Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial.

Q1 Medicine
Karen E A Burns, Jessica Wong, Leena Rizvi, Myriam Lafreniere-Roula, Kevin Thorpe, John W Devlin, Deborah J Cook, Andrew Seely, Peter M Dodek, Maged Tanios, Thomas Piraino, Audrey Gouskos, Kenneth C Kiedrowski, Phyllis Kay, Susan Mitchell, George W Merner, Michael Mayette, Frederick D'Aragon, Francois Lamontagne, Bram Rochwerg, Alexis Turgeon, Ying Tung Sia, Emmanuel Charbonney, Pierre Aslanian, Gerard J Criner, Robert C Hyzy, Jeremy R Beitler, Elias Baedorf Kassis, Demetrios James Kutsogiannis, Maureen O Meade, Janice Liebler, Santhi Iyer-Kumar, Jennifer Tsang, Robert Cirone, Carl Shanholtz, Nicholas S Hill
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引用次数: 0

Abstract

Importance: The optimal screening frequency and spontaneous breathing trial (SBT) technique to liberate adults from ventilators are unknown.

Objective: To compare the effects of screening frequency (once-daily screening vs more frequent screening) and SBT technique (pressure-supported SBT with a pressure support level that was >0-≤8 cm H2O and a positive end-expiratory pressure [PEEP] level that was >0-≤5 cm H2O vs T-piece SBT) on the time to successful extubation.

Design, setting, and participants: Randomized clinical trial with a 2 × 2 factorial design including critically ill adults who were receiving invasive mechanical ventilation for at least 24 hours, who were capable of initiating spontaneous breaths or triggering ventilators, and who were receiving a fractional concentration of inspired oxygen that was 70% or less and a PEEP level of 12 cm H2O or less. Recruitment was between January 2018 and February 2022 at 23 intensive care units in North America; last follow-up occurred October 18, 2022.

Interventions: Participants were enrolled early to enable protocolized screening (more frequent vs once daily) to identify the earliest that patients met criteria to undergo pressure-supported or T-piece SBT lasting 30 to 120 minutes.

Main outcome and measures: Time to successful extubation (time when unsupported, spontaneous breathing began and was sustained for ≥48 hours after extubation).

Results: Of 797 patients (198 in the once-daily screening and pressure-supported SBT group, 204 in once-daily screening and T-piece SBT, 195 in more frequent screening and pressure-supported SBT, and 200 in more frequent screening and T-piece SBT), the mean age was 62.4 (SD, 18.4) years and 472 (59.2%) were men. There were no statistically significant differences by screening frequency (hazard ratio [HR], 0.88 [95% CI, 0.76-1.03]; P = .12) or by SBT technique (HR, 1.06 [95% CI, 0.91-1.23]; P = .45). The median time to successful extubation was 2.0 days (95% CI, 1.7-2.7) for once-daily screening and pressure-supported SBT, 3.1 days (95% CI, 2.7-4.8) for once-daily screening and T-piece SBT, 3.9 days (95% CI, 2.9-4.7) for more frequent screening and pressure-supported SBT, and 2.9 days (95% CI, 2.0-3.1) for more frequent screening and T-piece SBT. An unexpected interaction between screening frequency and SBT technique required pairwise contrasts that revealed more frequent screening (vs once-daily screening) and pressure-supported SBT increased the time to successful extubation (HR, 0.70 [95% CI, 0.50-0.96]; P = .02). Once-daily screening and pressure-supported SBT (vs T-piece SBT) did not reduce the time to successful extubation (HR, 1.30 [95% CI, 0.98-1.70]; P = .08).

Conclusions and relevance: Among critically ill adults who received invasive mechanical ventilation for more than 24 hours, screening frequency (once-daily vs more frequent screening) and SBT technique (pressure-supported vs T-piece SBT) did not change the time to successful extubation. However, an unexpected and statistically significant interaction was identified; protocolized more frequent screening combined with pressure-supported SBTs increased the time to first successful extubation.

Trial registration: ClinicalTrials.gov Identifiers: NCT02399267 and NCT02969226.

筛查频率和自主呼吸试验技术:随机临床试验
重要性:将成人从呼吸机中解放出来的最佳筛查频率和自主呼吸试验(SBT)技术尚不清楚:目的:比较筛查频率(每日一次筛查 vs 更频繁筛查)和自主呼吸试验技术(压力支持自主呼吸试验,压力支持水平>0-≤8 cm H2O,呼气末正压 [PEEP] 水平>0-≤5 cm H2O vs T片式自主呼吸试验)对成功拔管时间的影响:随机临床试验,采用 2 × 2 因式设计,包括接受有创机械通气至少 24 小时、能够启动自主呼吸或触发呼吸机、吸入氧分压浓度为 70% 或更低、PEEP 水平为 12 cm H2O 或更低的重症成人。招募时间为2018年1月至2022年2月,地点在北美23个重症监护病房;最后一次随访时间为2022年10月18日:提前招募参与者,以便进行协议筛选(更频繁与每天一次),以确定患者最早符合标准,接受持续 30 至 120 分钟的压力支持或 T 片 SBT:成功拔管的时间(拔管后开始无支持的自主呼吸并持续≥48小时的时间):在 797 名患者中(198 名患者为每日一次筛查和压力支持 SBT 组,204 名患者为每日一次筛查和 T 片式 SBT 组,195 名患者为更频繁筛查和压力支持 SBT 组,200 名患者为更频繁筛查和 T 片式 SBT 组),平均年龄为 62.4(SD,18.4)岁,472 名男性(59.2%)。筛查频率(危险比 [HR],0.88 [95% CI,0.76-1.03];P = .12)或 SBT 技术(HR,1.06 [95% CI,0.91-1.23];P = .45)无统计学差异。每日一次筛查和压力支持式 SBT 的成功拔管中位时间为 2.0 天(95% CI,1.7-2.7),每日一次筛查和 T 片式 SBT 的成功拔管中位时间为 3.1 天(95% CI,2.7-4.8),筛查更频繁和压力支持式 SBT 的成功拔管中位时间为 3.9 天(95% CI,2.9-4.7),筛查更频繁和 T 片式 SBT 的成功拔管中位时间为 2.9 天(95% CI,2.0-3.1)。筛查频率与 SBT 技术之间的交互作用出乎意料,需要进行配对对比,结果显示筛查频率越高(与每日一次筛查相比),加压支持 SBT 的成功拔管时间越长(HR,0.70 [95% CI,0.50-0.96];P = 0.02)。每日一次筛查和压力支持 SBT(vs T 片 SBT)并没有缩短成功拔管的时间(HR,1.30 [95% CI,0.98-1.70];P = .08):在接受有创机械通气超过 24 小时的成人重症患者中,筛查频率(每天一次 vs 更频繁的筛查)和 SBT 技术(压力支持式 vs T 片式 SBT)不会改变成功拔管的时间。然而,我们发现了一种意想不到的、具有统计学意义的交互作用;协议化的更频繁筛查结合压力支持式 SBT 增加了首次成功拔管的时间:试验注册:ClinicalTrials.gov Identifiers:试验注册:ClinicalTrials.gov Identifiers:NCT02399267 和 NCT02969226。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
45.40
自引率
0.00%
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期刊介绍: JAMA, published continuously since 1883, is an international peer-reviewed general medical journal. JAMA is a member of the JAMA Network, a consortium of peer-reviewed, general medical and specialty publications.
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