High-flow oxygen during spontaneous breathing trial for patients at high risk of weaning failure

Fossat, Guillaume; Nay, Mai-Anh; Jacquier, Sophie; Desmalles, Emmanuelle; Boulain, Thierry

doi:10.1007/s00134-021-06450-x

Cited by 6 publications

(16 citation statements)

References 5 publications

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“…Of the 19 studies further assessed for eligibility, 9 were excluded (Figure 1). In addition to 31 previously included trials, we identified 10 new full publications, including 1 full publication that replaced a previously included abstract publication. Of the 40 trials included (n = 6797 randomized and n = 6716 patients with outcomes), 9 were new trials (n = 3130 patients analyzed), 6 trials compared 3 SBT techniques (but for 1 of the 3-arm trials, the 5-cm H 2 O and 10-cm H 2 O CPAP groups were combined for a single comparison with the third T-piece group), and 1 trial compared 4 SBT techniques (Table 1).…”

Section: Resultsmentioning

confidence: 99%

“…Twenty-one trials (52.5%) (5 new and 16 previously included) and 23 trials (57.5%) (6 new and 17 previously included) were judged to be at low risk of bias for randomization and allocation concealment, respectively. Four trials (10.0%) were judged to be at high risk of bias with regard to allocation concealment, including 1 quasi-randomized trial allocating patients based on even or odd days.…”

Section: Resultsmentioning

confidence: 99%

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Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill

Burns,

Khan,

Phoophiboon

et al. 2024

JAMA Netw Open

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ImportanceConsiderable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use.ObjectiveTo summarize trials comparing alternative SBTs.Data SourcesSeveral databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis.Study SelectionRandomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected.Data Extraction and SynthesisPaired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models.Main Outcomes and MeasuresPrimary outcomes included SBT success, extubation success, and reintubation.ResultsThe systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P &lt; .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P &lt; .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = &lt;.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found.Conclusions and RelevanceIn this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill

Burns,

Khan,

Phoophiboon

et al. 2024

JAMA Netw Open

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“…One recent pilot RCT of patients at high risk of weaning failure showed that the high-flow oxygen SBT neither accelerated mechanical ventilation weaning nor increased the reintubation rate compared with T-piece SBT [16]. Interestingly, the probability of reintubation over time was significantly higher for T-piece SBT than for highflow oxygen SBT (p = 0.04).…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, the physiological effects of high-flow oxygen therapy via tracheostomy (HFOT TRACHEAL ) are lower than HFNC, likely because the tracheostomy connection interface is completely open system [15]. To date, only one recent pilot RCT of patients at high risk of weaning failure showed that the high-flow oxygen SBT neither increased the reintubation rate nor accelerated mechanical ventilation weaning compared with T-piece SBT [16].…”

Section: Introductionmentioning

confidence: 99%

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

Lee

2022

Crit Care

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Background A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation. Methods This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality. Results Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, − 6.1–13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, − 3.4–25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04–0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded. Conclusions Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.

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“…Using high-flow nasal oxygen (HFNO) during T-piece SBT may help by providing warm and humidified oxygen. In a single-center, pilot randomized controlled trial [5], rates of reintubation within 7 days after extubation were 16% in T-piece with standard oxygen and 3.9% in SBT with HFNO (P = 0.05). It is also important to let the patient rest after a SBT [6], by reconnecting the patient to the ventilator during a 1-h rest [2].…”

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confidence: 98%

How to optimize extubation?

2023

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Extubation failure, defined as the inability to sustain spontaneous breathing after removal of the artificial airway and need for reintubation within 24-72 h or up to 7 days, is associated with high morbidity and mortality, as well as long term disability [1]. Many studies have attempted to identify risk factors for extubation failure in order to prevent it. Nevertheless, the incidence of extubation failure in intensive care units (ICUs) remains quite high in the literature, between 10% within 48 h [1] and 15% within 7 days [2].Two main causes of extubation failure can be identified [1]: weaning failure, the patient's unreadiness to breathe without respiratory assistance, or airway failure, the patient's unreadiness to breathe without an artificial airway.The aim of this paper is to provide an update on strategies to optimize extubation, before and after extubation procedure (Fig. 1). Anticipate the cause of extubation failure before extubationThe FREE-REA study [1] identified risk factors for airway failure vs weaning failure among cases of extubation failure in a large multicenter, prospective cohort of extubated medical and surgical critically ill patients. Potentially actionable risk factors were identified: absence of strong cough associated with both airway failure and weaning failure, copious secretions associated with airway failure and Sequential Organ Failure Assessment (SOFA) score ≥ 8 associated with weaning failure.

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High-flow oxygen during spontaneous breathing trial for patients at high risk of weaning failure

Cited by 6 publications

References 5 publications

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

How to optimize extubation?

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