In difficult-to-wean patients, does early extubation to noninvasive ventilation, compared with the standard spontaneous breathing trial, decrease the time to being free from all forms of ventilation?

In critically ill patients who are difficult-to-wean from a mechanical ventilator, using a weaning protocol that transitions patients to noninvasive ventilation does not shorten the time to liberation from all forms of ventilation as compared with the standard weaning protocol but may provide other benefits, such as decreased time spent in critical care. (LOE = 1b)

Perkins GD, Mistry D, Gates S, et al, for the Breathe Collaborators. Effect of protocolized weaning with early extubation to noninvasive ventilation vs. invasive weaning on time to liberation from mechanical ventilation among patients with respiratory failure. JAMA 2018;320:1881-1888.  [PMID:30347090]

Randomized controlled trial (nonblinded)

Government

Concealed

Inpatient (ICU only)

Patients in the intensive care unit on mechanical ventilation who failed a spontaneous breathing trial were randomized to receive either a noninvasive ventilation weaning protocol (n = 182) or an invasive weaning protocol (n = 182). In the noninvasive group, patients underwent extubation and were immediately placed on noninvasive ventilation by face mask that provided inspiratory and expiratory positive airway pressures similar to the levels provided by the ventilator with titration to patient comfort. The patients in this group were assessed every 2 hours to reduce the level of positive airway pressure or to remove the face mask to allow a self-ventilation trial until the patient tolerated 12 hours of unsupported spontaneous ventilation. In the invasive weaning group, patients were assessed every 2 hours on the ventilator and had pressure support decreased or increased based on clinical status. In this group, spontaneous breathing trials were repeated daily until a patient could be successfully extubated. Patients in both groups were similar at baseline. Approximately 60% of the patients in the trial had pneumonia or postsurgery respiratory failure as the reason for mechanical ventilation. There was no significant difference detected between the groups regarding the primary outcome of time to liberation from all forms of ventilation (4.3 days in the noninvasive group vs 4.5 days in the invasive group). As expected, patients in the noninvasive group had significantly less invasive ventilation (1 days vs 4 days). They also received sedation for fewer days (4.1 vs 5.5 days), spent less time in critical care (10.8 vs 12.2 days), and were less likely to receive antibiotics for respiratory infections (60% vs 70%). Adverse events, tracheostomy rates, and 30-day survival rates were not significantly different between the groups.