Immediate extubation vs. gradual ventilator weaning in comfort care
No good data exist to guide the process of withdrawal of invasive mechanical ventilation just prior to the end of life–variously known as “terminal extubation,” “compassionate withdrawal,” “extubation to comfort care,” et al.
At most centers, once the decision is made by the patient or family, an opioid infusion is initiated, all non-palliative medications are discontinued, the endotracheal tube is removed, and a skilled nurse provides palliative opioids and/or benzodiazepines to promptly (one hopes) relieve any signs of distress.
A minority of centers employ so-called gradual weaning, in which ventilator support is reduced stepwise over 10 to 60 minutes prior to extubation (e.g., to FIO2 30% and PEEP 5 cm H2O, vent alarms off), with analgesics and anxiolytics provided as needed if distress develops. In theory, gradual weaning allows a patient time to adjust to the increased stress prior to extubation, and for symptoms to be palliated as they arise.
Keep reading with a 7-day free trial
Subscribe to PulmCCM to keep reading this post and get 7 days of free access to the full post archives.