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Original Investigation
Caring for the Critically Ill Patient
June 11, 2019

Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

Author Affiliations
  • 1Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
  • 2Hospital Virgen de la Salud, Toledo, Spain
  • 3Hospital del Mar, Barcelona, Spain
  • 4Hospital U, Central de Asturias, Oviedo, Spain
  • 5Hospital Marqués de Valdecilla, Santander, Spain
  • 6Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
  • 7Universitat Internacional de Catalunya, Barcelona, Spain
  • 8Hospital General de Granollers, Granollers, Spain
  • 9Hospital de Mataró, Mataró, Spain
  • 10Hospital Gregorio Marañón, Madrid, Spain
  • 11Consorci Sanitari de Terrassa, Terrassa, Spain
  • 12Hospital del Henares, Coslada, Spain
  • 13Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
  • 14Complexo Hospitalario Universitario de Ourense, Ourense, Spain
  • 15Hospital d’Elx, Elche, Alicante, Spain
  • 16Hospital Vall d’Hebron, Barcelona, Spain
  • 17Hospital Universitario de Araba, Araba, Spain
  • 18Hospital de Sagunt, Sagunt, Spain
  • 19Hospital Mútua Terrassa, Terrassa, Spain
  • 20CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
JAMA. 2019;321(22):2175-2182. doi:10.1001/jama.2019.7234
Visual Abstract.
Visual Abstract.
Pressure Support Compared With T-Piece Ventilation Strategies During Spontaneous Breathing Trials
Pressure Support Compared With T-Piece Ventilation Strategies During Spontaneous Breathing Trials
Key Points

Question  What is the effect of a less demanding (30 minutes of pressure support ventilation) vs a more demanding (2 hours of T-piece ventilation) spontaneous breathing trial on rates of successful extubation?

Findings  In this randomized clinical trial that included 1153 adults receiving mechanical ventilation, the proportion of patients successfully extubated was 82.3% among those who received 30 minutes of pressure support ventilation compared with 74% among those who received 2 hours of T-piece ventilation, a difference that was statistically significant.

Meaning  These findings support the use of a shorter, less demanding strategy of 30 minutes of pressure support ventilation for spontaneous breathing trials.

Abstract

Importance  Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial.

Objective  To evaluate the effect of an SBT consisting of 30 minutes of pressure support ventilation (an approach that is less demanding for patients) vs an SBT consisting of 2 hours of T-piece ventilation (an approach that is more demanding for patients) on rates of successful extubation.

Design, Setting, and Participants  Randomized clinical trial conducted from January 2016 to April 2017 among 1153 adults deemed ready for weaning after at least 24 hours of mechanical ventilation at 18 intensive care units in Spain. Follow-up ended in July 2017.

Interventions  Patients were randomized to undergo a 2-hour T-piece SBT (n = 578) or a 30-minute SBT with 8-cm H2O pressure support ventilation (n = 557).

Main Outcome and Measures  The primary outcome was successful extubation (remaining free of mechanical ventilation 72 hours after first SBT). Secondary outcomes were reintubation among patients extubated after SBT; intensive care unit and hospital lengths of stay; and hospital and 90-day mortality.

Results  Among 1153 patients who were randomized (mean age, 62.2 [SD, 15.7] years; 428 [37.1%] women), 1018 (88.3%) completed the trial. Successful extubation occurred in 473 patients (82.3%) in the pressure support ventilation group and 428 patients (74.0%) in the T-piece group (difference, 8.2%; 95% CI, 3.4%-13.0%; P = .001). Among secondary outcomes, for the pressure support ventilation group vs the T-piece group, respectively, reintubation was 11.1% vs 11.9% (difference, −0.8%; 95% CI, −4.8% to 3.1%; P = .63), median intensive care unit length of stay was 9 days vs 10 days (mean difference, −0.3 days; 95% CI, −1.7 to 1.1 days; P = .69), median hospital length of stay was 24 days vs 24 days (mean difference, 1.3 days; 95% CI, −2.2 to 4.9 days; P = .45), hospital mortality was 10.4% vs 14.9% (difference, −4.4%; 95% CI, −8.3% to −0.6%; P = .02), and 90-day mortality was 13.2% vs 17.3% (difference, −4.1% [95% CI, −8.2% to 0.01%; P = .04]; hazard ratio, 0.74 [95% CI, 0.55-0.99]).

Conclusions and Relevance  Among patients receiving mechanical ventilation, a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials.

Trial Registration  ClinicalTrials.gov Identifier: NCT02620358

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