1. In patients with a high risk of extubation failure, using pressure-support ventilation (PSV) for spontaneous breathing trials did not result in more ventilator-free days than breathing trials conducted with T-piece ventilation.

2. Rates of reintubation did not differ significantly in the PSV or T-piece ventilation groups. 

Evidence Rating Level: 1 (Excellent)

Study Rundown: Reducing the amount of time that patients are exposed to invasive mechanical ventilation is crucial to avoid complications. Therefore, the early identification of patients who are able to breathe spontaneously on their own can hasten the time to tracheal extubation and reduce the duration of mechanical ventilation. A spontaneous breathing trial is a standard test to assess a patient for extubation readiness and can be performed with the use of a T-piece or with the use of a low level of PSV. However, there is a gap in knowledge as to whether PSV trials may result in a shorter time to extubation than T-piece trials, without resulting in a higher risk of reintubation among patients who have a high risk of extubation failure. Overall, this study found that for patients with a high risk of extubation failure, spontaneous breathing trials performed with the use of PSV did not result in significantly more ventilator-free days at day 28 than spontaneous breathing trials performed with the use of a T-piece. This study was limited by not being conducted as a double-blind trial, as well as specific information about sedation use was not collected in this trial. Nevertheless, these study’s findings are significant, as they demonstrate that spontaneous breathing trials performed with the use of PSV did not result in significantly more ventilator-free days at day 28 than spontaneous breathing trials performed with the use of a T-piece.

Click to read the study in NEJM

Relevant Reading: Improved Protocols for Ventilator Liberation

In-Depth [randomized controlled trial]: This multicenter, open-label, randomized controlled trial was conducted at 31 intensive care units (ICUs) in France. Patients who had undergone intubation more than 24 hours earlier, had a high risk of extubation failure, and were considered to be ready to undergo an initial spontaneous breathing trial were eligible for the study. Patients who had been admitted for traumatic brain injury, those who had a pre-existing peripheral neuromuscular disease, and those who had a do-not-reintubate order at the time of initial spontaneous breathing trial were excluded. The primary outcome measured was the total time alive and without exposure to invasive mechanical ventilation from the initial spontaneous breathing trial (day 1) through day 28. Outcomes in the primary analysis were assessed via intention-to-treat analyses and nonparametric Mann-Whitney U test. Based on the primary analysis, at day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% Confidence Interval [CI], −0.5 to 1; p=0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5%; 95% CI, 0.01 to 10.9), and extubation was performed within seven days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3%; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3%; 95% CI, −3.1 to 5.8). Overall, this study demonstrated that the use of a PSV was not significantly associated with more ventilator-free days at day 28 than compared to using a T-piece.

Image: PD

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