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Among patients with a high risk of reintubation, spontaneous-breathing trials performed with pressure-support ventilation did not result in significantly more ventilator-free days at day 28 than T-piece trials.

Background Extubation failure leading to reintubation is associated with high mortality. In patients at high-risk of extubation failure, clinical practice guidelines recommend prophylactic non-invasive ventilation (NIV) over high-flow nasal oxygen (HFNO) immediately after extubation. However, the physiological effects supporting the beneficial effect of NIV have been poorly explored. We hypothesized that NIV may reduce patient inspiratory efforts to a greater extent than HFNO after extubation. Methods In a prospective physiological study, patients at high-risk of extubation failure (> 65 years old or underlying cardiac or respiratory disease) were included to receive after planned extubation prophylactic NIV and HFNO in a randomized crossover order, followed by standard oxygen. Inspiratory efforts were assessed by calculation of the simplified esophageal pressure–time-product per minute (sPTP es in cmH 2 O s/min). Tidal volumes, distribution and homogeneity of ventilation were estimated using electrical impedance tomography. Results Twenty patients were retained in the analysis. Inspiratory efforts were lower with NIV than with HFNO (sPTP es 196 cm H 2 O s/min [116–234] vs. 220 [178–327], p  < 0.001) whereas tidal volumes were larger with NIV than with HFNO (8.4 mL/kg of predicted body weight [6.7–9.9] vs. 6.9 [5.3–8.6], p  = 0.005). There was a non-significant increase in dorsal region ventilation under NIV compared to HFNO. Conclusions In patients at high-risk of extubation failure, prophylactic NIV significantly decreased inspiratory efforts with increased tidal volumes compared to HFNO. The clinical benefits of NIV to prevent reintubation in patients at high-risk may be mediated by these physiological effects. Trial registration Clinicaltrials.gov: ID NCT04036175), retrospectively registered 17 June 2019.

Abstract Rationale Oxygen is commonly administered after extubation. Although several devices are available, data about their clinical efficacy are scarce. Objectives To compare the effects of the Venturi mask and the nasal high-flow (NHF) therapy on PaO2/FiO2SET ratio after extubation. Secondary endpoints were to assess effects on patient discomfort, adverse events, and clinical outcomes. Methods Randomized, controlled, open-label trial on 105 patients with a PaO2/FiO2 ratio less than or equal to 300 immediately before extubation. The Venturi mask (n = 52) or NHF (n = 53) were applied for 48 hours postextubation. Measurements and Main Results PaO2/FiO2SET, patient discomfort caused by the interface and by symptoms of airways dryness (on a 10-point numerical rating scale), interface displacements, oxygen desaturations, need for ventilator support, and reintubation were assessed up to 48 hours after extubation. From the 24th hour, PaO2/FiO2SET was higher with the NHF (287 ± 74 vs. 247 ± 81 at 24 h; P = 0.03). Discomfort related both to the interface and to airways dryness was better with NHF (respectively, 2.6 ± 2.2 vs. 5.1 ± 3.3 at 24 h, P = 0.006; 2.2 ± 1.8 vs. 3.7 ± 2.4 at 24 h, P = 0.002). Fewer patients had interface displacements (32% vs. 56%; P = 0.01), oxygen desaturations (40% vs. 75%; P < 0.001), required reintubation (4% vs. 21%; P = 0.01), or any form of ventilator support (7% vs. 35%; P < 0.001) in the NHF group. Conclusions Compared with the Venturi mask, NHF results in better oxygenation for the same set FiO2 after extubation. Use of NHF is associated with better comfort, fewer desaturations and interface displacements, and a lower reintubation rate. Clinical trial registered with www.clinicaltrials.gov (NCT 01575353).

Purpose Noninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure. Methods Highly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early or standard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality. Results We enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0–7.0) vs. 5.5 (4.0–9.0) days, respectively, p  = 0.004], while ICU LOS was not significantly different [8.0 (6.0–12.0) vs. 9.0 (6.5–12.5) days, respectively ( p  = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p  = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p  = 0.001), and hospital LOS, 20 (13–32) vs. 27(18–39) days ( p  = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies. Conclusions In highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.

PurposeSpontaneous breathing trials (SBT) evaluate the patient's capacity to maintain inspiratory effort after extubation. SBT practices are heterogeneous and not individualised. The objective of this study was to assess which SBT best reproduces inspiratory effort after extubation in five critical illnesses.MethodsIn this multicentre randomized cross-over study, adult intensive care unit patients under invasive mechanical ventilation for at least 24-h and ready for extubation, underwent three 15-min SBTs in random order: pressure support ventilation level of 7-cmH2O with positive end-expiratory pressure (PEEP) level of 0-cmH2O (PSV7PEEP0), PSV 0-cmH2O with PEEP 0-cmH2O (PSV0PEEP0) and T-piece trial. Primary outcome was the variation of pressure–time-product per minute (PTPmin) between each SBT and 20-min after extubation. Five categories of critical illnesses were selected: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease (COPD) and miscellaneous.ResultsFive hundred measures of effort from 100 patients were analysed. PTPmin (cmH2O s/min, median and interquartile range, IQR) was 256 (208–321) after extubation, 192 (127–281) at the end of PSV7PEEP0 (p < 0.001 in comparison to after extubation), 291 (235–347) at the end of PSV0PEEP0 and 262 (198–338) at the end of T-piece (both no different from after extubation). One method of SBT in patients with brain injury (PSV0PEEP0), two in abdominal surgery (PSV0PEEP0 and T-piece) and miscellaneous patients (PSV7PEEP0 and T-piece) and all three methods in chest trauma and COPD exacerbation patients replicated reasonably accurately the postextubation effort to breathe.ConclusionUnassisted SBTs, namely PSV0PEEP0 and T-piece trial, are the most appropriate to replicate the postextubation effort to breathe.

Background The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. Methods We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. Results We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05–1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 –1.25), high flow nasal cannulae (HFNC) [1.07 (1.00–1.13) (all moderate certainty), and ATC [RR 1.11, (1.03–1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03–1.09); high certainty], ATC [RR 1.13, (1.05–1.21); moderate certainty], and HFNC [RR 1.06, (1.02–1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91–1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61–5.03); moderate certainty] and ATC [RR 2.95 (1.57–5.56); moderate certainty] SBTs compared to HFNC SBTs. Conclusions SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.

Purpose We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. Methods Prospective nationwide before–after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013–31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6–8 cm H 2 O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. Results A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0–80) vs. 67 (0–80) days; P  = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention ( P  < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66–82) and 71 (0–80) days, respectively; P  = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group ( P  = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41–2.26; P  < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56–3.26, P  < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. Conclusions Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number : NCT01885507.

Background Spontaneous breathing trials (SBT) can be exhausting, but the preventive role of rest has never been studied. This study aimed to evaluate whether reconnection to mechanical ventilation (MV) for 1 h after the effort of a successful SBT could reduce the need for reintubation in critically ill patients. Methods Randomized multicenter trial conducted in 17 Spanish medical-surgical intensive care units (Oct 2013–Jan 2015). Patients under MV for longer than 12 h who fulfilled criteria for planned extubation were randomly allocated after a successful SBT to direct extubation (control group) or reconnection to the ventilator for a 1-h rest before extubation (rest group). The primary outcome was reintubation within 48 h. Analysis was by intention to treat. Results We recruited 243 patients randomized to the control group and 227 to the rest group. Median time from intubation to SBT did not differ between groups [5.5 (2.7, 9.6) days in the control group vs. 5.7 (2.7, 10.6) in the rest group; p  = 0.85]. Reintubation within 48 h after extubation was more common in the control than in the rest group [35 (14%) vs. 12 (5%) patients; OR 0.33; 95% CI 0.16–0.65; p  < 0.001]. A multivariable regression model demonstrated that the variables independently associated with reintubation were rest [OR 0.34 (95%CI 0.17–0.68)], APACHE II [OR 1.04 (1.002–1.077)], and days of MV before SBT [OR 1.04 (1.001–1.073)], whereas age, reason for admission, and type and duration of SBT were not. Conclusion One-hour rest after a successful SBT reduced the rates of reintubation within 48 h after extubation in critically ill patients. Trial registration Clinicaltrials.gov identifier NCT01915563.

IntroductionThe cuff leak test (CLT) is hypothesised to help optimise extubation by assessing for laryngeal oedema which, if unrecognised and untreated, could lead to post-extubation stridor, post-extubation airway obstruction, and reintubation. However, the diagnostic accuracy of the CLT to detect post-extubation stridor (and hence potentially airway obstruction) remains uncertain. Given the equipoise that exists surrounding the CLT, we are conducting a pilot randomised clinical trial (RCT) examining the CLT as part of the pathway to extubation. Herein, we report the protocol for the Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients (COSMIC): a Pilot Feasibility Randomized Clinical trial (RCT).Methods and analysisThis is a multicentre, international, parallel-group, pragmatic, pilot RCT. We will enrol 100 mechanically ventilated patients in the intensive care unit (ICU) who are deemed ready for extubation and have at least one risk factor for laryngeal oedema. In the intervention arm, respiratory therapists will perform a qualitative CLT before extubation. If a patient passes the CLT (suggesting no laryngeal oedema), extubation will be performed in keeping with standard care. If the patient fails the CLT (suggesting laryngeal oedema), extubation will be delayed allowing for administration of dexamethasone, consideration of diuresis, and the CLT will be repeated in 12–24 hours. In the control arm, patients will be extubated without completing a CLT, without steroid administration, and without delay. Randomization will be by a 1:1 allocation, stratified by centre. The primary feasibility outcomes will include recruitment and protocol adherence. Secondary outcomes will include post-extubation stridor, reintubation within 72 hours, emergency surgical airway within 72 hours, and ICU and hospital mortality within 30 days.Ethics and disseminationThis trial has been approved by Clinical Trials Ontario, Hamilton Integrated Research Ethics Board, State of Kuwait Ministry of Health, University of Texas Health Committee for the Protection of Human Subjects and Brant Community Health Systems Research Ethics Committee. The trial has received a No Objection Letter from Health Canada. Trial results will be disseminated via publication in peer-reviewed journals.Trial registration numberNCT05456542.

Background Self-extubation is a common complication in intubated patients in the intensive care unit (ICU) and is associated with a high rate of reintubation. This study aimed to identify predictors of reintubation following self-extubation (SE) and assess the prognosis of these patients. Methods Data were extracted from the French ICU database, OutcomeRea™. The primary objective was to identify factors associated with reintubation within 48 h after self-extubation. Secondary objectives included evaluating the association between reintubation and mortality, ICU length of stay, and nosocomial pneumonia. Results Between November 1996 and May 2022, 12,917 patients were intubated in the ICU. Among them, 701 patients experienced SE without therapeutic limitations at the time, and 276 (39.4%) required reintubation. In adjusted analyses, the following factors were independently associated with reintubation: a higher non-neurological SOFA score on the day before SE (OR 1.16 [1.01; 1.34]; p = 0.03), duration of invasive mechanical ventilation > 7 days before SE (OR 1.79 [1.04; 3.26]; p = 0.04), enteral nutrition on the day of SE (OR 2.59 [1.75; 3.84]; p < 0.01) and the use of non-invasive ventilation (NIV) within 24 h after SE (OR 0.28 [0.16; 0.5];p < 0.01). Reintubation within 48 h after SE was independently associated with increased 28-day mortality (HR = 3.03 [1.79; 5.12]; p < 0.01) and 90-day mortality (HR = 2.86 [1.86; 4.4]; p < 0.01), a higher risk of nosocomial pneumonia (sdHR, 18.28 [7.70; 43.42]; p < 0.01), and a 13-day increase in ICU length of stay (p < 0.01). Conclusion Enteral nutrition on the day of SE, prolonged mechanical ventilation prior to SE, higher non-neurological SOFA scores, and use of NIV after SE were independently associated with the need for reintubation. Reintubation was also associated with increased mortality, a higher risk of nosocomial pneumonia, and prolonged ICU stay.