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Meta-Analysis
. 2024 Feb 5;7(2):e2356794.
doi: 10.1001/jamanetworkopen.2023.56794.

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis

Karen E A Burns  1   2   3   4   5 , Jeena Khan  1   6 , Vorakamol Phoophiboon  1   7 , Vatsal Trivedi  8   9 , J Carolina Gomez-Builes  8 , Benedetta Giammarioli  8 , Kimberley Lewis  5   10   11 , Dipayan Chaudhuri  10   11 , Kairavi Desai  12 , Jan O Friedrich  1   2   3   4
Affiliations
Meta-Analysis

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis

Karen E A Burns et al. JAMA Netw Open. .

Abstract

Importance: Considerable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use.

Objective: To summarize trials comparing alternative SBTs.

Data sources: Several databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis.

Study selection: Randomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected.

Data extraction and synthesis: Paired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models.

Main outcomes and measures: Primary outcomes included SBT success, extubation success, and reintubation.

Results: The systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P < .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P < .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = <.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found.

Conclusions and relevance: In this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Burns reported receiving grants from the Canadian Institutes of Health Research during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram of Trial Selection
Of the 40 included trials, 10 were full trial publications, of which 9 were new publications and 1 was a full publication that replaced a previously identified abstract. MV indicates mandatory ventilation; SBT, spontaneous breathing trial. aIncluded updated search through February 1, 2023, limited to newly indexed citations since prior search.
Figure 2.
Figure 2.. Association of Pressure Support Compared With T-Piece Spontaneous Breathing Trials (SBTs) on SBT Outcome
Exclusion of the single pediatric trial (Farias et al) changed the summary estimate to 1.04 (95% CI, 0.96-1.11); P = .33; I2 = 75%. Squares indicate risk ratios, with the size of squares indicating weight; horizontal lines, 95% CIs; and diamonds, overall risk ratios, with outer points of the diamonds indicating 95% CIs. NA indicates not applicable.
Figure 3.
Figure 3.. Association of Pressure Support Compared With T-Piece Spontaneous Breathing Trials on Successful Extubation
Exclusion of the single pediatric trial (Farias et al) did not change the summary estimate of effect for this outcome. Squares indicate risk ratios, with size of squares indicating weight; horizontal lines, 95% CIs; and diamond, overall risk ratio, with outer points of the diamond indicating 95% CIs.
See this image and copyright information in PMC

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