Effect of a Personalized Weaning Strategy on Weaning Success

Weaning from mechanical ventilation is a daily challenge in intensive care units, as it can take up to 50% of the total duration of ventilation. The longer the duration of ventilation is, the more there is complication related with it.Even when the spontaneous breathing trial is succeeded, 10 to 20% of extubations are failed and requires re-intubation.There is two different ways to assess if the patient is capable of breathing by its own : T-piece which can be considered as hard to succeed (it can delay extubation for some patients) or pressure support ventilation with no PEEP which can be too easy and lead to an extubation too early.Studies have identified risk factors of weaning induced pulmonary oedema wich is one of the main cause of failed extubation (up to 60%).The purpose of P-WEAN is to evaluate whether a personalized strategy for weaning from mechanical ventilation, including daily search for weaning criteria and individualization of the weaning modality (T-piece or pressure support ventilation with zero PEEP) based on the existence of WIPO risk factors (obesity, COPD, cardiopathy) improves weaning success compared with usual practice.

Inclusion Criteria : all patients ≥ 18 y.o admitted to the ICU, under invasive mechanical ventilation for more then 24 hours and fullfilling the following weaning criteria :Resolution or improvement of the condition that led to intubation, as judged by the clinician in charge of the patient.Hemodynamic stability, defined as systolic blood pressure between 90 and 160 mmHg, heart rate less than 140 beats/min, without or with low doses of vasopressors.Glasgow score of 13 or greater and Richmond Agitation-Sedation Scale (RASS) score between -1 and +1.Respiratory stability defined as: oxygen saturation > 90% with inspired oxygen fraction ≤ 0.5 and PEEP ≤ 8 cmH2O, respiratory rate < 35/min, spontaneous tidal volume > 5 mL/kg, and peak inspiratory pressure ≤ 15 cmH2O.Few secretions (< 3 aspirations in the past 8 hours).Effective cough.Negative leak test (>100 mL or >10%).No surgery planned within 72 hours.Patients with a social security plan.Exclusion Criteria:Acute cerebral pathology requiring admission to intensive care and/or mechanical ventilation with tracheal intubation for neurological reasons (Glasgow score <13 at the time of intubation or CT scan abnormality): hemorrhagic stroke without or with vascular malformation (aneurysm, arterio-venous malformation...), ischemic stroke, head trauma, cerebral anoxo-ischemia after cardiac arrest.Tetraplegic or paraplegic patients with lesion level higher than D8.Peripheral neuromuscular pathology (underlying myopathy or myasthenia).ICU's Neuromyopathy.Tracheostomy.Patients with a decision of non-reintubation or terminal intubation.Pregnant or lactating women.Patients already included in this study.