NEJM
November 17, 2022
Spontaneous-Breathing Trials with Pressure-Support Ventilation or a T-Piece
Mazen Kherallah
Summarized by:
What was the research question?
Does the use of PSV trials in patients with a high risk of extubation failure result in a shorter time to tracheal extubation without a higher risk of reintubation compared to T-piece trials?
How did they do it?
A multicenter, open-label trial at 31 ICUs in France.
969 high-risk extubation failure patients (i.e., were >65 years of age or had an underlying chronic cardiac or respiratory disease) were randomly assigned to either pressure-support ventilation (PSV) or a T-piece for spontaneous-breathing trials.
The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) on day 28 after the initial spontaneous-breathing trial.
The secondary outcomes of this study were extubation within 24 hours and 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.
What did they find?
The median number of ventilator-free days was not significantly different between the PSV group and the T-piece group (27 vs 27 days, P=0.31).
Extubation within 24 hours was not significantly different between the PSV group and the T-piece group (77.7% vs. 72.2%), nor it was within 7 days after the spontaneous trial (97.7% vs. 94.4%).
The reintubation rates for both groups were similar: 14.9% for the PSV group and 13.6% for the T-piece group.
Cardiac or respiratory arrest as a reason for reintubation was seen in a total of 9 cases (3 from PSV group and 6 from T-piece).
Are there any limitations?
Blinding was not possible due to the nature of the intervention.
A relatively low percentage of patients (around 13-15%) required reintubation in both groups, as compared to what has been observed in the past. This finding suggests that the study participants may not have had a high risk for failing extubation.
The majority of patients received prophylactic noninvasive ventilation after extubation; and since this is not a routine practice in all ICUs, the results might not apply to all patients.
What does it mean?
Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece.
Until more information is available, either PSV or T-piece spontaneous breathing trials can be used in patients with a high risk of extubation.