
cine, and Societé de Réanimation de Langue Francaise recently
convened an International Conference on weaning from mechan-
Am J Respir Crit Care Med Vol 184. pp 430–437, 2011
Originally Published in Press as DOI: 10.1164/rccm.201011-1887OC on May 26, 2011 ical ventilation. From this, a new weaning classification was pro-
Internet address: www.atsjournals.org posed according to the difficulty and length of the weaning
Peñuelas, Frutos-Vivar, Fernández, et al.: Outcome of Liberation from Mechanical Ventilation 431

Figure 1. Flow chart of exclusion–inclusion criteria for the analysis and mode of withdrawal from mechanical ventilation of included patients. ICU ¼
intensive care unit.

process. Weaning was categorized into three groups (simple, dif- Follow-up Protocol
ficult, and prolonged weaning) (5). This classification was based The following information was collected on each enrolled patient at base-
on expert opinion rather than from rigorous analysis of a cohort line: demographic data (age, sex, height, and weight); Simplified Acute
of ventilated patients; hence, little is known about clinical out- Physiology Score (SAPS II) at the time of admission to the ICU; day of
comes and validity among these groups. This new weaning clas- initiating mechanical ventilation; the primary indications for mechanical
sification has been evaluated in clinical practice by only two ventilation, including acute on chronic pulmonary disease (chronic ob-
small studies (6, 7). In both studies, only the prolonged weaning structive pulmonary disease [COPD], asthma, chronic pulmonary disease
group was associated with increased mortality in the intensive other than COPD); coma; neuromuscular disease; acute respiratory fail-
ure (acute respiratory distress syndrome [ARDS], postoperative, congestive
care unit (ICU).
heart failure, aspiration, pneumonia, sepsis, trauma, cardiac arrest, and
Our objectives were to describe a cohort of heterogeneous other). The following variables were collected daily during ventilatory
mechanically ventilated patients using this new weaning classifi- support until the first attempt of withdrawal of mechanical ventilation
cation and to analyze the risk of death based on the duration of up to Day 28: ventilator settings (VT, respiratory rate, positive end-
the weaning process. Some of the results of this study have been expiratory pressure [PEEP], peak pressure, plateau pressure), use of
previously reported in the form of abstract (8). sedative, use of neuromuscular blockers, and complications arising dur-
ing the course of the mechanical ventilation (ARDS, barotrauma,
ventilator-associated pneumonia, sepsis, and multiorgan failure [cardio-
METHODS vascular, respiratory, renal, hepatic, and hematologic] defined as a score
higher than 2 points in the Sequential Organ Failure Assessment). The
Patients onset of weaning was the time that the physician in charge considered
In a prospective study, we enrolled consecutive patients who received the patient likely to resume and sustain spontaneous breathing after
mechanical ventilation for at least 12 hours after admission to one of a patient met standard criteria for weaning readiness (9): improvement
349 participating ICUs in 23 participating countries. Beginning March of the cause of respiratory failure, PaO2 to FIO2 ratio above 200, PEEP 5
1, 2004, we enrolled patients over a 1-month period at each center cm H2O or less, and stable cardiovascular function. We noted the date
and followed each patient for the duration of mechanical ventilation, weaning started, the method of weaning (daily spontaneous breathing
up to 28 days. Only the investigative team members at each site were trial [T-tube circuit, pressure support ventilation of 7 cm H2O, contin-
aware of the purpose and the precise timing of the study. The research uous positive airway pressure of 5 cm H2O, other mode] or gradual
ethics board of each participating institution approved the study protocol reduction of support [pressure support, synchronized intermittent man-
with a waiver of informed consent. datory ventilation with or without pressure support, other mode]), the
For the purpose of this secondary analysis we selected only the date of extubation, the need for reintubation (and when it occurred),
patients who were successfully weaned and underwent a scheduled extu- and the need for tracheostomy after a first extubation. The patients were
bation in the study ICU. prospectively followed for outcomes until hospital discharge.
432 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 184 2011

TABLE 1. CHARACTERISTICS OF PATIENTS ACCORDING TO THE WEANING CLASSIFICATION

Simple Difficult Prolonged
Weaning Weaning Weaning
(N ¼ 1,502) (N ¼ 1,058) (N ¼ 154) P Value

Age, mean (SD), yr 57 (18) 59 (18) 58 (16) 0.008

SAPS II, points, mean (SD) 38 (16) 42 (17) 43 (16) ,0.001
Female, n (%) 599 (40) 441 (42) 74 (48) 0.13
Reason to start mechanical ventilation, n (%)
COPD 60 (4) 53 (5) 7 (4.5) 0.47
Asthma 35 (2) 7 (1) 0 0.001
Chronic pulmonary disease, non-COPD 4 (0.3) 16 (1.5) 5 (3) ,0.001
Coma 269 (18) 183 (17) 32 (21) 0.57
Neuromuscular disease 10 (1) 16 (1.5) 2 (1) 0.11
Acute respiratory failure
ARDS 24 (2) 20 (2) 4 (3) 0.62
Postoperative 531 (35) 268 (25) 28 (18) ,0.001
Congestive heart failure 81 (5) 63 (6) 7 (4.5) 0.71
Pneumonia 85 (6) 116 (11) 23 (15) ,0.001
Sepsis 79 (5) 88 (8) 14 (9) 0.004
Trauma 101 (7) 52 (5) 11 (7) 0.14
Cardiac arrest 59 (4) 39 (4) 6 (4) 0.95
Aspiration 31 (2) 34 (3) 4 (3) 0.19
Other 133 (9) 103 (10) 11 (7) 0.51
Management during mechanical ventilation
VT, mean (SD), ml/kg predicted body weight
Highest recorded daily 10.1 (2.4) 10.2 (2.5) 10.1 (2.8) 0.42
Lowest recorded daily 8.6 (2.0) 8.5 (2.2) 8.0 (2.6) 0.01
Highest daily PEEP, mean (SD), cm H2O 6.3 (3.4) 7.3 (3.9) 8.4 (4.8) ,0.001
Use of sedatives, n (%) 1,064 (71) 822 (78) 123 (80) ,0.001
Use of neuromuscular blockers, n (%) 115 (8) 95 (9) 21 (14) 0.03
Complications over the course of mechanical ventilation, n (%)
Barotrauma 35 (2) 38 (4) 4 (3) 0.16
ARDS 22 (1.5) 38 (4) 10 (6.5) ,0.001
Sepsis 70 (5) 62 (6) 17 (11) 0.003
Ventilator-associated pneumonia 77 (5) 87 (8) 25 (16) ,0.001
Cardiovascular failure 513 (34) 464 (44) 86 (57) ,0.001
Respiratory failure 1,170 (78) 880 (83) 140 (91) ,0.001
Renal failure 277 (18) 260 (25) 47 (30.5) 0.001
Hepatic failure 199 (13) 181 (17) 34 (22) 0.001
Hematologic failure 318 (21) 240 (23) 44 (29) 0.09
Days of mechanical ventilation before first attempt of 3 (2, 4) 4 (2, 7) 5 (3, 8) ,0.001
withdrawal from mechanical ventilation, median (IQR)

Definition of abbreviations: ARDS ¼ acute respiratory distress syndrome; COPD ¼ chronic obstructive pulmonary disease; IQR ¼ interquartile range; PEEP ¼ positive
end-expiratory pressure.

Objectives and End Points weaning group, including patients who were extubated on the
same day as their first attempt of withdrawal from mechanical
1. To characterize patients according to the duration of withdrawal ventilation; difficult weaning group, including patients who re-
(weaning) from mechanical ventilation and identify predictors for quired up to 7 days to be extubated from the first attempt of
difficult or prolonged weaning. For this purpose, patients were withdrawal from mechanical ventilation; prolonged weaning
classified into one of three weaning groups as follows: simple group, including patients who required more than 7 days of

TABLE 2. METHODS OF WITHDRAWAL FROM MECHANICAL VENTILATION USED IN EACH GROUP

First Attempt Weaning

Simple Difficult Prolonged Difficult Prolonged

Weaning Weaning Weaning Weaning Weaning
(N ¼ 1,502) (N ¼ 1,058) (N ¼ 154) P Value (N ¼ 1,058) (N ¼ 154) P Value

Spontaneous breathing trial, n (%) 1,227 (82) 495 (47) 58 (38) ,0.001 312 (29.5) 31 (20) 0.02
T-piece 49 36 38 41 45
CPAP 27 38 33 36 35.5
Pressure support , 8 cm H2O 22 24 29 21.5 19
Other 2 2 — 2 —
Gradual reduction of support, n (%) 275 (18) 563 (53) 96 (62) ,0.001 746 (70.5) 123 (80) 0.02
Pressure support 62 67 71 67 72
SIMV-PS 24 24 25 24 24
SIMV 2 5 1 5 1
Other 12 4 3 4 2

Definition of abbreviations: CPAP ¼ continuous positive airway pressure; PS ¼ pressure support; SIMV ¼ synchronized intermittent mandatory ventilation
Data are presented as % unless otherwise specified.
Peñuelas, Frutos-Vivar, Fernández, et al.: Outcome of Liberation from Mechanical Ventilation 433

TABLE 3. VARIABLES ASSOCIATED WITH DIFFICULT AND PROLONGED WEANING IN THE MULTIPLE LOGISTIC REGRESSION
Difficult Weaning Prolonged Weaning

OR (95% CI) P Value OR (95% CI) P Value

SAPS II, per unit 1.013 (1.008–1.018) ,0.001 1.011 (1.001–1.022) 0.031
Days of mechanical ventilation before first attempt of 1.043 (1.018–1.068) 0.001 1.096 (1.058–1.134) ,0.001
withdrawal from mechanical ventilation, per day
Reason for mechanical ventilation
Chronic pulmonary disease, non-COPD 6.030 (1.990–18.266) 0.020 13.259 (3.444–51.047) ,0.001
Postoperative acute respiratory failure 0.805 (0.667–0.971) 0.023 0.633 (0.405–0.989) 0.045
Pneumonia 1.601 (1.180–2.171) 0.002 1.817 (1.073–3.078) 0.026
PEEP before first attempt of withdrawal 1.057 (1.032–1.082) ,0.001 1.088 (1.044–1.135) ,0.001
from mechanical ventilation, per cm H2O

Definition of abbreviations: CI ¼ confidence interval; OR ¼ odds ratio; PEEP ¼ positive end-expiratory pressure; SAPS ¼ Simplified Acute Physiology Score.
Simple weaning is the reference category.

weaning after the first attempt of withdrawal from mechanical underwent a scheduled extubation (Figure 1). Of these, 1,502
ventilation. patients (55%) were classified as simple weaning, 1,058 patients
2. To estimate if duration of weaning was independently associated (39%) as difficult weaning, and 154 (6%) as prolonged weaning.
with mortality after adjustment for other variables related to The characteristics of each group are shown in Table 1.
mortality.

Statistical Analysis Methods of Weaning

Data are expressed as mean (SD), median (interquartile range), and pro- Table 2 shows the methods of withdrawal from mechanical ven-
portions, as appropriate. Analysis of variance and Kruskall-Wallis H test tilation used in each group. A spontaneous breathing trial with
were used to compare continuous variables, and chi-square test or Fisher T-piece was more commonly used in the simple weaning group
exact test were used to compare proportions. than in other groups. In the difficult and prolonged weaning
A multinomial logistic regression with backward stepwise selection was groups, a gradual reduction of pressure support was the preferred
performed to estimate the variables associated with difficult or prolonged
method for weaning.
weaning, taking the easy weaning group as their reference. Variables with
a P value less than 0.10 in the univariate analysis were entered in the
multivariable analysis, including: age, SAPS II, body mass index, asthma, Variables Associated with Weaning Classification
chronic pulmonary disease other than COPD, postoperative acute respi-
The variables related to difficult and prolonged weaning are shown
ratory failure, pneumonia, sepsis, neuromuscular blockers, ventilatory
settings (the highest PEEP and the lowest VT used during ventilatory
in Table 3, taking the simple weaning group as a reference.
support before the first attempt of withdrawal from mechanical ventila- Patients with high severity of illness at admission to the ICU
tion), ARDS during mechanical ventilation, sepsis during mechanical and those with chronic pulmonary disease other than COPD or
ventilation, ventilator-associated pneumonia, cardiovascular failure, re- pneumonia as the reason to start mechanical ventilation were
spiratory failure (with or without criteria for ARDS), renal failure, he- more likely to have a difficult/prolonged weaning. Patients with
patic failure, hematologic failure, and duration of mechanical ventilation postoperative acute respiratory failure were more likely to be
before first attempt of withdrawal from mechanical ventilation. A P value easily weaned. A longer duration of mechanical ventilation be-
less than 0.05 was considered significant. fore the start of weaning was associated with a longer duration of
To estimate if duration of weaning was associated with mortality, we weaning. Last, the need to be ventilated with a high PEEP during
performed a logistic regression with backward stepwise selection to ad-
active ventilatory support was also related to difficult/prolonged
just for the following variables: age, SAPS II, reason to start mechanical
ventilation, complications and organ dysfunctions developed during me- weaning.
chanical ventilation before start weaning, duration of mechanical venti-
lation before the weaning period, and duration of weaning entered using Outcomes
the new weaning classification as a dummy variable taking the simple
weaning group as the reference.
Table 4 shows the comparison of outcomes for the three groups.
Statistical analyses were performed with SPSS 17.0 statistical software According to the definitions of the classification of the Euro-
(IBM Inc., Armonk, NY). pean Consensus, there were significant differences (P , 0.001)
noted in median (interquartile range) time of weaning between
RESULTS the three groups: 1 (1, 1) versus 3 (2, 4) versus 9 (8, 13) days in
the simple, difficult, and prolonged groups, respectively.
Patients The prolonged weaning group had a nonsignificant trend to-
From the cohort of 4,968 mechanically ventilated patients, in this ward higher rates of reintubation and tracheostomy compared
analysis we included the 2,714 patients who were weaned and with the simple and difficult groups. The prolonged weaning group

TABLE 4. COMPARISON OF OUTCOMES

Simple Weaning Difficult Weaning Prolonged Weaning
(N ¼ 1,502) (N ¼ 1,058) (N ¼ 154) P Value

Reintubation, n (%) 147 (10) 177 (10) 24 (16) 0.08

Tracheostomy,* n (%) 88 (6) 63 (6) 15 (10) 0.15
Length of stay in the ICU, median (IQR) 6 (3, 10) 9 (6, 15) 18 (14, 25) ,0.001
Mortality in the ICU, n (%) 101 (7) 72 (7) 20 (13) 0.01

Definition of abbreviations: ICU ¼ intensive care unit; IQR ¼ interquartile range.

* All tracheostomies were performed in patients who required reintubation.
434 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 184 2011

Figure 2. Mean (SD) adjusted probability of

death in the intensive care unit for each day
of duration of withdrawal from mechanical
ventilation.

also had a significantly longer length of stay and a higher observed the duration of ventilator support before weaning began was as-
ICU mortality rate compared with the other two groups (P , sociated with weaning failure (relative rate of successful weaning
0.001). per 1-day increment, 0.94; 95% CI, 0.90–0.98). Vallverdú and
The overall ICU mortality of the included cohort was 7.1% (193 colleagues (11) found that the number of days receiving mechan-
of 2,714 patients). After adjustment for other variables, only the ical ventilation before the weaning trial was significantly higher in
prolonged weaning group was associated with a significantly the weaning failure group than in the successful weaning group
(P ¼ 0.01) higher mortality compared with the simple weaning (12 6 12 vs. 7 6 7; P , 0.001). Increased length of time receiving
group (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.17– mechanical ventilation before the first spontaneous breathing tri-
3.31), whereas the mortality for the difficult weaning group had al may identify a cohort with greater severity of initial injury and
a similar mortality to the simple weaning group (OR, 0.89; 95% identify patients more likely to receive sedation, analgesia, and
CI, 0.65–1.22). Figure 2 shows that the adjusted probability of muscle paralysis.
death remained constant for any duration of weaning up to Day The second variable associated with weaning outcome is the
7, after which point the risk of death appeared to increase. reason to start mechanical ventilation in the first place. We have
previously shown that pneumonia as the reason to initiate mechan-
ical ventilation was associated with increased risk for extubation
DISCUSSION failure (12). Our hypothesis is that these patients may not have
The main finding of our study is that, in our cohort of heteroge- fully cleared the microbial load from their pneumonia and there-
neous mechanically ventilated patients, duration of weaning lon- fore require a longer ventilatory support. Another reason associ-
ger than 7 days (corresponding to the prolonged weaning group in ated with prolonged/difficult weaning was chronic pulmonary
the European Consensus classification for weaning) had a signifi- disease other than COPD. There is little published information
cantly higher mortality than patients with simple weaning. Other on the outcome of mechanical ventilation and weaning of patients
findings of our study were: (1) patients with prolonged weaning with a chronic pulmonary disease such as bronchiectasis or in-
represent a small proportion of ventilated patients reaching the terstitial lung diseases. The reasons for the difficulty in weaning
weaning period; (2) the duration of mechanical ventilation before of these patients are likely similar to those described for patients
the start of weaning is associated with weaning outcome; (3) with severe COPD: disturbances in different aspects of lung me-
patients with chronic pulmonary disease, but not COPD, with chanics (13) or respiratory muscles (14). Patients with COPD are
neuromuscular disease or patients with pneumonia as the reason typically regarded as difficult to wean, but this was not observed in
for initiating mechanical ventilation were more likely to have our study or in a previous epidemiological study (15). In contrast,
difficult or prolonged weaning; and (4) the level of PEEP neces- Esteban and colleagues (10) found that 41% of patients with
sary during ventilatory support was statistically associated with COPD failed the first attempt at spontaneous breathing. Also,
prolonged weaning. Vallverdú and colleagues (11) showed that 61% of patients with
The outcome of weaned patients classified based on the new COPD needed progressive withdrawal of mechanical ventilation.
classification (5) has been reported in two previous studies (6, One of the possible explanations for these divergent results could
7). In a smaller study, Funk and colleagues (6) reported an in- be the method used during the spontaneous breathing trial. For
creased hospital mortality in patients with prolonged weaning example, in the presence of increased work of breathing due to
(32%) in comparison to those with simple weaning (13%) (OR, auto-PEEP, weaning failure may be more likely with T-piece than
4.89; 95% CI, 1.32–18.08). In agreement with Funk and col- with continuous positive airway pressure or pressure support with
leagues, we found no difference in ICU mortality when compar- PEEP (13). In the current study, only 31% of patients with COPD
ing simple and difficult weaning. Therefore, weaning that is had their spontaneous breathing trial conducted on a T-piece.
delayed but still successful within 1 week of onset does not ad- Last, we have shown that the level of PEEP applied over the
versely impact ICU survival. In fact, in our cohort weaning time course of ventilatory support was associated with a longer duration
did not appear to affect ICU mortality until the patient reached 7 of weaning. This was a statistically significant difference, but at
days of weaning. We have identified several factors associated only 2 cm H2O it is of questionable clinical relevance. A possible
with prolonged/difficult weaning. One of the factors described biological explanation for this finding is that patients who re-
is the duration of mechanical ventilation before the first attempt quired higher PEEP were patients with a higher incidence of
of spontaneous breathing. Previously, several studies had ARDS, who required more sedation and more neuromuscular
reported that finding. Esteban and colleagues (10) reported that blocking. All these factors have been associated with difficult
Peñuelas, Frutos-Vivar, Fernández, et al.: Outcome of Liberation from Mechanical Ventilation 435

weaning. To our knowledge, previous studies have not evaluated Buenos Aires), P. Pratesi (Hospital Universitario Austral, Pilar), M. Blasco and F.
Villarejo (Clı́nica Olivos, Olivos), G. Olarte and C. Bevilacqua (Clı́nica Modelo de
the relationship between ventilatory settings during mechanical Morón/Hospital San Juan de Dios, R.Mejı́a), M. Quinteros (Sanatorio San Lucas,
ventilation and the subsequent duration of weaning. In a recent San Isidro), P. Ripoll (Clı́nica La Sagrada Familia, Buenos Aires), S. Filippus (Clı́nica
metaanalysis of studies comparing higher PEEP versus lower del Valle, Comodoro Rivadavia), F. Guzman Dı́az and M.Deheza (Hospital B.
Rivadavia, Buenos Aires), E. Garcı́a and J. Arrieta (Hospital Regional de Comodoro
PEEP in patients with acute lung injury (16), it is reported that Rivadavia), P. Pardo and J. Neira (Sanatorio de la Trinidad de Palermo, Buenos
median of days with unassisted breathing was similar in both Aires), J. Núñez and F. Pálizas (Clı́nica Bazterrica, Buenos Aires), A. Ciccolini and
groups (13 d in higher PEEP vs. 11 d in lower PEEP). G. Murias (Sanatorio Santa Isabel, Buenos Aires), W. Vázquez and M. Grilli (Hos-
An interesting observation was that patients withdifficult orpro- pital Español de Mendoza, Godoy Cruz), F. Chertcoff and E. Soloaga (Hospital
Británico, Buenos Aires), D. Vargas and J. Berón (Hospital Pablo Soria, San Salva-
longed weaning were more likely to be weaned with a gradual re- dor de Jujuy), A. Maceira and P. Schoon (Hospital Prof. Luis Güemes, Haedo), D.
ductionof support. Itcouldbearguedthatthe use ofgradual support Pina (Sanatorio Franchı́n, Buenos Aires), E. Sobrino and A. Raimondi (Sanatorio
may have contributed to more time on the ventilator and to an in- Mater Dei, Buenos Aires), E. De Vito (IIM Alfredo Lanari, Buenos Aires).
creased likelihood of complications, such as ventilator-associated Belgium: M. Malbrain (Ziekenhuis Netwerk, Antwerpen).
pneumonia. In our study, a gradual reduction of pressure support
was the most frequent method used in patients weaned with a grad- Bolivia: Coordinator: Freddy Sandi Lora (Hospital obrero N8 1, La Paz).
ual reduction of support. A systematic review of trials evaluating A. Lavandez and C. Alfaro (Complejo Hospitalario Viedma, La Paz), J. Guerra (Insti-
modes ofweaningshowed that only synchronizedintermittent man- tuto gastroenterológico boliviano japonés, Santa Cruz).
datory ventilation may lead to a longer duration of the weaning pro-
Canada: Coordinators Niall D. Ferguson (Toronto Hospital Western Division) and
cess than either T-piece or pressure support ventilation (17). We Maureen O. Meade (McMaster University).
therefore believe that it is more likely a selection bias and an asso-
ciation that prolonged weaning patients received gradual reduc- J. T. Granton (Toronto General Hospital), S. E. Lapinsky (Mount Sinai, Toronto), J.
Meyer (St. Josephs Hospital, Toronto), D. C. Scales (St. Michael’s Hospital, Tor-
tions, rather than a causal effect. Also striking is the differential onto), R. A. Fowler (Sunnybrook Health Sciences Centre, Toronto), B. Kashin
success rate on the first attempt of weaning with a spontaneous (William Osler Health Centre, Brampton, Ontario), D. J. Cook (St. Joseph’s
breathing trial (SBT) (69%) versus a gradual reduction (29%). Healthcare).
Although patient selection bias may also play a role here, this Colombia: Coordinator: Marco A. González (Clı́nica Medellı́n y Universidad Pon-
may suggest that some patients could have been weaned more tificia Bolivariana, Medellı́n).
quickly if they had received an initial SBT.
Our study has several limitations. First, we were unable to get A. Guerra (Hospital General de Medellı́n and Clı́nica SOMA, Medellı́n), C. Cadavid
(Hospital Pablo Tobón Uribe, Medellı́n), R. Panesso (Clı́nica Las Américas, Medel-
information about the implementation of specific weaning or se- lı́n), M. Granados (Clı́nica Valle del Lilli, Cali), C. Dueñas (Hospital Bocagrande,
dation protocols, nor the exact duration or settings used for spon- Cartagena), F. Molina (Clı́nica Bolivariana, Medellı́n), R. Camargo (Clı́nica Gen-
taneous breathing trials, which could have affected the weaning eral del Norte de Barranquilla), G. Ortiz (Hospital de Santa Clara, Bogotá), M.
Gómez (Hospital de San José).
process and/or outcome (4, 18). Second, we did not analyze the
influence of polyneuropathy associated with weaning time (19, Chile: Coordinator: Vinko Tomicic (Clı́nica Alemana de Santiago).
20). In this regard, we collected information about the use of
L. Soto (Instituto Nacional del Tórax, Santiago), C. Romero (Hospital Clı́nico
sedative and muscular blocker medications, and we found that Pontificia Universidad Católica, Santiago), M. Teresa Caballero and L. Chiang
the difficult weaning group had a significantly higher use of those (Hospital naval almirante NEF), E. Poch (Instituto de Neurocirugı́a), J. Canteros
medications compared with the simple weaning group. Third, we Gatica (Hospital Curico), H. Ugarte (Hospital de Coquimbo), M. Calvo, C. Vargas,
have no information about the complications, including delirium, and M. Yacsich. (Hospital Regional de Valdivia), E. Tobar (Hospital Clı́nico de la
Universidad de Chile, Santiago), J. G. Urra (Clı́nica Alemana de Temuco).
experienced over the weaning time. In our study, we found a non-
significant higher rate of tracheostomy and reintubation in pro- England: Coordinator: Peter Nightingale (Wythenshawe Hospital, Manchester).
longed weaning compared with simple weaning and difficult
J. Hunter (Macclesfield District General Hospital, Macclesfield), J. Hunter (Rother-
weaning. Nevertheless, it could have been interesting to analyze dam District General Hospital, Rotherdam), S. Mousdale (Blackburn Royal Infi-
complications over the course of weaning period that may be re- mary, Blackburn), J. Harper (Royal Liverpool University Hospital, Liverpool), A.
sponsible for weaning failure (21). Conn (Wansbeck General Hospital, Ashington), D. Higgins (Southend Hospital,
Westcliffe-on-Sea), D. Jayson (Southport & Formby District General Hospital,
In conclusion, among patients who begin weaning, a weaning Southport), D. Hawkins (North Staffordshire Hospital, Stoke on Trent).
duration longer than 7 days identifies a subgroup of patients at
increased risk for death. Ecuador: Coordinator: Manuel Jibaja (Hospital Militar de Quito).

Author disclosure: None of the authors has a financial relationship with a com- G. Paredes and E. Bazantes (Hospital Enrique Garcés, Quito), P. Jiménez (Hospital
mercial entity that has an interest in the subject of this manuscript. Carlos Andrade Martı́n, Quito), J. Vergara and L. González (Hospital Luis Vernaza
Valdez, Guayaquil).
Ventila Group Collaborators
France: Coordinators: Laurent Brochard (Hôpital Henri Mondor, Créteil) and
Argentina: Coordinators: Carlos Apezteguı́a (Hospital Prof. A. Posadas, El Palo- Arnaud Thille (Hôpital Henri Mondor, Créteil).
mar, Buenos Aires) and Pablo Desmery (Sanatorio Mitre, Buenos Aires).
L. Mallet (Centre Hospitalier D’Auch), P. Andrivet (Centre Médico-Chirurgical de
A. Sarasino and D. Ceraso (Hospital Dr. Juan A. Fernández, Buenos Aires), D. Bligny, Bris-sous-Forges), O. Peyrouset (Hôpital Ambroise Paré, Boulogne Billan-
Pezzola and F. Villarejo (Hospital Prof. A. Posadas, El Palomar), C. Cozzani and court), I. Mohammedi (Hôpital Edouard Herriot, Lyon), E. Guerot (Hôpital
M. Torres-Boden (Hospital Dr. C. Argerich, Buenos Aires), C. Santos and E. Cap- Européen Georges Pompidou, Paris), N. Deye (Hôpital Lariboisière, Paris), S.
parelli (Hospital Eva Perón, San Martı́n), M. Tavella and C. Irrazábal (Hospital de Monsel and F. Bouvet (Hôpital Pitié Salpétrière, Paris), M. Darmon (Hôpital Saint
Clı́nicas José de San Martı́n, Buenos Aires), L. Cardonnet and A. Diez (Hospital Louis, Paris), M. Fartoukh and A. Harb (Hôpital Tenon, Paris), N. Anguel (Hôpital
Provincial del Centenario, Rosario), A. Giannelli and L. Vargas (Policlı́nico de de Bicêtre, Kremlin-Bicêtre).
Neuquén), M. Bustamante (Hospital Héroes de Malvinas, Merlo), E. Turchetto
(Hospital Privado de la Comunidad, Mar del Plata), J. Teves and O. Elefante Germany: Coordinator: Konstantinos Raymondos (Medizinische Hochschule
(Hospital Oscar Alende, Mar del Plata), C. Sola and J. Mele (Hospital Dr. José Hannover).
Penna, Bahı́a Blanca), V. Sciuto and P. Grana (Hospital Provincial de Neuquén),
G. Jannello and R. Valentini (CEMIC, Buenos Aires), S. Ilutovich (Sanatorio Mitre, A. Nowak, T. Pahlitzsch and K. F. Rothe (Krankenhaus Dresden-Friedrichstadt), M.
Buenos Aires), L. Huespe Gardel (Hospital Escuela José F. de San Martı́n, Cor- Ragaller and T. Koch (Universitaetsklinikum Carl Gustav Carus Dresden), G. Sterzel
rientes), J. Scapellato and E. Orsini (Hospital F. Santojanni, Buenos Aires), G. (Kreiskrankenhaus Loebau, Ebersbach), R. Wittich (Carl-Thiem-Klinikum Cottbus
Agüero and Á. Sánchez (Policlı́nico Regional J. Perón, Mercedes), R. Fernández gGmbH), K. Rudolph and J. Raumanns (St. Elisabeth gGmbH Leipzig), U.
and L. Villalobos Castañeda (Hospital Italiano, Buenos Aires), F. González and E. Grueneisen and F. Stupacher (Bundeswehrkrankenhaus Leipzig), H. Bromber,
Estenssoro (Hospital General San Martı́n, La Plata), S. Lasdica (Hospital Privado G. Leonhardt and J. Soukup (Universitaetsklinikum der Martin-Luther-Universitaet
del Sur, Bahı́a Blanca), A. Gómez and J. Scapellato (Clı́nica de la Esperanza, Halle-Wittenberg), C. Wuttke (Krankenhaus St. Elisabeth und St. Barbara Halle,
436 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 184 2011

Saale), M. Holler (Staedtisches Krankenhaus Martha-Maria Halle-Doelau gGmbH), J. Victoria), C. Salcedo and D. Bruzone (Hospital Nacional Daniel Alcides Carrión,
Haberkorn (Georgius-Agricola-Klinikum Zeitz), P. Jehle (Paul-Gerhard-Stiftung, Callao), J. Quiñones (Hospital de Emergencias Grau, Lima), M. Suárez Lazo (Hos-
Lutherstadt Wittenberg), B. Albrecht (Zeisigwaldkliniken Bethanien Chemnitz), pital Nacional Hipólito Unanue, El Agustino), A. Cifuentes (Hospital de Emergen-
D.M. Klut (Kreiskrankenhaus Rochlitz), H. J. Hartung (Vivantes Krankenhaus cias José Casimiro Ulloa, Miraflores), M. Mayorga (Clı́nica San Pablo, Lima).
am Urban, Berlin-Kreuzberg), H. Gerlach (Vivantes-Klinikum Neukoelln, Berlin),
T. Henneberg, S.Weber-Carstens, K. Haid, and C. Melzer-Gartzke, M. Oppert Portugal: Coordinator: Rui Moreno (Hospital de Santo António dos Capuchos,
(Charité Universitaetsklinikum, Campus Virchow, Berlin), M. Reffenberg (Lungen- Lisboa).
klinik Heckeshorn, Berlin), Ch. Werel and A. Kopietz (Klinikum Barnim GmbH,
Werner Forßmann Krankenhaus, Eberswalde), T. Nippraschk and D. Hoffmeister P. Casanova (Hospitais da Universidade de Coimbra), R. Matos and A. L. Jardim
(Ruppiner Klinikum GmbH, Neuruppin), M. Schneider (Dietrich-Bonhoeffer- (Hospital de Santo António dos Capuchos, UCIP, Lisboa), A. Godinho (Hospital
Klinikum-Neubrandenburg), D. A.Vagts and G. Noeldge-Schomburg (Medizini- dos SAMS, UCI, Lisboa), P. Póvoa (Hospital São Francisco Xavier, UCIM, Lisboa),
sche Fakultaet der Universitaet Rostock), G. Savinski and T. Kloess (Allgemeines P. Coutinho (Centro Hospitalar de Coimbra), L. Reis (Hospital de São José, Uni-
Krankenhaus Harburg, Hamburg), C. Frenkel, D. Yakisan, H. Schroeder, and C. dade de Urgência Médica, Lisboa).
Daniels (Staedtisches Klinikum Lueneburg), B. Sedemund-Adib (Universitaetskli-
nikum Schleswig Holstein - Campus Luebeck), S. Krueper (Klinikum Hannover Saudi Arabia: Coordinator: Yaseen Arabi (King Fahad National Guard Hospital).
Nordstadt), J. Ahrens, U. Molitoris, and K. Johanning (Medizinische Hochschule
Hannover), D. Korth and W. Seitz (Kreiskrankenhaus Hameln), J. Kleideiter and P. N. Abouchala (King Faisal Hospital), F. Hameed (King Khalid National Guard
Palomino (Staedtische Kliniken Bielefeld gGmbH), A. Lunkeit and J. Schlechtweg Hospital).
(Klinikum Bad Salzungen gGmbH), M. Quintel (Universitaetsklinikum der Georg-
August-Universitaet Goettingen), E. Schild and C.P. Criée (Evangelisches Spain: Coordinators: Nicolas Nin and Eva Tejerina (Hospital Universitario de
Krankenhaus Goettingen-Weende e.V., Bovenden-Lenglern), M. Bund (Albert- Getafe).
Schweitzer-Krankenhaus Northeim), M.Hundt, U.Schulze, and J. Kolle (Kreiskran-
kenhaus Charlottenstift, Stadtoldendorf), J. Offensand, S. Youssef, and J. P. F. Gordo (Fundación Hospital de Alcorcón), R. Fernandez (Complejo Hospitalario
Juvana (Klinikum Salzgitter GMBH), W. Seyde (Staedtisches Klinikum Wolfen- Parc Taulı́, Sabadell), R. de Pablo (Hospital Universitario Prı́ncipe de Asturias,
buettel), T. Luecke and A. Gruener (Universitaetsklinikum Mannheim), E. Calzia Alcalá de Henares), J. Ibañez (Hospital Son Dureta, Palma de Mallorca), E. Fer-
(Universitaetsklinikum fur Anasthesiologie, Ulm), J. Heine, M. Borth, U. von Leit- nández-Mondejar (Hospital Virgen de las Nieves, Granada), F. del Nogal (Hospi-
ner, and M. Hoffmann (Dr. Herbert-Nieper-Krankenhaus-Goslar), W. Brandt (Uni- tal Severo Ochoa, Leganés), F. Taboada (Hospital Central de Asturias, Oviedo), A.
versitaetsklinikum Magdeburg), A. Keller and S. Scieszka (Krankenhaus Neuwerk, Garcı́a Jiménez (Hospital Arquitecto Marcide, El Ferrol), Ll. Cabré and J. Morillas
Moenchengladbach), E. Schroeder and F. L. Deres (Kreiskrankenhaus Dorma- (Hospital de Barcelona-SCIAS), S. Macias (Hospital General de Segovia), R. de
gen), M. Burrichter, T.Bernhardt and W. Wilhelm (St.-Marien-Hospital, Luenen), Celis (Hospital de Galdakao), J. M. Añón (Hospital Virgen de la Luz, Cuenca), P.
M. Beiderlinden (Universitaetklinikum Essen), H. Steiniger and V. Weißkopf (Ruhr- Ugarte (Hospital Marqués de Valdecilla, Santander), T. Mut (Hospital de la Plana,
landklinik, Essen), H. Militzer (Evangelisches und Johanniter Klinikum, Dinslaken), Vila-Real), J. Diarte (Complejo Hospitalario de Ciudad Real), V. Sagredo (Hospital
K. Eicker and F. Hinder (Universitaetsklinikum Muenster), C. Weilbach and M. Clı́nico de Salamanca), M. Valledor (Hospital San Agustı́n, Avilés), G. González
Raab (St. Josefs-Stift Cloppenburg), F. Ragalmuto (Kliniken der Stadt Koeln Kran- and L. Rodrı́guez (Hospital Morales Meseguer, Murcia), V. Parra and E. Gómez
kenhaus Holweide), T. Moellhoff and K. Tsompanidis (Katholische Stiftung Mar- (Hospital de Sagunto), F. Jara (Hospital Mutua de Terrassa), J. M. Quiroga (Hos-
ienhospital Aachen), D. Henzler and R. Kuhlen (Universitaetsklinikum Aachen), pital de Cabueñes, Gijón), L. Arnaiz (Hospital Clı́nico Universitario de San Carlos,
H. Wrigge, C. Putensen, and F. L. Dumoulin (Universitaetsklinikum Bonn), Madrid), Á. Ayensa (Hospital Virgen de la Salud, Toledo), F. Suárez-Sippman
M. Foedisch and J. Busch (Evangelisches Waldkrankenhaus Bad Godesberg (Fundación Jiménez Dı́az), F. Charizosa (Hospital General de Jerez de la Frontera),
gGmbH, Bonn), W. Theelen (St. Johannes-Krankenhaus Troisdorf), A. Deller J. A. Rodrı́guez-Sarrı́a (Hospital de Elda), C. Homs (Hospital San Jorge, Huesca), A.
(Krankenhaus der Barmherzigen Brueder, Trier), W. Baier (St. Nikolaus- Dı́az-Lamas (Hospital Cristal Piñor, Ourense), M. León (Hospital Arnau de Vila-
Stiftshospital GmbH, Andernach), B. Eller (Staedt. Hellmig-Krankenhaus, Kamen), nova, Lleida), J. Allegue (Hospital Nuestra Señora del Rosell, Cartagena), M.
K. Schwarke (Evang. Krankenhaus Schwerte GmbH), J. Büttner (Evangelisches Ruano (Hospital La Fe, Valencia).
Krankenhaus Elisabethenstift gGmbH, Darmstadt), K. P. Wresch and K. Steidel
(St.-Vincentius-Krankenhaus Speyer), J. F. Meyer (Universitaetsklinikum der Tunisia: Coordinator: Fekri Abroug (Fattouma Bourguiba Monastir).
Ruprecht-Karls-Universitaet Heidelberg), M. Layer (Thoraxklinik Heidelberg
gGmbH), G. Meinhardt (Robert-Bosch-Krankenhaus, Stuttgart), J. Fritschi and M. Besbes, J. Ben Khelil, K. Belkhouja, and K. BenRomdhane (Hospital Abderrah-
P. Zaar (Ermstalklinik Staedtisches Krankenhaus Sindelfingen), H. P. Stegbauer mane Mami, Ariana), S. Ben Lakhal, S. Abdellatif and K. Bousselmi (La Rabta Tunis),
(Kreiskrankenhaus Leonberg), V. Tumbass and S. Hahn (Ermstalklinik Bad M. Amamou and H. Thabet (CAMUR), L. Besbes and N. Nciri (Fattouma Bourguiba
Urach), H. Mende, M. Fischer, J. Martin, and A. Assmann (Klinik am Eichert Monastir), M. Bouaziz, H. Kallel, and M. Bahloul (Habib Bourguiba Sfax), S. ElA-
Goeppingen), V. Schoeffel, K. van Deyk and S. Seyboth (Stadtklinik Baden- trous, S. Merghli, and M. Feki Hassen (Tahar Sfar Mahdia).
Baden), H. Kerger and J. Ernst (Evangelisches Diakoniekrankenhaus, Freiburg),
H. F. Ginz (Kreiskrankenhaus Loerrach), F. Brettner (Krankenhaus der Barmher- Turkey: Coordinator: Nahit Cakar (Istanbul Medical Faculty, Istanbul).
zigen Brueder, Muenchen), O. Karg (ASKLEPIOS Fachkliniken Muenchen-
Gauting), M. Glaser and T. P. Zucker (Klinikum Traunstein), J. Jahn and A. R. Iscimen (Uludag University School of Medicine, Bursa), M. Kyzylkaya (College of
Schneider (Fachkliniken Wangen), M. Burkert (Bundeswehrkrankenhaus Medicine, Ataturk University, Erzurum), B. Yelken (Osmangazi University, Eskise-
Ulm), H. Kuenzig and T. Bein (Klinikum der Universitaet Regensburg), A. mir), I. Kati (Medical Faculty of Yuzuncu Yil University, Van), T. Guldem (Haydar-
Speicher (Krankenhaus der Barmherzigen Brueder, Regensburg), J. Brederlau, pasa Numune Teaching and Research Hospital, Istambul), U. Koca (Dokuz Eylun
E. Kaufmann, F. Schuster, and C. Soellmann (Universitaetsklinik Wuerzburg), S. University, Istanbul), M. Cicek (Inonu University of Medical Faculty, Malatya), H.
Frenzel and L. Pfeiffer (Unstrut-Hainich Kreiskrankenhaus Muehlhausen), S. Sungurtekin (Pamukkale University Medical Faculty).
Weber-Carstens, K. Haid, C. Melzer-Gartzke, C. von Heymann, and B. Tem-
mesfeld (Charité Universitaetsklinikum, Campus Mitte, Berlin). United States: Coordinator: Antonio Anzueto (University of Texas Health Science
Center, San Antonio, Texas).
Greece: Coordinator: Dimitros Matamis (Papageorgiou General Hospital, The-
ssaloniki). A. C. Arroliga (Cleveland Clinic, Cleveland), O. Gajic and M. Ali (Mayo Clinic,
Rochester), D. Ost, A. Fein, A. Kyprianou, L. Shulman, and S. Chang (North Shore
H. Mouloudi (Ippokration General Hospital, Athens). University Hospital, New York), J. S. Steingrub, M. A. Tidswell, and K. Kozikowski
(Baystate Medical Center, Springfield), C. A. Piquette and L. Morrow (Creighton
Italy: Coordinator: Paolo Pelosi (Ospedale di Circolo di Varese). University Medical Center, Nebraska), P. Scheinberg and J. Green (Saint Joseph’s
Hospital, Atlanta), L. Penogreen and K. Kannady (Georgia State University Kenne-
A.Pesenti and N. Rossi (Ospedale San Gerardo, Monza), D. Chiumello and L. Gat- stone), M. Moss, M. Mealer, and R. D. Restrepo (Grady Hospital Georgia,
tinoni (Ospedale Maggiore Policlinico, Milano), P. Severgnini (Ospedale di Circolo Atlanta), H. E. Fessler, R. Brower, D. Hager, and A. Scully (John Hopkins University
di Varese), R. Fumagalli and A. Nikiforov (Ospedali Riuniti di Bergamo), S. Grasso Hospital, Baltimore), J. Beamis, D. E. Craven, and W. Miner (Lahey Clinic Medical
(Ospedale di Venere, Bari). Center, Burlington), S. Blosser, K. Miller, L. Cornman, and J. Breidinger (Penn
State Hershey Medical Center, Hershey), J. T. Huggins and Ch. Strange (Medical
Mexico: Coordinator: José Elizalde (Hospital ABC, México DF) University of South Carolina, Charleston), N. S. Hill and L. Lawler (Tufts-New
England Medical Center, Boston), M. Rembert (Newark Beth Israel Medical Cen-
P. Cerda (Centro Médico de las Américas, Mérida), R. Mercado (Hospital Uni- ter), H. K. Donnelly, J. D. D’Amico, R. G. Wunderink, N. Queseda, and J. Topin
versitario de Monterrey), J. Albe Castañón (Instituto mexicano del seguro social (Northwestern Memorial Home Health University, Chicago), G. T. Kinasewitz and
HECMNS XXI, México DF). G. L. Lee (University of Oklahoma Health Sciences Center, Oklahoma City), J.
Walls and V. Zimmer (Presbyterian Healthcare, Charlotte), A. X. Freire (Regional
Netherlands: P. H. M. Egbers and M. Koopmans (Medical Center Leeuwarden). Medical Center, Memphis), C. Steven and L. Caskey (Louisiana State University
Health Sciences Center, Shreveport), R. Dhand and L. A. Despins (University
Peru: Coordinator: Ana Marı́a Montañez. Hospital and Clinics MU Healthcare, Columbia), R. Hyzy, R. E. Dechert, C. Haas,
and D. Fickle (University of Michigan Medical Center), Ch. Burger and L. Gam-
M. Contardo, J. Cerna, and R. Roldán (Hospital Edgardo Rebagliati Martins, Jesús bino (Mayo Clinic, Jacksonville), D. Marks and S. Benslimane (University of Texas
Marı́a), J. Zevallos and S. Alcabes (Hospital Guillermo Almenara Irigoyen, La Health Science Center, San Antonio), V. J. Cardenas Jr. (University of Texas
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DC), R. D. Hite (Wake Forest Baptist Hospital Medical Center, Winston Salem),
P. J. McShane and K. N. Olivier (Wilford Hall Medical Center, Texas), K. W. dictors of prolonged weaning and survival during ventilator weaning
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IMPASA and Hospital de Clı́nicas, Montevideo). acteristics and outcome of ventilated patients according to a new
M. Borde, E. Echavarrı́a, S. Gómez, and M. Berón (Hospital Maciel, Montevideo), weaning classification [abstract]. Am J Respir Crit Care Med 2009;179:
F. Villalba (Sanatorio Casa de Galicia, Montevideo), I. Porras (Sanatorio CASMU 2, A3807.
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Machado (Sanatorio CAMOC, Carmelo), F. Torres (Sanatorio Mautone and Asis- Fernández R, de la Cal MA, Benito S, Tomás R, et al. A comparison
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(Hospital Paysandú), M. Dı́az (Hospital de Salto and Sanatorio Uruguay, Salto), characteristics, respiratory functional parameters, and outcome of
J. Martı́nez Ramos (Sanatorio Uruguay, Salto), I. Iturralde, W. González, and E. a two-hour T-piece trial in patients weaning from mechanical-
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