• Daniel R Ouellette, Sheena Patel, Timothy D Girard, Peter E Morris, Gregory A Schmidt, Jonathon D Truwit, Waleed Alhazzani, Suzanne M Burns, Scott K Epstein, Andres Esteban, Eddy Fan, Miguel Ferrer, Gilles L Fraser, GongMichelle NgMNDepartments of Medicine and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY., Catherine L Hough, Sangeeta Mehta, Rahul Nanchal, Amy J Pawlik, William D Schweickert, Curtis N Sessler, Thomas Strøm, and John P Kress.
• Henry Ford Health System, Detroit, MI. Electronic address: douelle1@hfhs.org.
• Chest. 2017 Jan 1; 151 (1): 166-180.

BackgroundAn update of evidence-based guidelines concerning liberation from mechanical ventilation is needed as new evidence has become available. The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have collaborated to provide recommendations to clinicians concerning liberation from the ventilator.MethodsComprehensive evidence syntheses, including meta-analyses, were performed to summarize all available evidence relevant to the guideline panel's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, and the results were summarized in evidence profiles. The evidence syntheses were discussed and recommendations developed and approved by a multidisciplinary committee of experts in mechanical ventilation.ResultsRecommendations for three population, intervention, comparator, outcome (PICO) questions concerning ventilator liberation are presented in this document. The guideline panel considered the balance of desirable (benefits) and undesirable (burdens, adverse effects, costs) consequences, quality of evidence, feasibility, and acceptability of various interventions with respect to the selected questions. Conditional (weak) recommendations were made to use inspiratory pressure augmentation in the initial spontaneous breathing trial (SBT) and to use protocols to minimize sedation for patients ventilated for more than 24 h. A strong recommendation was made to use preventive noninvasive ventilation (NIV) for high-risk patients ventilated for more than 24 h immediately after extubation to improve selected outcomes. The recommendations were limited by the quality of the available evidence.ConclusionsThe guideline panel provided recommendations for inspiratory pressure augmentation during an initial SBT, protocols minimizing sedation, and preventative NIV, in relation to ventilator liberation.Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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