Elderly patients are predisposed to respiratory failure because of physiological changes that occur with the aging process. These changes result in a loss of pulmonocardiac reserve and the relatively frequent need for mechanical ventilatory support. The management and weaning of elderly patients from mechanical ventilatory support is different from strategies used for younger patients. By focusing on the physiological changes that occur in the elderly, this article explains why the elderly experience more complications and higher mortality than younger patients with respiratory failure. It also suggests management strategies that incorporate newer insights into ventilatory and respiratory muscle failure.