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Randomized Controlled Trial
. 2024 Feb;50(2):258-267.
doi: 10.1007/s00134-024-07330-w. Epub 2024 Feb 14.

Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial

Gonzalo Hernández Martínez  1   2   3 , Patricia Rodriguez  4 , Jesus Soto  5 , Oriol Caritg  6   7 , Andrea Castellví-Font  8   9 , Borja Mariblanca  10 , Antonio Maria García  11 , Laura Colinas  4 , Jose Manuel Añon  5   12 , Francisco Jose Parrilla-Gomez  8   9 , Jose Alberto Silva-Obregón  10   13 , Joan Ramon Masclans  8   9   14 , Alicia Propin  15 , Alicia Cuadra  4 , Mario Guillermo Dalorzo  4 , Gemma Rialp  16 , Fernando Suarez-Sipmann  17 , Oriol Roca  18   19   20
Affiliations
Randomized Controlled Trial

Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial

Gonzalo Hernández Martínez et al. Intensive Care Med. 2024 Feb.

Abstract

Purpose: This study aimed to determine the best strategy to achieve fast and safe extubation.

Methods: This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.

Results: Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).

Conclusion: Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.

Trial registration: ClinicalTrials.gov NCT04758546.

Keywords: Extubation; Mechanical ventilation; Screening; Spontaneous breathing trial; Weaning.

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References

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