Pressure-Support Ventilation vs T-Piece During Spontaneous Breathing Trials Before Extubation Among Patients at High Risk of Extubation Failure

Thille, Arnaud W.; Coudroy, Rémi; Nay, Mai-Anh; Gacouin, Arnaud; Demoule, Alexandre; Sonneville, Romain; Beloncle, François; Girault, Christophe; Dangers, Laurence; Lautrette, Alexandre; Levrat, Quentin; Rouzé, Anahita; Vivier, Emmanuel; Lascarrou, Jean-Baptiste; Ricard, Jean‐Damien; Razazi, Keyvan; Barberet, Guillaume; Lebert, Christine; Ehrmann, Stéphan; Massri, Alexandre; Bourenne, Jérémy; Pradel, Gaël; Bailly, Pierre; Terzi, Nicolas; Dellamonica, Jean; Lacave, Guillaume; Robert, René; Ragot, Stéphanie; Frat, Jean‐Pierre; Boissier, Florence; Chatellier, Delphine; Deletage, Céline; Guignon, Carole; Joly, Florent; Olivry, Morgane; Veinstein, Anne; Benzékri-Lefèvre, Dalila; Boulain, Thierry; Muller, Grégoire; Tulzo, Yves Le; Tadié, Jean‐Marc; Maamar, Adel; Demiri, Suela; Mayaux, Julien; Decavèle, Maxens; Bouadma, Lila; Dupuis, Claire; Asfar, Pierre; Pierrot, Marc; Béduneau, G.; Boyer, Déborah; Delmas, Benjamin; Puech, Bérénice; Bachoumas, Konstantinos; Soum, Edouard; Cabasson, Séverin; Hoppe, Marie-Anne; Nseir, Saad; Pouly, Olivier; Bourdin, Gaël; Rosselli, Sylvène; Meur, Anthony Le; Garret, Charlotte; Martin, Maëlle; Berquier, Guillaume; Thiagarajah, Abirami; Carteaux, Guillaume; Mekontso-Dessap, Armand; Poidevin, Antoine; Dureau, Anne-Florence; Azais, Marie-Ange; Colin, Gwenhaël; Mercier, Emmanuelle; Morisseau, Marlène; Sabatier, C.; Picard, Walter; Gainnier, Marc; Nguyen, Thi-My-Hue; Prat, Gwénaël; Schwebel, Carole; Buscot, Matthieu

doi:10.1016/j.chest.2020.04.053

Cited by 18 publications

(16 citation statements)

References 22 publications

(28 reference statements)

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“…Likely the higher the postextubation respiratory assistance, the higher the expected benefit of the inspiratory pressure augmentation. Although the proportion of successfully extubated patients in the study by Subira et al 3 was higher compared with that in the study by Thille et al, 12 the benefit of inspiratory pressure augmentation was higher in the study by Thille et al 12 In addition, the specificity and positive predictive value do not seem to decline, as the reintubation rate remained similar in both studies. Comparisons between these two studies are limited because there were differences in the risk of extubation failure and the proportion of patients with preventive respiratory supportive therapies, 3,12 but differences in inspiratory pressure and the duration of the SBT could, at least in part, explain the differences in the observed results.…”

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confidence: 67%

“…One of the strengths of their protocol is the achievement of 24 hours per day of prevention by the use of the combination of NIV and HFNT, as previous trials obtained a maximum of 14 hours of NIV per day. 4 In this issue of CHEST, Thille et al 12 present a post hoc analysis of the previous trial, 2 comparing the results according to the type of SBT, T-tube, or 7 cm H 2 O of pressure support. To our knowledge, it is the first study analyzing the role of different SBTs for extubation success focused on a high-risk population receiving preventive therapy.…”

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confidence: 99%

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Redefining “Minimal Ventilator Settings”

Hernández

Roca

2020

Chest

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confidence: 67%

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confidence: 99%

Redefining “Minimal Ventilator Settings”

Hernández

Roca

2020

Chest

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“…The rate of successful SBTs was higher when they were performed under pressure support ventilation than under T-piece or continuous positive airway pressure [48]. However, extubation failure did not vary by type of SBT [49,50]. Therefore, type of SBT is unlikely to influence results for the association between cough strength and extubation failure.…”

Section: Discussionmentioning

confidence: 99%

Predictive power of extubation failure diagnosed by cough strength: a systematic review and meta-analysis

Duan

Zhang²,

Shen

2021

Crit Care

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Background The predictive power of extubation failure diagnosed by cough strength varies by study. Here we summarise the diagnostic power of extubation failure tested by cough strength. Methods A comprehensive online search was performed to select potentially eligible studies that evaluated the predictive power of extubation failure tested by cough strength. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC) to evaluate the predictive power of extubation failure. Results A total of 34 studies involving 45 study arms were enrolled, and 7329 patients involving 8684 tests were analysed. In all, 23 study arms involving 3018 tests measured cough peak flow before extubation. The pooled extubation failure was 36.2% and 6.3% in patients with weak and strong cough assessed by cough peak flow, respectively. The pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 0.76 (95% confidence interval [CI]: 0.72–0.80), 0.75 (0.69–0.81), 2.89 (2.36–3.54), 0.37 (0.30–0.45), 8.91 (5.96–13.32), and 0.79 (0.75–0.82), respectively. Moreover, 22 study arms involving 5666 tests measured the semiquantitative cough strength score (SCSS) before extubation. The pooled extubation failure was 37.1% and 11.3%, respectively, in patients with weak and strong cough assessed by the SCSS. The pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 0.53 (95% CI: 0.41–0.64), 0.83 (0.74–0.89), 2.50 (1.93–3.25), 0.65 (0.56–0.76), 4.61 (3.03–7.01), and 0.74 (0.70–0.78), respectively. Conclusions Weak cough is associated with increased extubation failure. Cough peak flow is superior to the SCSS for predicting extubation failure. However, both show moderate power for predicting extubation failure.

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“…In this population at high risk of reintubation a recent post host analysis from a large randomised controlled trial showed that execution of an initial SBT using PSV significantly increased the proportion of patients successfully extubated within the following 72 hours as compared with T-piece. 17 However, a large prospective clinical trial is needed to confirm these findings in this population before being in a position to apply this weaning strategy to all ICU patients.…”

Section: Patient and Public Involvementmentioning

confidence: 96%

T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised controlled trial (TIP-EX)

et al. 2020

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IntroductionIn intensive care unit (ICU), the decision of extubation is a critical time because mortality is particularly high in case of reintubation. To reduce that risk, guidelines recommend to systematically perform a spontaneous breathing trial (SBT) before extubation in order to mimic the postextubation physiological conditions. SBT is usually performed with a T-piece disconnecting the patient from the ventilator or with low levels of pressure-support ventilation (PSV). However, work of breathing is lower during PSV than during T-piece. Consequently, while PSV trial may hasten extubation, it may also increase the risk of reintubation. We hypothesise that, compared with T-piece, SBT performed using PSV may hasten extubation without increasing the risk of reintubation.Methods and analysisThis study is an investigator-initiated, multicentre randomised controlled trial comparing T-piece vs PSV for SBTs in patients at high risk of reintubation in ICUs. Nine hundred patients will be randomised with a 1:1 ratio in two groups according to the type of SBT. The primary outcome is the number of ventilator-free days at day 28, defined as the number of days alive and without invasive mechanical ventilation between the initial SBT (day 1) and day 28. Secondary outcomes include the number of days between the initial SBT and the first extubation attempt, weaning difficulty, the number of patients extubated after the initial SBT and not reintubated within the following 72 hours, the number of patients extubated within the 7 days following the initial SBT, the number of patients reintubated within the 7 days following extubation, in-ICU length of stay and mortality in ICU, at day 28 and at day 90.Ethics and disseminationThe study has been approved by the central ethics committee ‘Ile de France V’ (2019-A02151-56) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04227639.

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Pressure-Support Ventilation vs T-Piece During Spontaneous Breathing Trials Before Extubation Among Patients at High Risk of Extubation Failure

Cited by 18 publications

References 22 publications

Redefining “Minimal Ventilator Settings”

Redefining “Minimal Ventilator Settings”

Predictive power of extubation failure diagnosed by cough strength: a systematic review and meta-analysis

T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised controlled trial (TIP-EX)

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