Effect of Aggressive Vs Conservative Screening and Confirmatory Test on Time to Extubation Among Patients at Low or Intermediate Risk: a Randomized Clinical Trial

Overview

Journal Intensive Care Med

Specialty Critical Care

Date 2024 Feb 14

PMID 38353714

Authors

Gonzalo Hernandez Martinez

Patricia Rodriguez

Jesus Soto

Oriol Caritg

Andrea Castellvi-Font

Borja Mariblanca

Antonio Maria Garcia

Laura Colinas

Jose Manuel Anon

Francisco Jose Parrilla-Gomez

Jose Alberto Silva-Obregon

Joan Ramon Masclans

Alicia Propin

Alicia Cuadra

Mario Guillermo Dalorzo

Gemma Rialp

Fernando Suarez-Sipmann

Oriol Roca

Affiliations

Soon will be listed here.

Abstract

Purpose: This study aimed to determine the best strategy to achieve fast and safe extubation.

Methods: This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO) to fraction of inspired oxygen (FiO) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmHO plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmHO + PEEP 0 cmHO); (2) screening with ratio of partial pressure of arterial oxygen (PaO) to fraction of inspired oxygen (FiO) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO/FiO > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO/FiO > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.

Results: Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).

Conclusion: Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.

Citing Articles

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Weaning strategy in patients at low-to-medium risk of extubation failure. Author's reply.

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References

Esteban A, Alia I, Ibanez J, Benito S, Tobin M . Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. Chest. 1994; 106(4):1188-93. DOI: 10.1378/chest.106.4.1188. View

de Jonghe B, Bastuji-Garin S, Sharshar T, Outin H, Brochard L . Does ICU-acquired paresis lengthen weaning from mechanical ventilation?. Intensive Care Med. 2004; 30(6):1117-21. DOI: 10.1007/s00134-004-2174-z. View

Cinotti R, Citerio G, Asehnoune K . Extubation in neurocritical care patients: lesson learned. Intensive Care Med. 2022; 49(2):230-232. DOI: 10.1007/s00134-022-06907-7. View

Burns K, Rizvi L, Cook D, Lebovic G, Dodek P, Villar J . Ventilator Weaning and Discontinuation Practices for Critically Ill Patients. JAMA. 2021; 325(12):1173-1184. PMC: 7988370. DOI: 10.1001/jama.2021.2384. View

Beduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E, Jonas M . Epidemiology of Weaning Outcome according to a New Definition. The WIND Study. Am J Respir Crit Care Med. 2016; 195(6):772-783. DOI: 10.1164/rccm.201602-0320OC. View

Boles J, Bion J, Connors A, Herridge M, Marsh B, Melot C . Weaning from mechanical ventilation. Eur Respir J. 2007; 29(5):1033-56. DOI: 10.1183/09031936.00010206. View

Burns K, Lellouche F, Lessard M . Automating the weaning process with advanced closed-loop systems. Intensive Care Med. 2008; 34(10):1757-65. DOI: 10.1007/s00134-008-1154-0. View

Ely E . Challenges encountered in changing physicians' practice styles: the ventilator weaning experience. Intensive Care Med. 1998; 24(6):539-41. DOI: 10.1007/s001340050613. View

Kacmarek R, Villar J, Parrilla D, Alba F, Solano R, Liu S . Neurally adjusted ventilatory assist in acute respiratory failure: a randomized controlled trial. Intensive Care Med. 2020; 46(12):2327-2337. PMC: 7474954. DOI: 10.1007/s00134-020-06181-5. View

10.

Schmidt G, Girard T, Kress J, Morris P, Ouellette D, Alhazzani W . Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med. 2016; 195(1):115-119. DOI: 10.1164/rccm.201610-2076ST. View

11.

Tobin M, Jubran A . Variable performance of weaning-predictor tests: role of Bayes' theorem and spectrum and test-referral bias. Intensive Care Med. 2006; 32(12):2002-12. DOI: 10.1007/s00134-006-0439-4. View

12.

Thille A, Gacouin A, Coudroy R, Ehrmann S, Quenot J, Nay M . Spontaneous-Breathing Trials with Pressure-Support Ventilation or a T-Piece. N Engl J Med. 2022; 387(20):1843-1854. DOI: 10.1056/NEJMoa2209041. View

13.

Subira C, Hernandez G, Vazquez A, Rodriguez-Garcia R, Gonzalez-Castro A, Garcia C . Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA. 2019; 321(22):2175-2182. PMC: 6563557. DOI: 10.1001/jama.2019.7234. View

14.

Yang K, Tobin M . A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991; 324(21):1445-50. DOI: 10.1056/NEJM199105233242101. View

15.

Ouellette D, Patel S, Girard T, Morris P, Schmidt G, Truwit J . Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols.... Chest. 2016; 151(1):166-180. DOI: 10.1016/j.chest.2016.10.036. View

16.

Ely E, Baker A, Dunagan D, Burke H, Smith A, Kelly P . Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996; 335(25):1864-9. DOI: 10.1056/NEJM199612193352502. View

17.

Tobin M, Jubran A . Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning. Crit Care Med. 2007; 36(1):1-7. DOI: 10.1097/01.CCM.0000297883.04634.11. View

18.

Tobin M . Remembrance of weaning past: the seminal papers. Intensive Care Med. 2006; 32(10):1485-93. DOI: 10.1007/s00134-006-0338-8. View

19.

Esteban A, Frutos F, Tobin M, Alia I, Solsona J, Valverdu I . A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995; 332(6):345-50. DOI: 10.1056/NEJM199502093320601. View

20.

Walsh T, Dodds S, McArdle F . Evaluation of simple criteria to predict successful weaning from mechanical ventilation in intensive care patients. Br J Anaesth. 2004; 92(6):793-9. DOI: 10.1093/bja/aeh139. View