Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial

被引：7

作者：

Burns, Karen E. A. ^{[1
,2
,3
,4
]}

Wong, Jessica ^{[5
]}

Rizvi, Leena ^{[2
]}

Lafreniere-Roula, Myriam ^{[3
]}

Thorpe, Kevin ^{[3
,6
]}

Devlin, John W. ^{[7
,8
]}

Cook, Deborah J. ^{[4
,9
]}

Seely, Andrew ^{[10
,11
,12
]}

Dodek, Peter M. ^{[13
,14
,15
]}

Tanios, Maged ^{[16
,17
]}

Piraino, Thomas ^{[2
,9
]}

Gouskos, Audrey ^{[18
]}

Kiedrowski, Kenneth C. ^{[18
]}

Kay, Phyllis ^{[18
]}

Mitchell, Susan ^{[18
]}

Merner, George W. ^{[18
]}

Mayette, Michael ^{[19
,20
,21
]}

D'Aragon, Frederick ^{[19
,20
,21
]}

Lamontagne, Francois ^{[19
,20
,21
]}

Rochwerg, Bram ^{[4
,9
]}

Turgeon, Alexis ^{[22
,23
]}

Sia, Ying Tung ^{[24
,25
]}

Charbonney, Emmanuel ^{[26
,27
]}

Aslanian, Pierre ^{[26
,27
]}

Criner, Gerard J. ^{[28
]}

Hyzy, Robert C. ^{[29
]}

Beitler, Jeremy R. ^{[30
,31
]}

Kassis, Elias Baedorf ^{[32
,33
]}

Kutsogiannis, Demetrios James ^{[34
]}

Meade, Maureen O. ^{[4
,9
,35
]}

Liebler, Janice ^{[36
]}

Iyer-Kumar, Santhi ^{[36
]}

Tsang, Jennifer ^{[9
,37
]}

Cirone, Robert ^{[38
]}

Shanholtz, Carl ^{[39
,40
]}

Hill, Nicholas S. ^{[41
]}

机构：

[1] Univ Toronto, Interdept Div Crit Care, Toronto, ON, Canada

[2] St Michaels Hosp, Crit Care Dept, Unity Hlth Toronto, Toronto, ON, Canada

[3] St Michaels Hosp, Unity Hlth Toronto, Li Ka Shing Knowledge Inst, Appl Hlth Res Ctr, Toronto, ON, Canada

[4] McMaster Univ, Fac Hlth Sci, Dept Hlth Res Methods Evidence & Impact, Hamilton, ON, Canada

[5] Univ Toronto, Temerty Fac Med, Toronto, ON, Canada

[6] Univ Toronto, Dalla Lana Sch Publ Hlth, Toronto, ON, Canada

[7] Northeastern Univ, Bouve Coll Hlth Sci, Boston, MA USA

[8] Brigham & Womens Hosp, Div Pulm & Crit Care Med, Boston, MA USA

[9] McMaster Univ, Fac Hlth Sci, Dept Anesthesia, Hamilton, ON, Canada

[10] Ottawa Hosp, Dept Crit Care, Ottawa, ON, Canada

[11] Univ Ottawa, Dept Surg, Div Thorac Surg, Ottawa, ON, Canada

[12] Univ Ottawa, Ottawa Hosp Res Inst, Ottawa, ON, Canada

[13] St Pauls Hosp, Div Crit Care Med, Vancouver, BC, Canada

[14] St Pauls Hosp, Ctr Adv Hlth Outcomes, Vancouver, BC, Canada

[15] Univ British Columbia, Vancouver, BC, Canada

[16] Univ Calif Irvine, Div Pulm & Crit Care Med, Irvine, CA USA

[17] Long Beach Mem Med Ctr, Pulm & Crit Care, Mem Care, Long Beach, CA USA

[18] St Michaels Hosp, Patient & Family Advisory Comm Frequency Screening, Div Gen Surg, Toronto, ON, Canada

[19] Univ Sherbrooke, Dept Med, Sherbrooke, PQ, Canada

[20] Univ Sherbrooke, Dept Anesthesia, Sherbrooke, PQ, Canada

[21] Ctr Hosp Univ Sherbrooke, Ctr Rech, Sherbrooke, PQ, Canada

[22] Univ Laval, Fac Med, Dept Anesthesiol & Crit Care Med, Quebec City, PQ, Canada

[23] Univ Laval, Res Ctr, CHU Quebec, Populat Hlth & Optimal Hlth Practices Res Unit, Quebec City, PQ, Canada

[24] Ctr Integre Univ Sante Serv Sociaux Rivieres Mauri, Dept Med, Trois Rivieres, PQ, Canada

[25] Ctr Quebec, Trois Rivieres, PQ, Canada

[26] Univ Montreal, Dept Med, Montreal, PQ, Canada

[27] Ctr Hosp Univ Montreal, Montreal, PQ, Canada

[28] Temple Univ, Lewis Katz Sch Med, Dept Thorac Med & Surg, Philadelphia, PA 19140 USA

[29] Univ Michigan, Div Pulm & Crit Care Med, Dept Med, Ann Arbor, MI USA

[30] Columbia Univ, Ctr Acute Resp Failure, New York, NY 10027 USA

[31] Columbia Univ, Dept Internal Med, New York, NY USA

[32] Harvard Univ, Sch Med, Boston, MA USA

[33] Beth Israel Deaconess Med Ctr, Div Pulm & Crit Care, Boston, MA 02215 USA

[34] Univ Alberta, Fac Med & Dent, Dept Crit Care Med, Edmonton, AB, Canada

[35] Hamilton Hlth Sci, Dept Crit Care, Hamilton, ON, Canada

[36] Univ Southern Calif, Keck Sch Med, Div Pulm & Crit Care Med, Los Angeles, CA 90007 USA

[37] Niagara Hlth, Niagara Hlth Knowledge Inst, St Catharines, ON, Canada

[38] St Michaels Hosp, Dept Crit Care Med & Respirol, Unity Hlth Toronto, Toronto, ON, Canada

[39] Univ Maryland, Sch Med, Dept Med, Baltimore, MD USA

[40] Univ Maryland, Sch Med, Div Pulm & Crit Care Med, Baltimore, MD USA

[41] Tufts Med Ctr, Div Pulm Crit Care & Sleep Med, Boston, MA USA

来源：

JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2024年 / 332卷 / 21期

关键词：

COLLABORATION FAST-NAWC; SBT TECHNIQUE TRIAL; MECHANICAL VENTILATION; PRESSURE-SUPPORT; MULTICENTER; PROTOCOL; ENGAGEMENT; EXTUBATION; DURATION; OUTCOMES;

D O I：

10.1001/jama.2024.20631

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

Importance The optimal screening frequency and spontaneous breathing trial (SBT) technique to liberate adults from ventilators are unknown. Objective To compare the effects of screening frequency (once-daily screening vs more frequent screening) and SBT technique (pressure-supported SBT with a pressure support level that was >0-<= 8 cm H2O and a positive end-expiratory pressure [PEEP] level that was >0-<= 5 cm H2O vs T-piece SBT) on the time to successful extubation. Design, Setting, and Participants Randomized clinical trial with a 2 x 2 factorial design including critically ill adults who were receiving invasive mechanical ventilation for at least 24 hours, who were capable of initiating spontaneous breaths or triggering ventilators, and who were receiving a fractional concentration of inspired oxygen that was 70% or less and a PEEP level of 12 cm H2O or less. Recruitment was between January 2018 and February 2022 at 23 intensive care units in North America; last follow-up occurred October 18, 2022. Interventions Participants were enrolled early to enable protocolized screening (more frequent vs once daily) to identify the earliest that patients met criteria to undergo pressure-supported or T-piece SBT lasting 30 to 120 minutes. Main Outcome and Measures Time to successful extubation (time when unsupported, spontaneous breathing began and was sustained for >= 48 hours after extubation). Results Of 797 patients (198 in the once-daily screening and pressure-supported SBT group, 204 in once-daily screening and T-piece SBT, 195 in more frequent screening and pressure-supported SBT, and 200 in more frequent screening and T-piece SBT), the mean age was 62.4 (SD, 18.4) years and 472 (59.2%) were men. There were no statistically significant differences by screening frequency (hazard ratio [HR], 0.88 [95% CI, 0.76-1.03]; P = .12) or by SBT technique (HR, 1.06 [95% CI, 0.91-1.23]; P = .45). The median time to successful extubation was 2.0 days (95% CI, 1.7-2.7) for once-daily screening and pressure-supported SBT, 3.1 days (95% CI, 2.7-4.8) for once-daily screening and T-piece SBT, 3.9 days (95% CI, 2.9-4.7) for more frequent screening and pressure-supported SBT, and 2.9 days (95% CI, 2.0-3.1) for more frequent screening and T-piece SBT. An unexpected interaction between screening frequency and SBT technique required pairwise contrasts that revealed more frequent screening (vs once-daily screening) and pressure-supported SBT increased the time to successful extubation (HR, 0.70 [95% CI, 0.50-0.96]; P = .02). Once-daily screening and pressure-supported SBT (vs T-piece SBT) did not reduce the time to successful extubation (HR, 1.30 [95% CI, 0.98-1.70]; P = .08). Conclusions and Relevance Among critically ill adults who received invasive mechanical ventilation for more than 24 hours, screening frequency (once-daily vs more frequent screening) and SBT technique (pressure-supported vs T-piece SBT) did not change the time to successful extubation. However, an unexpected and statistically significant interaction was identified; protocolized more frequent screening combined with pressure-supported SBTs increased the time to first successful extubation. Trial Registration ClinicalTrials.gov Identifiers: NCT02399267 and NCT02969226

引用

页码：1808 / 1821

页数：14

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