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Is the patient able to oxygenate?

It is essential to minimize  the amount of lost oxygenation due to diffusion abnormalities, ventilation-perfusion mismatch, dead space and shunt. Certain factors may limit successful weaning – persistent lower respiratory tract infection, alveolar edema, airway/lobar collapse, lung fibrosis. Good quality physical therapy is required to mobilize secretions - the commonest cause of airway collapse is absorption atelectasis, distal to mucus plugs. As we have seen, re-expansion of collapsed lung units requires considerable work, particularly in patients with depleted reserve.

If the patient is requiring moderate to high levels of PEEP to oxygenate (PEEP prevents derecruitment at end expiration), then weaning is unlikely.

Persistent cardiogenic pulmonary edema makes the lungs stiff and boggy. This causes diffusion defects and shunt. The hearts performance needs to be optimized, be it with cautious doses of diuretics, inotropes or ACE inhibitors.

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