Effect of Pressure Support vs Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation: A Randomized Trial | Critical Care Medicine | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Scheinhorn DJ, Hassenpflug MS, Votto JJ,  et al; Ventilation Outcomes Study Group.  Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study.  Chest. 2007;131(1):85-9317218560PubMedGoogle ScholarCrossref
Scheinhorn DJ, Chao DC, Stearn-Hassenpflug M, LaBree LD, Heltsley DJ. Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center.  Chest. 1997;111(6):1654-16599187189PubMedGoogle ScholarCrossref
Carson SS, Garrett J, Hanson LC,  et al.  A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation.  Crit Care Med. 2008;36(7):2061-206918552692PubMedGoogle ScholarCrossref
Stauffer JL, Fayter NA, Graves B, Cromb M, Lynch JC, Goebel P. Survival following mechanical ventilation for acute respiratory failure in adult men.  Chest. 1993;104(4):1222-12298404197PubMedGoogle ScholarCrossref
Wagner DP. Economics of prolonged mechanical ventilation.  Am Rev Respir Dis. 1989;140(2 pt 2):S14-S182669583PubMedGoogle ScholarCrossref
Seneff MG, Wagner D, Thompson D, Honeycutt C, Silver MR. The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation.  Crit Care Med. 2000;28(2):342-35010708164PubMedGoogle ScholarCrossref
Polverino E, Nava S, Ferrer M,  et al.  Patients' characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units.  Intensive Care Med. 2010;36(1):137-14219784622PubMedGoogle ScholarCrossref
Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospital utilization after critical illness.  JAMA. 2010;303(22):2253-225920530778PubMedGoogle ScholarCrossref
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr.Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS).  Caring for the critically ill patient: current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?  JAMA. 2000;284(21):2762-277011105183PubMedGoogle ScholarCrossref
Kahn JM. The evolving role of dedicated weaning facilities in critical care.  Intensive Care Med. 2010;36(1):8-1019784621PubMedGoogle ScholarCrossref
Brochard L, Rauss A, Benito S,  et al.  Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation.  Am J Respir Crit Care Med. 1994;150(4):896-9037921460PubMedGoogle ScholarCrossref
Esteban A, Frutos F, Tobin MJ,  et al; Spanish Lung Failure Collaborative Group.  A comparison of four methods of weaning patients from mechanical ventilation.  N Engl J Med. 1995;332(6):345-3507823995PubMedGoogle ScholarCrossref
Lellouche F, Mancebo J, Jolliet P,  et al.  A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation.  Am J Respir Crit Care Med. 2006;174(8):894-90016840741PubMedGoogle ScholarCrossref
Hill NS. Following protocol: weaning difficult-to-wean patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2001;164(2):186-18711463583PubMedGoogle ScholarCrossref
Vitacca M, Vianello A, Colombo D,  et al.  Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days.  Am J Respir Crit Care Med. 2001;164(2):225-23011463592PubMedGoogle ScholarCrossref
Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation.  N Engl J Med. 1991;324(21):1445-14502023603PubMedGoogle ScholarCrossref
Jubran A, Grant BJ, Laghi F, Parthasarathy S, Tobin MJ. Weaning prediction: esophageal pressure monitoring complements readiness testing.  Am J Respir Crit Care Med. 2005;171(11):1252-125915764727PubMedGoogle ScholarCrossref
Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea.  Am J Respir Crit Care Med. 1997;155(6):1940-19489196100PubMedGoogle ScholarCrossref
Jubran A, Tobin MJ. Passive mechanics of lung and chest wall in patients who failed or succeeded in trials of weaning.  Am J Respir Crit Care Med. 1997;155(3):916-9219117026PubMedGoogle ScholarCrossref
Parthasarathy S, Jubran A, Laghi F, Tobin MJ. Sternomastoid, rib cage, and expiratory muscle activity during weaning failure.  J Appl Physiol. 2007;103(1):140-14717395760PubMedGoogle ScholarCrossref
Marini JJ, Smith TC, Lamb V. Estimation of inspiratory muscle strength in mechanically ventilated patients: the measurement of maximal inspiratory pressure.  J Crit Care. 1986;1(1):32-38Google ScholarCrossref
Laghi F, Cattapan SE, Jubran A,  et al.  Is weaning failure caused by low-frequency fatigue of the diaphragm?  Am J Respir Crit Care Med. 2003;167(2):120-12712411288PubMedGoogle ScholarCrossref
Jubran A, Van de Graaff WB, Tobin MJ. Variability of patient-ventilator interaction with pressure-support ventilation in patients with COPD.  Am J Respir Crit Care Med. 1995;152:129-1367599811PubMedGoogle ScholarCrossref
Kaplan EL, Meier P. Nonparametric estimation from incomplete observations.  J Am Stat Assoc. 1958;53:457-481Google ScholarCrossref
Cox DR. Regression models and life-tables.  J R Stat Soc Series B Stat Methodol. 1972;34:187-220Google Scholar
Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation.  Am J Respir Crit Care Med. 1997;155(3):906-9159117025PubMedGoogle ScholarCrossref
MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S.National Association for Medical Direction of Respiratory Care.  Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference.  Chest. 2005;128(6):3937-395416354866PubMedGoogle ScholarCrossref
Tobin MJ, Jubran A. Weaning from mechanical ventilation. In: Tobin MJ, ed. Principles and Practice of Mechanical Ventilation. 3rd ed. New York, NY: McGraw-Hill; 2012:1307-1351
Sassoon CS, Light RW, Lodia R, Sieck GC, Mahutte CK. Pressure-time product during continuous positive airway pressure, pressure support ventilation, and T-piece during weaning from mechanical ventilation.  Am Rev Respir Dis. 1991;143(3):469-4752001053PubMedGoogle ScholarCrossref
Tobin MJ. Extubation and the myth of “minimal ventilator settings.”  Am J Respir Crit Care Med. 2012;185(4):349-35022336673PubMedGoogle ScholarCrossref
Tobin MJ, Laghi F, Jubran A. Ventilatory failure, ventilator support and ventilator weaning.  Comprehensive Physiology. 2012;2:2871-2921Google Scholar
Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients.  Intensive Care Med. 2010;36(7):1171-117920352189PubMedGoogle ScholarCrossref
Parthasarathy S, Tobin MJ. Effect of ventilator mode on sleep quality in critically ill patients.  Am J Respir Crit Care Med. 2002;166(11):1423-142912406837PubMedGoogle ScholarCrossref
Rothman K. Modern Epidemiology. Boston, MA: Little Brown & Co; 1986
Caring for the Critically Ill Patient
February 20, 2013

Effect of Pressure Support vs Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation: A Randomized Trial

Author Affiliations

Caring for the Critically Ill Patient Section Editor: Derek C. Angus, MD, MPH, Contributing Editor, JAMA (angusdc@upmc.edu).

Author Affiliations: Division of Pulmonary and Critical Care Medicine, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois, and Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois (Drs Jubran, Collins, and Tobin); Fayetteville VA Medical Center, Fayetteville, North Carolina and University at Buffalo, Buffalo, New York (Dr Grant); RML Specialty Hospital, Hinsdale, Illinois (Ms Duffner); University of Illinois at Chicago (Dr Collins); University of Wisconsin, Madison (Dr Lanuza); and University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Hoffman).

JAMA. 2013;309(7):671-677. doi:10.1001/jama.2013.159

Importance Patients requiring prolonged mechanical ventilation (>21 days) are commonly weaned at long-term acute care hospitals (LTACHs). The most effective method of weaning such patients has not been investigated.

Objective To compare weaning duration with pressure support vs unassisted breathing through a tracheostomy collar in patients transferred to an LTACH for weaning from prolonged ventilation.

Design, Setting, and Participants Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation. Of 500 patients who underwent a 5-day screening procedure, 316 did not tolerate the procedure and were randomly assigned to receive weaning with pressure support (n = 155) or a tracheostomy collar (n = 161). Survival at 6- and 12-month time points was also determined.

Main Outcome Measure Primary outcome was weaning duration. Secondary outcome was survival at 6 and 12 months after enrollment.

Results Of 316 patients, 4 were withdrawn and not included in analysis. Of 152 patients in the pressure-support group, 68 (44.7%) were weaned; 22 (14.5%) died. Of 160 patients in the tracheostomy collar group, 85 (53.1%) were weaned; 16 (10.0%) died. Median weaning time was shorter with tracheostomy collar use (15 days; interquartile range [IQR], 8-25) than with pressure support (19 days; IQR, 12-31), P = .004. The hazard ratio (HR) for successful weaning rate was higher with tracheostomy collar use than with pressure support (HR, 1.43; 95% CI, 1.03-1.98; P = .033) after adjusting for baseline clinical covariates. Use of the tracheostomy collar achieved faster weaning than did pressure support among patients who did not tolerate the screening procedure between 12 and 120 hours (HR, 3.33; 95% CI, 1.44-7.70; P = .005), whereas weaning time was equivalent with the 2 methods in patients who did not tolerate the screening procedure within 0 to 12 hours. Mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 months (55.92% vs 51.25%; 4.67% difference, 95% CI, −6.4% to 15.7%) and at 12 months (66.45% vs 60.00%; 6.45% difference, 95% CI, −4.2% to 17.1%).

Conclusion and Relevance Among patients requiring prolonged mechanical ventilation and treated at a single long-term care facility, unassisted breathing through a tracheostomy, compared with pressure support, resulted in shorter median weaning time, although weaning mode had no effect on survival at 6 and 12 months.

Trial Registration clinicaltrials.gov Identifier: NCT01541462