Background: Inclusion of noninvasive ventilation in weaning among chronic obstructive pulmonary disease (COPD) patients has been shown to reduce total duration of ventilation and invasive ventilator days with an associated reduction in morbidity and mortality. It is not well studied whether these results apply to general ICU patients.
Dr. Nhan Vuong
Study design: Randomized, allocation-concealed, open-label, multicenter trial.
Setting: United Kingdom National Health Service ICUs.
Synopsis: Patients from 41 general adult ICUs met inclusion criteria after they had been intubated for less than 48 hours and failed a spontaneous breathing trial. Intention-to-treat analysis in 319 of 364 patients (mean age, 63.1 years; 50.5% male) showed median time to liberation of 4.3 days in the noninvasive group versus 4.5 days in the invasive group (adjusted hazard ratio, 1.1; 95% confidence interval, 0.89-1.40). However, secondary outcomes showed reduction in median time of invasive ventilation (1 day vs. 4 days) and total ventilator days (3 days vs. 4 days) in the noninvasive group without a significant difference in adverse events.
Not all secondary outcomes were powered to detect treatment differences. Hospitalists should consider noninvasive ventilation as an adjunct in weaning, especially in COPD patients, to reduce ventilator-associated complications and ICU resources when appropriate.
Bottom line: Protocolized early extubation to noninvasive ventilation was not associated with earlier liberation from all types of ventilation in the general ICU population.
Citation: Perkins GD et al. Effect of protocolized weaning with early extubation to noninvasive ventilation vs invasive weaning on time to liberation from mechanical ventilation among patients with respiratory failure: The breathe randomized clinical trial. JAMA. 2018;320(18):1881-8.
Dr. Vuong is an associate physician in the division of hospital medicine at the University of California, San Diego.