About 20% to 30% of patients are difficult to wean from invasive mechanical ventilation. The pathophysiology of difficult weaning is complex. Accordingly, determining the reason for difficult weaning and subsequently developing a treatment strategy require a dedicated clinician with in-depth knowledge of the pathophysiology of weaning failure. This review presents a structural framework ('ABCDE') for the assessment and treatment of difficult-to-wean patients. Earlier recognition of the underlying causes may expedite weaning from mechanical ventilation.

The reasons for failing a weaning trial are diverse. When a patient does not pass a weaning trial, structural evaluation could help to identify factors that played a role in that specific patient. Our opinion-based 'ABC' algorithm could be helpful. It should be noted that the algorithm has several loose ends as our understanding of weaning failure is far from complete.

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