Mechanically Ventilated Patient
Assess daily for readiness to wean
All Pathways
Critical CareManagement
Liberation from Mechanical Ventilation
Liberation from Mechanical Ventilation: Mechanically Ventilated Patient → Daily Readiness Screening → SAT: Spontaneous Awakening Trial → SAT Passed? → S...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Daily Readiness Screening
Assess each morning before noon
- Underlying cause improving/resolved
- FiO2 ≤0.4, PEEP ≤5-8
- Hemodynamically stable (minimal/no pressors)
- No active myocardial ischemia
- Able to initiate respiratory effort
03Action SAT: Spontaneous Awakening Trial
Stop sedation to assess readiness
- Stop or minimize continuous sedation
- Assess mental status
- Pass SAT if: opens eyes, follows commands
- Coordinate with SBT (SAT + SBT = better outcomes)
04Decision SAT Passed?
Patient awake and interactive
05Action SBT: Spontaneous Breathing Trial
30-120 minute trial
- T-piece OR PS 5-8/PEEP 0-5
- AARC 2024: Can be done with or without PS
- Duration: 30 min usually sufficient
- Up to 120 min for prolonged MV
06Action Monitor During SBT
Watch for failure signs
- RR >35 for >5 min
- SpO2 <90% sustained
- HR >140 or change >20%
- SBP >180 or <90
- Agitation, diaphoresis, distress
07Decision SBT Passed?
Tolerated trial without failure criteria
08Decision High Risk for Post-Extubation Stridor?
Consider cuff leak test
- Prolonged intubation >7 days
- Traumatic intubation
- Large ETT relative to airway
- Prior failed extubation for stridor
09Action Cuff Leak Test
If high risk for stridor
- Deflate cuff, measure exhaled TV
- Leak >110 mL suggests adequate
- Low/no leak: consider steroids x24h
- Methylprednisolone 20mg q4h x4 doses
10Action Extubate
Remove endotracheal tube
- Suction oropharynx
- Have reintubation equipment ready
- Consider NIV post-extubation if high risk
- Observe closely for 24-48h
11Decision High Risk for Extubation Failure?
Consider prophylactic NIV
- Age >65
- Cardiac or respiratory comorbidity
- Failed prior SBT
- Hypercapnic during SBT
12Action Prophylactic NIV Post-Extubation
For high-risk patients - ATS recommendation
- BiPAP or HFNC
- Decreases reintubation rate
- Apply immediately post-extubation
- Duration typically 24-48h
13Outcome Successfully Liberated
Monitor for 24-48h, continue respiratory care
- Path rejoins step 13Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
14Action SBT Failed
Return to comfortable ventilatory support
- Resume previous settings
- Identify cause of failure
- Retry in 24 hours
- Consider causes: cardiac, fluid overload, weakness
- Path rejoins step 02Shared downstream outcome
15Action SAT Failed/Not Safe
Continue sedation, reassess tomorrow
- Severe agitation/hemodynamic instability
- Optimize sedation to light target
- Address underlying issues
- Retry next day
- Path rejoins step 02Shared downstream outcome
Guideline Source
Official Executive Summary of an ATS/ACCP Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- RSBI has limited predictive value (AARC 2024 update)
- Cuff leak test interpretation varies
- Does not address specific disease states
- Patients with tracheostomy may have different considerations
- Assumes underlying cause of respiratory failure is improving
Contraindicated Populations
pediatricneonatal
Applicable Regions
USEUGlobal
Global: ATS/ACCP 2017 with AARC 2024 update
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Liberation from Mechanical Ventilation?
The Liberation from Mechanical Ventilation is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Official Executive Summary of an ATS/ACCP Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults.
What guideline is the Liberation from Mechanical Ventilation based on?
This algorithm is based on Official Executive Summary of an ATS/ACCP Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults (DOI: 10.1164/rccm.201610-2076ST).
What are the limitations of the Liberation from Mechanical Ventilation?
Known limitations include: RSBI has limited predictive value (AARC 2024 update); Cuff leak test interpretation varies; Does not address specific disease states; Patients with tracheostomy may have different considerations; Assumes underlying cause of respiratory failure is improving. Individual patient factors may require deviation from these recommendations.
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