Recommendations
➤ For acutely hospitalized adults who have been mechanically
ventilated for >24 hours, the ATS and CHEST suggest protocolized
rehabilitation directed toward early mobilization.
(Conditional recommendation, low certainty in the evidence)
• Remark: There is insufficient evidence to recommend any rehabilitation
protocol over another.
➤ The ATS and CHEST suggest managing acutely hospitalized adults
who have been mechanically ventilated for >24 hours with a ventilator
liberation protocol.
(Conditional recommendation, low certainty in the evidence)
• Remark: The ventilator liberation protocol may be either personnel-driven or
computer-driven.
➤ The ATS and CHEST suggest performing a cuff leak test (CLT) in
mechanically ventilated adults who meet extubation criteria and are
deemed high risk for post-extubation stridor (PES).
(Conditional recommendation, very low certainty in the evidence)
• Remark: Risk factors for PES include: traumatic intubation, intubation >6
days, large endotracheal tube, female sex, and reintubation after unplanned
extubation.
➤ For adults who have failed a CLT but are otherwise ready for
extubation, the ATS and CHEST suggest administering systemic
steroids 4 –24 hours before extubation.
(Conditional recommendation, moderate certainty in the evidence)
• Remark: A repeat CLT is not required following the administration of
systemic steroids.
Sources
Schmidt GA, et al. Official Executive Summary of an American oracic Society / American
College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical
Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017; 195(1):115-119 and
CHEST 2017; 151(1):160–165.
Girard TD, et al. Liberation from Mechanical Ventilation in Critically Ill Adults: An Official
American oracic Society/American College of Chest Physicians Clinical Practice Guideline.
Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit
Care Med 2017; 195(1):120–133.
Ouellette DR, et al. Liberation from Mechanical Ventilation in Critically Ill Adults: An Official
American College of Chest Physicians/American oracic Society Clinical Practice Guideline.
Inspiratory Pressure Augmentation during Spontaneous Breathing Trials, Protocols Minimizing
Sedation, and Non-invasive Ventilation Immediately Aer Extubation. CHEST 2017; 151(1):
166–180.
