Ventilator Weaning Strategies in Acute and Acute-on-Chronic Respiratory Failure: A Systematic Review

Introduction: Acute and acute-on-chronic respiratory failure in adult and pediatric patients is associated with high mortality and healthcare costs, in part from prolonged invasive mechanical ventilation. This systematic review evaluates ventilator weaning strategies and their impact on clinical outcomes in these populations.


Methods: We conducted a systematic review of observational studies and randomized controlled trials that enrolled critically ill adults and children with acute or acute-on-chronic respiratory failure. Included studies compared at least two ventilator weaning strategies and reported at least one outcome of interest: duration of mechanical ventilation (DMV), ventilator free days (VFD), intensive care unit length of stay (LOS), mortality, need for tracheostomy, and development of ventilator-associated pneumonia (VAP).


Results: We identified 3,139 references of which 14 studies met eligibility criteria (nine in adults, three in children, and two in mixed populations), enrolling a total of 1,544 participants. Sixteen distinct ventilator weaning strategies were described with minimal overlap precluding meta-analysis. Strategies involving volume support (n = 1 study), proportional assist (n = 1 study), and adaptive support ventilation (n = 1 study) were associated with a shorter DMV and LOS compared to pressure support ventilation. Neurally adjusted ventilatory assist (n = 1 study) was associated with a shorter DMV and longer VFD compared to non-neurally adjusted modes. Abrupt weaning with CPAP and pressure support shortened DMV (n = 1 study) and LOS (n = 1 study) compared to gradual weaning of pressure and rate. Nine studies showed no association between weaning strategy and outcome. No strategies were associated with decreased mortality, VAP, or tracheostomy placement.


Conclusions: Despite the healthcare burden of acute and acute-on-chronic respiratory failure, evidence guiding weaning strategies remains limited. Heterogeneity across studies precludes meaningful meta-analysis and nine studies found no outcome differences. Adaptive support, proportional assist, and neurally adjusted ventilation show promise in select studies, but larger comparative trials are needed to identify optimal approaches.