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      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

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          Abstract

          Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial.

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          Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group.

          A. Esteban, I Alía, M Tobin … (1999)
          The duration of spontaneous breathing trials before extubation has been set at 2 h in research studies, but the optimal duration is not known. We conducted a prospective, multicenter study involving 526 ventilator-supported patients considered ready for weaning, to compare clinical outcomes for trials of spontaneous breathing with target durations of 30 and 120 min. Of the 270 and 256 patients in the 30- and 120-min trial groups, respectively, 237 (87.8%) and 216 (84.8%), respectively, completed the trial without distress and were extubated (p = 0.32); 32 (13.5%) and 29 (13.4%), respectively, of these patients required reintubation within 48 h. The percentage of patients who remained extubated for 48 h after a spontaneous breathing trial did not differ in the 30- and 120-min trial groups (75.9% versus 73.0%, respectively, p = 0.43). The 30- and 120-min trial groups had similar within-unit mortality rates (13 and 9%, respectively) and in-hospital mortality rates (19 and 18%, respectively). Reintubation was required in 61 (13.5%) patients, and these patients had a higher mortality (20 of 61, 32.8%) than did patients who tolerated extubation (18 of 392, 4.6%) (p < 0.001). Neither measurements of respiratory frequency, heart rate, systolic blood pressure, and oxygen saturation during the trial, nor other functional measurements before the trial discriminated between patients who required reintubation from those who tolerated extubation. In conclusion, after a first trial of spontaneous breathing, successful extubation was achieved equally effectively with trials targeted to last 30 and 120 min.
          Article 0 comments Cited 150 times – based on 0 reviews     Review now
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            Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group.

            A. Esteban, I Alía, F Gordo … (1997)
            A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation. However, some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial. We carried out a prospective, randomized, multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and standard weaning parameters. Patients were randomly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways: with a T-tube system or with pressure support ventilation of 7 cm H2O. If a patient had signs of poor tolerance at any time during the trial, mechanical ventilation was reinstituted. Patients without these features at the end of the trial were extubated. Of the 246 patients assigned to the T-tube group, 192 successfully completed the trial and were extubated; 36 of them required reintubation. Of the 238 patients in the group receiving pressure support ventilation, 205 were extubated and 38 of them required reintubation. The percentage of patients who remained extubated after 48 h was not different between the two groups (63% T-tube, 70% pressure support ventilation, p = 0.14). The percentage of patients falling the trial was significantly higher when the T-tube was used (22 versus 14%, p = 0.03). Clinical evolution during the trial was not different in patients reintubated and successfully extubated. ICU mortality among reintubated patients was significantly higher than in successfully extubated patients (27 versus 2.6%, p < 0.001). Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing.
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              Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation.

              Marco González, Vinko Tomicic, Cristina Martínez-Fernández de la Cámara … (2011)
              A new classification of patients based on the duration of liberation of mechanical ventilation has been proposed. To analyze outcomes based on the new weaning classification in a cohort of mechanically ventilated patients. Secondary analysis included 2,714 patients who were weaned and underwent scheduled extubation from a cohort of 4,968 adult patients mechanically ventilated for more than 12 hours. Patients were classified according to a new weaning classification: 1,502 patients (55%) as simple weaning,1,058 patients (39%) as difficult weaning, and 154 (6%) as prolonged weaning.Variables associated with prolonged weaning(.7d)were: severity at admission (odds ratio [OR] per unit of Simplified Acute Physiology Score II, 1.01; 95% confidence interval [CI], 1.001–1.02), duration of mechanical ventilation before first attempt of weaning (OR per day, 1.10; 95% CI, 1.06–1.13), chronic pulmonary disease other than chronic obstructive pulmonary disease (OR,13.23; 95% CI, 3.44–51.05), pneumonia as the reason to start mechanical ventilation (OR, 1.82; 95% CI, 1.07–3.08), and level of positive end-expiratory pressure applied before weaning (OR per unit,1.09; 95% CI, 1.04–1.14). The prolonged weaning group had a nonsignificant trend toward a higher rate of reintubation (P ¼ 0.08),tracheostomy (P ¼ 0.15), and significantly longer length of stay and higher mortality in the intensive care unit (OR for death, 1.97;95%CI, 1.17–3.31). The adjusted probability of death remained constant until Day 7, at which point it increased to 12.1%.
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                Author and article information

                Journal
                Title: JAMA
                Abbreviated Title: JAMA
                Publisher: American Medical Association (AMA)
                ISSN (Print): 0098-7484
                Publication date Created: June 11 2019
                Publication date (Print): June 11 2019
                Volume: 321
                Issue: 22
                Page: 2175
                Affiliations
                [1 ]Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
                [2 ]Hospital Virgen de la Salud, Toledo, Spain
                [3 ]Hospital del Mar, Barcelona, Spain
                [4 ]Hospital U, Central de Asturias, Oviedo, Spain
                [5 ]Hospital Marqués de Valdecilla, Santander, Spain
                [6 ]Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
                [7 ]Universitat Internacional de Catalunya, Barcelona, Spain
                [8 ]Hospital General de Granollers, Granollers, Spain
                [9 ]Hospital de Mataró, Mataró, Spain
                [10 ]Hospital Gregorio Marañón, Madrid, Spain
                [11 ]Consorci Sanitari de Terrassa, Terrassa, Spain
                [12 ]Hospital del Henares, Coslada, Spain
                [13 ]Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
                [14 ]Complexo Hospitalario Universitario de Ourense, Ourense, Spain
                [15 ]Hospital d’Elx, Elche, Alicante, Spain
                [16 ]Hospital Vall d’Hebron, Barcelona, Spain
                [17 ]Hospital Universitario de Araba, Araba, Spain
                [18 ]Hospital de Sagunt, Sagunt, Spain
                [19 ]Hospital Mútua Terrassa, Terrassa, Spain
                [20 ]CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
                Article
                DOI: 10.1001/jama.2019.7234
                PMC ID: 6563557
                PubMed ID: 31184740
                SO-VID: 99d681e9-b9c3-4085-b78b-a13b26f11ed8
                Copyright © © 2019
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