Dual-mode weaning strategy for difficult-weaning tracheotomy patients: a feasibility study

Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis

BACKGROUND

Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data.

RESULTS

We identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) -4.62 days, 95% CI -5.91 to -3.34) and hospital stay (MD -6.29 days, 95% CI -8.90 to -3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD -0.57, 95% CI -1.08 to -0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations.

CONCLUSION

Non-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients.

PROSPERO REGISTRATION NUMBER

CRD42020201402.

Prophylactic noninvasive positive pressure ventilation in the weaning of difficult-weaning tracheotomy patients

Background

Prophylactic noninvasive positive pressure ventilation (NPPV) reduces reintubation in endotracheal intubation patients. However, the efficacy of using the prophylactic NPPV in the weaning of tracheotomy patients is unclear.

Methods

We performed prophylactic NPPV in 11 tracheotomy patients who passed a spontaneous breathing trial (SBT), removed the tracheotomy tube, and closed the incision (intervention group). We matched another 11 tracheotomy patients who also passed an SBT but weaning and removing of tracheotomy tube were managed as conventional methods (control group).

Results

Patients in the control group had reinstitution of mechanical ventilation 36 times after the initial SBT success. Compared with the control group, the interventional group had fewer weaning days (3.0±2.1 vs. 11.3±9.2, P=0.01) from initial SBT success to successful weaning and shorter intensive care unit (ICU) length of stay (11.6±4.2 vs. 20.3±11.6, P=0.03) after initial SBT success. The interventional group had lower nosocomial pneumonia rates after initial SBT success (0/11 vs. 2/11), lower ICU mortality (0/11 vs. 2/11), lower hospital mortality (0/11 vs. 3/11), and higher successful weaning rate (11/11 vs. 8/11), but it didn’t reach significant difference. Also, there was no significant difference between groups in total duration of ventilation (25.5±13.3 vs. 34.7±24.2 days), hospital stay after initial SBT success (24.0±22.3 vs. 37.4±31.3 days), total ICU stay (35.7±15.3 vs. 45.0±29.5 days), and total hospital stay (48.7±33.1 vs. 68.6±52.6 days).

Conclusions

Prophylactic NPPV may be useful to accelerate weaning, and shorten ICU stay after initial SBT success in tracheotomy patients.

Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review

Supplemental Digital Content is available in the text.

To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.

Semiquantitative cough strength score for predicting reintubation after planned extubation

BACKGROUND

Semiquantitative cough strength score (SCSS, graded 0-5) and cough peak flow (CPF) have been used to predict extubation outcome in patients in whom extubation is planned; however, the correlation of the 2 assessments is unclear.

METHODS

In the intensive care unit of a university-affiliated hospital, 186 patients who were ready for extubation after a successful spontaneous breathing trial were enrolled in the study. Both SCSS and CPF were assessed before extubation. Reintubation was recorded 72 hours after extubation.

RESULTS

Reintubation rate was 15.1% within 72 hours after planned extubation. Patients in whom extubation was successful had higher SCSSs than did reintubated patients (mean [SD], 3.2 [1.6] vs 2.2 [1.6], P = .002) and CPF (74.3 [40.0] vs 51.7 [29.4] L/min, P = .005). The SCSS showed a positive correlation with CPF (r = 0.69, P < .001). Mean CPFs were 38.36 L/min, 39.51 L/min, 44.67 L/min, 57.54 L/min, 78.96 L/min, and 113.69 L/min in patients with SCSSs of 0, 1, 2, 3, 4, and 5, respectively. The discriminatory power for reintubation, evidenced by area under the receiver operating characteristic curve, was similar: 0.677 for SCSS and 0.678 for CPF (P = .97). As SCSS increased (from 0 to 1 to 2 to 3 to 4 to 5), the reintubation rate decreased (from 29.4% to 25.0% to 19.4% to 16.1% to 13.2% to 4.1%).

CONCLUSIONS

SCSS was convenient to measure at the bedside. It was positively correlated with CPF and had the same accuracy for predicting reintubation after planned extubation.

Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure

BACKGROUND

Noninvasive positive-pressure ventilation (NPPV) provides ventilatory support without the need for an invasive airway. Interest has emerged in using NPPV to facilitate earlier removal of an endotracheal tube and to decrease complications associated with prolonged intubation.

OBJECTIVES

We evaluated studies in which invasively ventilated adults with respiratory failure of any cause (chronic obstructive pulmonary disease (COPD), non-COPD, postoperative, nonoperative) were weaned by means of early extubation followed by immediate application of NPPV or continued IPPV weaning. The primary objective was to determine whether the noninvasive positive-pressure ventilation (NPPV) strategy reduced all-cause mortality compared with invasive positive-pressure ventilation (IPPV) weaning. Secondary objectives were to ascertain differences between strategies in proportions of weaning failure and ventilator-associated pneumonia (VAP), intensive care unit (ICU) and hospital length of stay (LOS), total duration of mechanical ventilation, duration of mechanical support related to weaning, duration of endotracheal mechanical ventilation (ETMV), frequency of adverse events (related to weaning) and overall quality of life. We planned sensitivity and subgroup analyses to assess (1) the influence on mortality and VAP of excluding quasi-randomized trials, and (2) effects on mortality and weaning failure associated with different causes of respiratory failure (COPD vs. mixed populations).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 5, 2013), MEDLINE (January 1966 to May 2013), EMBASE (January 1980 to May 2013), proceedings from four conferences, trial registration websites and personal files; we contacted authors to identify trials comparing NPPV versus conventional IPPV weaning.

SELECTION CRITERIA

Randomized and quasi-randomized trials comparing early extubation with immediate application of NPPV versus IPPV weaning in intubated adults with respiratory failure.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses assessed (1) the impact of excluding quasi-randomized trials, and (2) the effects on selected outcomes noted with different causes of respiratory failure.

MAIN RESULTS

We identified 16 trials, predominantly of moderate to good quality, involving 994 participants, most with chronic obstructive pulmonary disease (COPD). Compared with IPPV weaning, NPPV weaning significantly decreased mortality. The benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24 to 0.56) versus mixed populations (RR 0.81, 95% CI 0.47 to 1.40). NPPV significantly reduced weaning failure (RR 0.63, 95% CI 0.42 to 0.96) and ventilator-associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43); shortened length of stay in an intensive care unit (mean difference (MD) -5.59 days, 95% CI -7.90 to -3.28) and in hospital (MD -6.04 days, 95% CI -9.22 to -2.87); and decreased the total duration of ventilation (MD -5.64 days, 95% CI -9.50 to -1.77) and the duration of endotracheal mechanical ventilation (MD - 7.44 days, 95% CI -10.34 to -4.55) amidst significant heterogeneity. Noninvasive weaning also significantly reduced tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97) rates. Noninvasive weaning had no effect on the duration of ventilation related to weaning. Exclusion of a single quasi-randomized trial did not alter these results. Subgroup analyses suggest that the benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD versus mixed populations.

AUTHORS' CONCLUSIONS

Summary estimates from 16 trials of moderate to good quality that included predominantly participants with COPD suggest that a weaning strategy that includes NPPV may reduce rates of mortality and ventilator-associated pneumonia without increasing the risk of weaning failure or reintubation.