Liberating from the Ventilator

• Pair daily SAT + SBT once FiO₂ ≤40%, PEEP ≤8, minimal sedation, pressors low or off.
• Run the SBT on a T-piece or PSV 5/5 for 30–120 min; RR >35, SpO₂ <90%, distress, or arrhythmia means failure.
• Extubate once awake, passing the SBT, with manageable secretions; high-risk patients (COPD, age >65, CHF) get post-extubation NIV/HFNO.
• Plan tracheostomy if ventilation >7–10 d is expected: earlier in TBI or poor GCS.

Readiness for Liberation and Weaning from Mechanical Ventilation

• Ready for a spontaneous breathing trial? (underlying cause of respiratory failure reversing · awake, alert, cooperative · adequate oxygenation — PEEP ≤5 cm H₂O, PaO₂ >60 mm Hg on FiO₂ <0.50 · hemodynamically stable — no vasopressor/inotropic agents or stable minimal doses, no myocardial ischemia, HR <140 · afebrile T <38.0°C · pH and PaCO₂ at patient baseline)
• Start a spontaneous breathing trial via CPAP, PSV, or T-tube for 30 to 60 minutes
• Stay on mechanical ventilation; keep treating cause(s) of respiratory failure; recheck trial readiness daily
• Tolerating the spontaneous breathing trial? (RSBI <105 breaths/min/L · acceptable gas exchange — SaO₂ ≥90%, PaO₂ ≥60 mm Hg, pH ≥7.32, PaCO₂ rise ≤10 mm Hg from trial start · stable respiratory rate — RR ≤30–35, change <50% · hemodynamically stable — HR <120–140, HR rise <20%, SBP >90 and <180, SBP change <20% · no major mental status change, anxiety, agitation · no diaphoresis or increased work of breathing)
• Stay on mechanical ventilation; recheck readiness daily
• Ready for extubation? (airway patent? · protects airway? · clears secretions?)
• Proceed to extubation — high-risk patients (COPD, age >65, CHF) go straight onto NIV or HFNO
• Stay on mechanical ventilation, consider causes of weaning failure, and consider tracheostomy evaluation