Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial

Casey, Jonathan D; Vaughan, Erin M; Lloyd, Bradley D.; Billas, Peter A; Jackson, Karen E.; Hall, Eric J.; Toporek, A.; Buell, Kevin G; Brown, Ryan M; Richardson, Roger K; Rooks, J Craig; Buie, Reagan; Wang, Li; Lindsell, Christopher J.; Ely, E. Wesley; Self, Wesley H.; Bernard, Gordon R.; Rice, Todd W.; Semler, Matthew W.

doi:10.1164/rccm.202009-3561oc

Cited by 17 publications

(16 citation statements)

References 38 publications

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“…We found that patients with ≤ 3 risk factors (accounting for 65% of those considered at high-risk under the traditional definition) are likely to have a non-inferior response to preventive HFNC (reintubation rate 12.2%) than to NIV (reintubation rate 16.5%), whereas those with ≥ 4 risk factors are likely to have a better response to preventive NIV (reintubation rate 23.9%) than to HFNC (reintubation rate 45.3%). This result is in accordance to that recently reported by Casey et al [ 15 ] showing an additive effect of simultaneous risk factors and possibly leading to underuse of NIV.…”

Section: Discussionsupporting

confidence: 93%

“…It is worth noting that, to date, no model for predicting extubation failure has been validated [ 13 , 14 ]. Moreover, the definition of high risk for reintubation used in previous studies (≥ 1 risk factor) can result in heterogeneous populations [ 14 , 15 ]. Some subgroups of high-risk patients benefit with at least partial time on NIV, like those defined by Thille et al [ 13 , 16 , 17 ] (e.g., aged, obese, patients on mechanical ventilation ≥ 7 days, with ineffective cough or with underlying chronic heart or lung disease) and Ferrer et al [ 5 ] (e.g., patients who develop hypercapnia at the end of the spontaneous breathing trial).…”

Section: Introductionmentioning

confidence: 99%

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Benefit with preventive noninvasive ventilation in subgroups of patients at high-risk for reintubation: a post hoc analysis

et al. 2022

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Background High-flow nasal cannula (HFNC) was shown to be non-inferior to noninvasive ventilation (NIV) for preventing reintubation in a general population of high-risk patients. However, some subgroups of high-risk patients might benefit more from NIV. We aimed to determine whether the presence of many risk factors or overweight (body mass index (BMI) ≥ 25 kg/m2) patients could have different response to any preventive therapy, NIV or HFNC in terms of reduced reintubation rate. Methods Not pre-specified post hoc analysis of a multicentre, randomized, controlled, non-inferiority trial comparing NFNC and NIV to prevent reintubation in patients at risk for reintubation. The original study included patients with at least 1 risk factor for reintubation. Results Among 604 included in the original study, 148 had a BMI ≥ 25 kg/m2. When adjusting for potential covariates, patients with ≥ 4 risk factors (208 patients) presented a higher risk for reintubation (OR 3.4 [95%CI 2.16–5.35]). Patients with ≥ 4 risk factors presented lower reintubation rates when treated with preventive NIV (23.9% vs 45.7%; P = 0.001). The multivariate analysis of overweight patients, adjusted for covariates, did not present a higher risk for reintubation (OR 1.37 [95%CI 0.82–2.29]). However, those overweight patients presented an increased risk for reintubation when treated with preventive HFNC (OR 2.47 [95%CI 1.18–5.15]). Conclusions Patients with ≥ 4 risk factors for reintubation may benefit more from preventive NIV. Based on this result, HFNC may not be the optimal preventive therapy in overweight patients. Specific trials are needed to confirm these results.

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Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

confidence: 99%

Benefit with preventive noninvasive ventilation in subgroups of patients at high-risk for reintubation: a post hoc analysis

et al. 2022

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“…The main reason for this discrepancy is probably the additive effect of the presence of more than 3 risk factors for reintubation in our 10-factor model. A recent study by Casey et al [ 26 ] reported no significant differences with a short time prevention time based on clinical parameters, showing a linear increase in the reintubation rate in patients with more high risk factors for reintubation. This study reinforces the idea that clinical benefit is strongly related to the real time on prevention and the number of high-risk factors.…”

Section: Discussionmentioning

confidence: 99%

Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial

et al. 2022

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Purpose High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure). Methods Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation. Results Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference −15.5%; 95% confidence interval (CI) −28.3 to −1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5–21.1]). No additional differences in the other secondary outcomes were observed. Conclusions Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06919-3.

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“…When approaching the critically ill person under invasive mechanical ventilation, weaning from ventilation involves a multidisciplinary effort (SARTI et al, 2020), which requires an effective and standardized approach in order to promote the removal of ventilatory support as early as possible (NETO et al, 2020). This procedure respects strict safety standards that contribute to the absence of complications resulting from prolonged mechanical ventilation, such as: the increase in the length of stay in intensive care, the high average length of hospital stays, the high mortality rate in intensive care, iatrogenic pneumothorax and ventilator-associated pneumonia (NETO et al, 2020;CASEY et al, 2021).…”

Section: Introductionmentioning

confidence: 99%

Ventilator weaning: protocol of a bibliometric analysis

Santos¹,

Santos²,

Assunção³

et al. 2022

SHS

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Introduction: Ventilator weaning has been frequently addressed by the international scientific community, observing different types of approach, which leads to a disparity in the results obtained in the various studies and in the systematization and/or standardization of procedures, at this crucial moment, for the person in critical care units. With scientific progress, several experimental studies have been conducted that document this need, and there are few secondary studies that add to these conclusions. Objective: The bibliometric analysis designed in this document aims to analyse the behaviour of scientific publications in the context of ventilator weaning, dissecting trends and highlighting research opportunities. Methods: Protocol of a mixed methods study that will include quantitative and qualitative studies. In addition to primary studies, systematic reviews and meta-analyses will also be considered. As there is no specific methodological framework for bibliometric analysis protocols, it is important to mention that the study will follow the guidelines of DONTU et al (2021) in the quantitative phase of the research and will follow the guidelines of BHANDARI (2022) in the qualitative phase of the research. The research will include Web of Science (Clarivate) indexed studies, as a database that presents tools that allow gathering bibliometric indicators that can be analysed in specific software (Sitescape and VOSViewer), and that will allow defining the evolution, over time, of scientific production and which are the most relevant studies in this conceptual area. MAXQDA software will allow the qualitative analysis of the articles included (studies published since 2015) and will determine: the methodological trends in this line of investigation; the contributions of the development of this procedure to clinical practice in intensive care; limitations pointed out by the selected studies; and the future perspectives envisioned by their authors. The results will be presented in graphical, tabular and narrative format.

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Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial

Cited by 17 publications

References 38 publications

Benefit with preventive noninvasive ventilation in subgroups of patients at high-risk for reintubation: a post hoc analysis

Benefit with preventive noninvasive ventilation in subgroups of patients at high-risk for reintubation: a post hoc analysis

Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial

Ventilator weaning: protocol of a bibliometric analysis

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