How to Withdraw Mechanical Ventilation - American Association of ...

AACN18_4_397-403 10/20/07 14:23 Page 397
397
AACN Advanced Critical Care
Volume 18, Number 4, pp.397–403
© 2007, AACN
How to Withdraw Mechanical Ventilation
A Systematic Review of the Literature
Margaret L. Campbell, PhD, RN, FAAN
ABSTRACT
Eight published accounts about ventilator
withdrawal spanning 1992–2004 were selected
for review. Articles were selected if
they contained data that described the
processes comprising the withdrawal of
mechanical ventilation as a terminal illness
event. The purpose of this article is to synthesize
the existing evidence about
processes for the compassionate withdrawal
of mechanical ventilation from
Artificial ventilation has been used for
decades to support breathing when patients
experienced acute or chronic respiratory
failure. Beginning with negative pressure ventilation
(iron lungs) during the polio epidemic,
clinicians had the means to prolong life. Modern
ventilators provide a variety of modes and
mechanisms for supporting even patients with
the most severe pulmonary impairments.
In 1975, a young woman named Karen Ann
Quinlan existed in a persistent vegetative state.
Her life was prolonged with mechanical ventilation
and enteral feedings. Her parents recognized
that her prognosis for functional neurologic
recovery was poor, and they requested
withdrawal of the ventilator. Karen’s physicians
had never faced this type of request and
would have found no support in the professional
literature for how to respond. The clinicians
believed that Karen would die without
the ventilator and that by acting to remove it,
they would be complicit in her death.
Karen’s condition and her parent’s request
were given a great deal of ethical and legal
intensive care unit patients, including measures
of distress, premedication, medication
during withdrawal, withdrawal methods,
extubation considerations, duration of survival,
and relationship of opioids or benzodiazepines
to duration of survival. Practice
recommendations will be suggested.
Keywords: dyspnea, dying, life supports,
mechanical ventilation, terminal weaning,
terminal care, withdrawal
attention. In 1976, the New Jersey Supreme
Court ruled in favor of the ventilator withdrawal.
To the surprise of her physicians, she
was able to sustain herself with spontaneous
breathing and lived 10 more years in a vegetative
state with enteral feeding and hydration
before dying from pneumonia.
The 1970s were characterized by a proliferation
of new and improving life-sustaining
therapies and the continued evolution of critical
care as a specialty. The development of ethical
standards and the creation of legal statutes
lagged behind the expansion and implementation
of life-sustaining therapies. The 1980s
featured “right to die” cases resolved in the
courts and the formulation of ethical standards
to guide this type of care decision. 1
Margaret L. Campbell is Palliative Care Nurse Practitioner,
Detroit Receiving Hospital, Associate Director of Research,
Center to Advance Palliative Care Excellence, and Assistant
Professor-Research, Center for Health Research, College of
Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI
48202 (Mcampbe3@dmc.org).

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CAMPBELL AACN Advanced Critical Care
Numerous cases across the country found
their way into the courts, providing the basis
for case law and eventually statutes to guide
clinical decision making. A Presidential Commission
to address ethical issues in medicine
was formed; one of their reports addressed decisions
to forgo life-sustaining treatment. 2 The
Commission examined how decisions were
made to forgo therapy, clarified the issues, and
suggested appropriate procedures for making
decisions that are the basis for current practice.
By the early 1990s, clinical standards,
policies, and procedures about forgoing lifesustaining
therapy were in wide use and reflected
broad agreement about the underlying
principles regarding these decisions. The Patient
Self-Determination Act was introduced
to provide federal statutory support of the patient’s
right to use advance directives. 3
Currently, decisions are made every day to
forgo life-sustaining therapies. In the vast majority
of cases, all parties directly involved—
patients, families, and clinicians—are in agreement
with the decision. Referral to a court or
an ethics committee is not necessary, except in
cases characterized by dispute.
Before 1990, the critical care literature focused
on ethical and legal decision making
about forgoing mechanical ventilation. There
was little empiric evidence to guide the process;
the “ought to” was described but not the “how
to.” The earliest article that suggested a method
for ventilator withdrawal was published in
1983 on the basis of the processes used in one
unit. Grenvik distinguished terminal weaning
from conventional weaning because terminal
weaning proceeds despite deteriorating vital
signs and other variables. He recommended
continued evaluation of blood gases during terminal
weaning to monitor the patient’s progress
toward death or successful weaning. Additionally,
he suggested that some patients should remain
intubated if airway obstruction and disconcerting
airway sounds can be anticipated. 4
More recently, Rubenfeld and Crawford
suggested that ventilator withdrawal be treated
similarly to other processes or procedures undertaken
in the intensive care unit (ICU). 5 For
example, a plan should be developed for the
ventilator withdrawal that considers what
processes will occur and in what order. Who
will be responsible for those processes?
Some critical care units have turned to protocols,
standing orders, or algorithms to guide
the process of ventilator withdrawal and an
398
ideal protocol should reflect the state of the
science. Thus, the purpose of this article is to
systematically review and synthesize extant evidence
about the processes of ventilator withdrawal,
in other words the “how to.” This article
does not include a summary of the
evidence about communicating to make the
decision or caring for families as those topics
are presented in other articles in this issue of
AACN Advanced Critical Care.
Method
Two electronic databases, MEDLINE (1980
to February 2007) and CINAHL (1982 to
February 2007), were searched for studies in
English using the keywords mechanical ventilation
and withdrawal, life support withdrawal,
ventilator withdrawal, and terminal
weaning. The search yielded 207 citations, of
which 35 articles reflected the purpose of the
review and were selected for evaluation for
inclusion/exclusion criteria. Studies were included
if the target population was mechanically
ventilated adults having ventilation
withdrawn as a part of terminal illness care.
Articles were excluded if the data were collected
from a mixed sample of patients having
ventilation withdrawn or withheld, if the
sample was less than 12 patients, or if the article
described one or more case reports.
Table 1 summarizes the 8 articles included in
this review.
Data were extracted to predesigned summary
tables under the following headings: author(s),
year of publication, study design, sample
size, measures of distress, premedication or
medication during withdrawal, withdrawal
method(s), extubation considerations, duration
of survival, and correlation of survival
with administration of opioids and sedatives.
Because of variability in data extracted, it was
not possible to combine the findings of different
studies and, therefore, summaries of the
variables are reported.
How Is Dyspnea or Respiratory
Distress Measured?
Dyspnea, also known as “breathlessness,” is a
nociceptive phenomenon defined as “a subjective
experience of breathing discomfort that
consists of qualitatively distinct sensations that
vary in intensity. The experience derives from
interactions among multiple physiological, psychological,
social and environmental factors,
and may induce secondary physiological and

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VOLUME 18 • NUMBER 4 • OCTOBER–DECEMBER 2007 HOW TO WITHDRAW MECHANICAL VENTILATION
Table 1: Studies Included in Review of the Literature
Authors Year Design N
Faber-Langendoen 1992 Retrospective, descriptive 14
and Bartels 6
Daly et al 7 1996 Retrospective, descriptive 42
Campbell et al 8 1999 Prospective, descriptive, 31
correlational
Mayer and Kossoff 9 1999 Retrospective, descriptive, 32
correlational
Ankrom et al 10 2001 Retrospective, descriptive 13
O’Mahony et al 11 2003 Retrospective, descriptive 21
Rocker et al 12 2004 Prospective, descriptive 155
Chan et al 13 2004 Retrospective, descriptive 75
Abbreviation: N, study sample size.
behavioral responses.” 14(p321) Dyspnea can be
perceived and verified only by the person experiencing
it. Many patients who are undergoing
ventilator withdrawal are cognitively impaired
or unconscious as a result of underlying
neurologic lesions or hemodynamic, metabolic,
or respiratory dysfunction that produce
cognitive impairment or unconsciousness. 15
Respiratory distress has been characterized as
an observable (behavioral) corollary to dyspnea;
the physical and emotional suffering that
results from the experience of asphyxiation
that is characterized by behaviors that can be
observed and measured. 16,17 Dyspnea or respiratory
distress is anticipated during ventilator
withdrawal and should be the focus of patient
interventions during the process.
Neuromuscular blocking agents (NMBA)
are being used with less frequency in the ICU;
however, when in use, it is impossible to assess
the patient’s comfort. Thus, NMBA should be
discontinued with evidence of patient neuromuscular
recovery before ventilator withdrawal.
18–20 In some cases, the duration of action
of these agents is prolonged, such as when
the patient has liver or renal failure and impaired
clearance. Therefore, although controversial,
withdrawal can proceed with careful
attention to ensuring patient comfort if an unacceptable
delay in withdrawing mechanical
ventilation occurs because of protracted effects
of NMBA. 20
Daly et al conducted a chart review and indicated
that medications given during ventila-
399
tor withdrawal were titrated to maintain a
respiratory rate less than 30 breaths per
minute, or to an unspecified appearance of
comfort. 7 Campbell et al used 3 measures for
distress in a prospective observation study.
The bispectral index of EEG, Bizek agitation
scale (BAS), 21 and the COMFORT scale 22 were
used simultaneously to assess patients for respiratory
distress, and they strongly correlated
with each other. 8 The measures used were not
specific to respiratory distress: BIS is a measure
of wakefulness, BAS is an agitation scale,
and the COMFORT scale is intended to measure
distress in infants.
O’Mahoney et al reported after retrospective
chart review that initiating or escalating
sedation or analgesia was done if the patient
showed unspecified signs of dyspnea, agitation,
or anxiety, and to keep the respiratory
rate below 28 breaths/minute. 11 Additionally,
they reported that sedating medications were
administered if the respiratory rate increased
by 50% over baseline or if accessory muscle
use or nasal flaring was apparent.
Subjectivity characterizes the measures
used. Nurse-nurse interrater reliability was not
measured or reported in the previous studies,
nor were operational definitions provided for
“distress,” “signs of dyspnea,” “anxiety,” or
“agitation.” Skill is required to detect nuances
of behaviors, particularly when the patient is
unable to validate the nurse’s assessment. Evidence
is needed to reliably identify the behaviors
that signify respiratory distress, especially

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CAMPBELL AACN Advanced Critical Care
when patients are unable to reliably provide a
self-report about their experience. Recent investigation
of the reliability and validity of a
Respiratory Distress Observation Scale suggests
that there may be common behaviors displayed
by patients in response to hypercarbia,
hypoxemia, or inspiratory effort, including
tachycardia, tachypnea, accessory muscle use,
restlessness, nasal flaring, grunting at end-expiration,
and a fearful facial expression. 23
Some would argue that routine premedication
with opioids and sedatives will prevent distress
during ventilator withdrawal, however, many
clinicians fear hastening patient death and are
reluctant to medicate without clear evidence of
patient distress.
Recommendation
More studies are needed to identify reliable behaviors
that signify respiratory distress when
the patient is unable to generate a self-report.
Brain-dead patients by definition will not
show distress, cough, gag, or breath during or
following ventilator withdrawal, and sedation
or analgesia is not indicated. Comatose patients
are unlikely to demonstrate distress except
for, perhaps, tachypnea and tachycardia. 8
Initiation and escalation of sedatives and opioids
should be guided by patient behaviors.
Premedication
Four investigators reported about premedication.
Campbell et al recommended premedication
with morphine and/or a benzodiazepine
if the patient showed signs of distress before
withdrawal or if the conscious patient desired
medication. Because subjects in the sample
were comatose, only 13% of patients were
premedicated; an average Glasgow Coma
Scale (GCS) score of 7 was reported for those
premedicated and 4 for those with no premedication.
8 Investigators at the University of
Washington reported progressive escalation
of infusions of opioids or benzodiazepines in
the 8 hours preceding a planned ventilator
withdrawal. The justification for dose escalation
was not reported from this retrospective
review. 13 Ankrom et al reported that “small”
doses of morphine and a benzodiazepine
were given before ventilator withdrawal, but
doses and indications were not reported. 10
O’Mahoney reported premedication if the
patient was alert or had a history of recent
agitation before the withdrawal. 11
400
Medication During or
After Withdrawal
Variance in reporting characterized the descriptions
of medications used during ventilator
withdrawal. All investigators used an opioid,
usually morphine, and some used a benzodiazepine
occasionally or always. Table 2 is a
summary of the morphine characteristics
reported across investigations. As seen, doses
ranged from very small to very large. As discussed,
most studies did not report how distress
was measured or how dose escalation was
determined.
Recommendation
As is the standard with pain management, opioids
should be initiated to signs of distress and
the advice to “start low and titrate slowly” is
sage. Anticipatory premedication is a sound
practice if distress is already evident and if distress
can be anticipated. There is no justification
for medicating a brain-dead patient, and
one could argue that the patient in coma with
only minimal brainstem function is also unlikely
to experience distress. Doses that correspond
to customary dosing for the treatment
of dyspnea should guide dosing during ventilator
withdrawal. Documentation of the signs of
distress and rationale for dose escalation is important
to ensure continuity across professional
caregivers and to prevent overmedication
and the appearance of hastening death.
Weaning Method
Terminal extubation is characterized by ceasing
ventilatory support and removing the endotracheal
tube in one step. Extubation was
the only method used in 2 studies. 9,11, Terminal
weaning is a process of step-wise, gradual reductions
in oxygen and ventilation, terminating
with placement on a t-piece or with extubation.
Rapid terminal weaning was the only
method used in one study with an average
weaning interval of 15 minutes. 8 In 2 studies,
investigators reported various methods used
with no rationale provided for choice of
method. 6,7
In a survey of physician practices related to
ventilator withdrawal, investigators found
that surgeons and anesthesiologists preferred
terminal weaning compared with internists
and pediatricians who preferred extubation. 24
It is interesting to note that physician rather
than patient characteristics contributed to

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VOLUME 18 • NUMBER 4 • OCTOBER–DECEMBER 2007 HOW TO WITHDRAW MECHANICAL VENTILATION
Table 2: Summary of Reports of Morphine Administered During Ventilator Withdrawal
Author(s) Total morphine (duration) Average hourly dose Range of dosing
Faber-Langendoen NR NR 0–80 mg/h
and Bartels 6
Daly et al 7 NR NR 1–59 mg/h
Campbell et al 8 36 � 10 mg (24 h from 5.5 mg/h NR
beginning of withdrawal)
Mayer and Kossoff 9 6–456 mg (30 h from 6.3 mg/h 2.5–20 mg/h
beginning of withdrawal)
Ankrom et al 10 206 � 265 mg (patient survived NR NR
�30 min) 78 � 14 mg (patient
survived longer than 30 min)
O’Mahoney et al 11 12 mg (extubation until death) 6 mg/h 1–50 mg/h
Rocker et al 12 24 mg (4 h before death) 24 mg/h median 2–340 mg/h
Chan et al 13 81 mg (24 h before death) Increased from 4 mg/h NR
to 16.2 mg/h during
interval before
withdrawal
Abbreviation: NR, not reported.
choice of method. There are no known investigations
that compare these methods.
Recommendation
With no comparative evidence to support one
method over another, it is difficult to make a
recommendation. Rapid terminal weaning
may afford the clinician with the most control
because it allows for careful, sequential adjustments
to the ventilator with precise titration of
medications to ensure patient comfort. Continuous
patient monitoring with readily accessible
opioids and sedatives will afford the patient
and family comfort regardless of method
employed.
Extubation Considerations
Campbell et al were the only investigators who
recommended extubation as a separate decision
based on the patient’s airway integrity,
volume of pulmonary secretions, and ability to
experience distress. Of comatose patients,
35% were extubated after rapid terminal
weaning. Of note, survival was longer for
those who were extubated (85.3 � 35 hours)
compared with the patients who remained
intubated (12.95 � 4.96 hours; P � .01). 8
Rocker reported no significant difference in
duration of survival when the patients who
were extubated (median 1.1 hours) were com-
401
pared with those who had either a tracheostomy
or endotracheal tube maintained
(median 1.2 hours). 12
Recommendation
Removal of the endotracheal tube should be
performed whenever possible because of patient
comfort and the aesthetic appearance of
the patient. However, in some cases, airway
compromise can be anticipated, such as when
the patient has a swollen, protuberant tongue,
or has no gag or cough reflexes. In cases of airway
compromise, the disconcerting noises
may be more distressing to the attendant family
than the presence of the tube. Aerosolized
racemic epinephrine is a useful intervention to
reduce stridor after extubation. Family counseling
about usual noises that can be expected
and cause no distress should be done prior to
extubation.
Duration of Survival
All the investigators reported about duration
of survival. In 4 studies, patients who died following
ventilator withdrawal comprised the
sample; thus 100% of patients died. 9,12,13,25 All
the patients who were withdrawn died in 2
studies, 7,10 and 2 brain-dead patients were included
in the sample from Daly et al. 7
Campbell et al reported that of 31 comatose

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CAMPBELL AACN Advanced Critical Care
patients, 2 patients (6%) survived to hospital
discharge, and O’Mahoney et al discharged 3
of 21 (14%) patients after ventilator withdrawal.
8,11
Across studies the duration of survival
ranged from 2 minutes to 9 days after ventilator
withdrawal. Median survival across
studies ranged from 35 minutes 13 to 7.5
hours. 9 Campbell et al reported no relationship
between duration of survival and use of
sedation/analgesia, GCS score, or PaO 2/FiO 2
but there was a significant inverse correlation
with illness severity measured with
APACHE II 26 (r ��0.42, P � .05). 8 Mayer
et al also found no relationship between duration
of survival and GCS score. 9 Ankrom
et al reported no correlation between analgesia
use and duration of survival; however,
patients who died in less than 30 minutes received
an average total morphine dose of
206 � 265 mg morphine, and those who
died more than 30 minutes after withdrawal
received an average of 78 � 111 mg morphine.
10 This suggests a clinical significance,
although the analysis with a small sample
and a large standard deviation may not have
yielded a statistical significance.
Of note, both Campbell et al and Chan et al
reported no significant relationship between
analgesia/sedation and duration of survival. 8,13
However, with similar average reported GCS
scores (5.3 vs 4), Campbell reported an average
total morphine dose of 36 mg for the 24hour
period after withdrawal and an average
survival of 24.2 hours (median 2.3 hours).
This contrasts sharply with the average total
morphine dose of 81 mg for the 24-hour period
before death and the median survival after
ventilator withdrawal of 35 minutes
(range, 1 minute to 14.8 hours).
Summary
Small samples and largely retrospective chart
reviews characterize the body of evidence
about processes for ventilator withdrawal.
Thus, it seems fair to say that the evidence is
largely lacking to predict the best method that
ensures patient comfort without hastening
death. Palliation versus hastening death may
be difficult to distinguish in this context because
the patients are often near death before
the ventilator is withdrawn. The cited research
is not conclusive to make recommendations
in all cases of ventilator withdrawal.
Therefore, a number of suggested processes
402
may be useful in this clinical context as well as
with a team approach to the procedure and
patient care.
First, a common measure of dyspnea or respiratory
distress should be identified and used
across clinicians to guide the initiation and escalation
of opioids or sedatives, such as noting
the presence of behaviors specific to respiratory
distress. Additionally, monitoring the patient
for signs of affective distress, such as fear,
is essential. Brain-dead patients do not experience
or display signs of distress.
Premedication or medication during and
following withdrawal of mechanical ventilation
with opioids and benzodiazepines is
useful if the patient is experiencing distress
before withdrawal or likely to experience distress
during or after. Brain-dead patients do
not require medication because there is no
distress. Comatose patients may require little
or no analgesia or sedation unless objective
signs of respiratory distress are apparent.
Doses should be initiated according to the patient’s
tolerance and escalated only to signs or
reports of distress.
Every attempt should be made to extubate
patients after ceasing mechanical ventilation
because the endotracheal tube is a source of
iatrogenic discomfort. However, in some
cases, particularly when the patient is unresponsive,
it may be best to keep the endotracheal
tube, such as when the tongue is
swollen, when gag and cough reflexes are absent,
or when there is a large volume of pulmonary
secretions. Studies are needed to identify
best methods.
References
1. Meisel A. The legal consensus about forgoing life-sustaining
treatment: its status and its prospects. Kennedy
Inst Ethics J. 1993;2:309–335.
2. President’s Commission for the Study of Ethical Problems
in Medicine and Behavioral Research. Deciding to
Forego Life-Sustaining Treatment. Washington, DC: US
Government Printing Office; 1983.
3. Omnibus Budget Reconciliation Act. Washington, DC:
Government Printing Office; 1990.
4. Grenvik A. “Terminal weaning”: discontinuance of lifesupport
therapy in the terminally ill patient. Crit Care
Med. 1983;11:394–395.
5. Rubenfeld GD, Crawford SW. Principles and practice of
withdrawing life-sustaining treatment in the ICU. In:
Curtis JR, Rubenfeld GD, eds. Managing Death in the
ICU: The Transition From Cure to Comfort. New York:
Oxford University Press; 2001:127–147.
6. Faber-Langendoen K, Bartels DM. Process of forgoing
life-sustaining treatment in a university hospital: an empirical
study. Crit Care Med. 1992;20(5):570–577.
7. Daly BJ, Thomas D, Dyer MA. Procedures used in withdrawal
of mechanical ventilation. Am J Crit Care. 1996;
5:331–338.

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VOLUME 18 • NUMBER 4 • OCTOBER–DECEMBER 2007 HOW TO WITHDRAW MECHANICAL VENTILATION
8. Campbell ML, Bizek KS, Thill M. Patient responses during
rapid terminal weaning from mechanical ventilation:
a prospective study. Crit Care Med. 1999;27(1):73–77.
9. Mayer SA, Kossoff SB. Withdrawal of life support in the
neurological intensive care unit. Neurol. 1999;52(8):
1602–1609.
10. Ankrom M, Zelesnick L, Barofsky I, Georas S, Finucane
TE, Greenough WB, III. Elective discontinuation of lifesustaining
mechanical ventilation on a chronic ventilator
unit. J Am Geriatr Soc. 2001;49(11):1549–1554.
11. O’Mahony S, McHugh M, Zallman L, Selwyn P. Ventilator
withdrawal: procedures and outcomes. J Pain Symptom
Manag. 2003;26:954–961.
12. Rocker GM, Heyland DK, Cook DJ, Dodek PM,
Kutsogiannis DJ, O’Callaghan CJ. Most critically ill patients
are perceived to die in comfort during withdrawal
of life support: a Canadian multicentre study. Can J
Anesth. 2004;51:623–630.
13. Chan JD, Treece PD, Engelberg RA, et al. Narcotic and
benzodiazepine use after withdrawal of life support: association
with time to death? Chest. 2004;126:286–293.
14. American Thoracic Society. Dyspnea. Mechanisms, assessment,
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American Thoracic Society. Am J Respir Crit Care Med.
1999;159(1):321–340.
15. Campbell ML, Thill MC. Impact of patient consciousness
on the intensity of the do-not-resuscitate therapeutic
plan. Am J Crit Care. 1996;5(5):339–345.
16. Campbell ML. Terminal dyspnea and respiratory distress.
Crit Care Clin. 2004;20(3):403–417.
403
17. Campbell ML. Fear and pulmonary stress behaviors to
an asphyxial threat across cognitive states. Res Nurs
Health. In press.
18. Rushton C, Terry PB. Neuromuscular blockade and ventilator
withdrawal: ethical controversies. Am J Crit Care.
1995;4:112–115.
19. Truog RD, Burns JP. To breathe or not to breathe. J Clin
Ethics. 1994;5(1):39–42.
20. Truog RD, Campbell ML, Curtis JR, et al. Recommendations
for end-of-life care in the intensive care unit. Crit
Care Med. In press.
21. Bizek K. Optimizing sedation in critically ill, mechanically
ventilated patients. Crit Care Nurs Clin North Am.
1995;7:315–325.
22. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing
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95–109.
23. Campbell ML. Psychometric testing of a respiratory distress
observation scale. J Palliat Med. In press.
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patients receiving mechanical ventilation. A survey of
physician practice. Chest. 1994;106(3):880–888.
25. Faber-Langendoen K, Spomer A, Ingbar D. A prospective
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Crit Care Med. 1985;13:818–829.

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AACN18_4_404-405 17/11/07 1:19 Page 405
CE Test Questions
How to Withdraw Mechanical Ventilation: A Systematic
Review of the Literature
Objectives:
Upon completion of this article, the reader will be able to:
1. Identify 3 patient behaviors that signify respiratory distress.
2. Describe 2 weaning methods for ventilator withdrawal.
3. Discuss the processes for compassionate withdrawal of mechanical ventilation.
1. Which of the following patients was involved in a US
Supreme Court ruling in favor of ventilator withdrawal?
a. Karen Andrews
b. Nancy Cruzan
c. Terry Schiavo
d. Karen Ann Quinlan
2. Which of the following patient rights is provided for in
the Patient Self-Determination Act?
a. Advance directives
b. Ventilator withdrawal
c. Removal of feeding tube
d. Physician-assisted suicide
3. Which of the following symptoms is anticipated during
ventilator withdrawal and should be the focus of
interventions during the withdrawal process?
a. Pain
b. Death
c. Dyspnea
d. Agitation
4. Which of the following behaviors may be displayed by
patients in response to hypercarbia or hypoxemia?
a. Facial grimacing
b. Nasal flaring
c. Grunting during inspiration
d. Stridor
5. Which of the following should guide initiation and
escalation of sedatives and opioids during ventilator
withdrawal?
a. Routine administration throughout the withdrawal process
b. Blood pressure
c. Signs of respiratory distress
d. Glascow coma scale
6. Which of the following medications was most
commonly used by investigators during ventilator
withdrawal?
a. Morphine
b. Lorazepam
c. Fentanyl
d. Propofol
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7. Which of the following weaning intervals was used by
investigators during rapid terminal weaning?
a. 1 to 5 minutes
b. 15 to 20 minutes
c. 30 to 45 minutes
d. 60 to 90 minutes
8. The terminal extubation method of weaning:
a. is based on physician preference.
b. should not be used if strider is present.
c. is the safest method of withdrawal of mechanical ventilator.
d. should be done without the administration of opioids or
benzodiazepines.
9. Which of the following is a useful aerosol medication
to reduce stridor after extubation?
a. Epinephrine
b. Metaproterenol
c. Ephedrine
d. Ipratroprium bromide
10. Which of the following had a significant inverse
correlation with duration of survival after ventilator
withdrawal?
a. Ramsey sedation scale score
b. Glascow coma scale score
c. PaO2/FIO2 ratio
d. APACHE II score
11. Which of the following would not preclude extubation
after ceasing mechanical ventilation?
a. Swollen tongue
b. Absent gag reflex
c. Stridor
d. Increased secretions
12. Which of the following was the smallest average
hourly dose of morphine used by investigators for
ventilator withdrawal?
a. 3 mg/h
b. 5.5 mg/h
c. 6 mg/h
d. 8.5 mg/h