Randomised trials have demonstrated that ventilation techniques which support every spontaneous breath are the most efficacious weaning modes. Nasal continuous positive airway pressure after extubation reduces the likelihood of incidents leading to the need for reintubation in very low birthweight infants; further work is needed to determine if there are advantages of particular delivery techniques. Both methylxanthines and dexamethasone facilitate weaning and extubation; the efficacy of low-dose dexamethasone merits further investigation. Assessments of the efficacy of respiratory efforts and hence the balance of respiratory drive, muscle performance and respiratory load appear to best predict weaning and extubation success. Essential to the success of weaning and extubation are dedicated staff, whether this will be assisted by computerised decision-making tools requires testing. The above approaches are not mutually exclusive and those indicated by this review as appropriately evidence based should be considered by practitioners for current use to reduce difficult/unsuccessful extubation.
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Competing interests: AG has held grants and received honoraria for giving lectures and advising various manufacturers.
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