RESPIRATORY SYSTEM: Edited by Giacomo BellaniWeaning the patient: between protocols and physiologyHaaksma, Mark E.a,b,c; Tuinman, Pieter R.a,b,c; Heunks, Leoa,cAuthor Information aDepartment of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam bAmsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com) cAmsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, the Netherlands Correspondence to Leo Heunks, MD, PhD, Amsterdam University Medical Centers, Location VUmc, Post Box 7507, 1007MB Amsterdam, The Netherlands. E-mail: [email protected] Current Opinion in Critical Care: February 2021 - Volume 27 - Issue 1 - p 29-36 doi: 10.1097/MCC.0000000000000790 Buy Metrics Abstract Purpose of review Ventilator weaning forms an integral part in critical care medicine and strategies to shorten duration are rapidly evolving alongside our knowledge of the relevant physiological processes. The purpose of the current review is to discuss new physiological and clinical insights in ventilator weaning that help us to fasten liberation from mechanical ventilation. Recent findings Several new concepts have been introduced in the field of ventilator weaning in the past 2 years. Approaches to shorten the time until ventilator liberation include frequent spontaneous breathing trials, early noninvasive mechanical ventilation to shorten invasive ventilation time, novel ventilatory modes, such as neurally adjusted ventilatory assist and drugs to enhance the contractile efficiency of respiratory muscles. Equally important, ultrasound has been shown to be a versatile tool to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome. Summary A thorough understanding of the physiological adaptations during withdrawal of positive pressure ventilation is extremely important for clinicians in the ICU. We summarize and discuss novel insights in this field. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.