Frequency of Screening and Spontaneous Breathing Trial Techniques
Authors: Burns Karen E. A. , Wong Jessica , Rizvi Leena , Lafreniere-Roula Myriam , Thorpe Kevin , Devlin John W. , Cook Deborah J. , Seely Andrew , Dodek Peter M. , Tanios Maged , Piraino Thomas , Gouskos Audrey , Kiedrowski Kenneth C. , Kay Phyllis , Mitchell Susan , Merner George W. , Mayette Michael , D’Aragon Frederick , Lamontagne Francois , Rochwerg Bram , Turgeon Alexis , Sia Ying Tung , Charbonney Emmanuel , Aslanian Pierre , Criner Gerard J. , Hyzy Robert C. , Beitler Jeremy R. , Kassis Elias Baedorf , Kutsogiannis Demetrios James , Meade Maureen O. , Liebler Janice , Iyer-Kumar Santhi , Tsang Jennifer , Cirone Robert , Shanholtz Carl , Hill Nicholas S. ,   Canadian Critical Care Trials Group, Dawdy Kim , Mariano Zana , Sandhu Gyan , Santos Marlene , Khalid Imrana , Salway Kurtis , Hodder Jennifer , Smith Orla , Hajj Jessica , Buchanan Samantha , Severdija Vivianne , Medvetskaya Anna , Enriquez Sarah , Michaels John , Kavikondala Kanthi , Watpool Irene , Porteous Rebecca , Montroy Kaitlyn , Miezitis Sydney , Haines Jessica , Langlois Heather , Bastianon Jackie , Rawjani Saba , Nesom Aaron , Gomes Brigette , Leclair Liane , Greco Jay , Masse Marie-Hélène , Marchand Joannie , Bouchard Marie-Pier , Carbonneau Elaine , Belisle Julie , Ladouceur Marilène , Grondin Karine , Clarke France , Hoad Neala , Karachi Timothy , Millen Tina , Leroux Jennifer , Naud Jean-Francois , Roy Isabelle , Faucher Martin , Bellefeuille Mélissa , Tapps Danielle Tapps , Laplante Mylena , Mailloux Cassandra , Durocher Lea , Lebrasseur Martine , Cantin Marie-Eve , Boumahni Dounia , Benettaib Fatna Benettaib , Ghamraoui Ali , Salamé Maya , Gagnon Karine-Candy , Bellemare David , Blais Joannie , Boulanger Marie-Claude , Cloutier Eve , Costerousse Olivier , Côté Hélène , Couillard-Chénard Emilie , Daigle Marjorie , Francoeur Charles , Guilbault Gabrielle , Grenier Stéphanie , Lauzier Francois , Leblanc Guillaume , Rodrigue Shany , St. Hilaire Isabelle , St. Onge Maude , Tremblay Antoine , Thompson Patrica , Hewer Tayne , Smit Cynthia , Alcuaz Victoria , Farina Lena , Jichici Draga , Hand Lori , Poulin Claudia , Duan Erick , Camargo-Penuela Mercedes , Patterson Lisa , Yue Jeremy , Fuagno Anthony (TJ) , Hayes Mary M. , Pires Abigail , Kersker Grace , Martinez Guasch Fernando , Paz Mancia Adriana , Capobianco Courtney , Lussier Leslie , Park Hyunsoon , Arreola Kelvin , Le Kenneth , Nguyen Son , Peters-Fitzpatrick Kristi , Blank Amy , Cosa Joshua , Marshall Arin , De La Pena Cedrik , McGonagle Francine , Srivastava-Malhotra Shubhra , George Sheril , Shore-Brown Heidi , Miller Lauren , Ayres Linda , Miller David , Nelson Kristine , Haas Carl , Jimenez Jose Victor , Weirauch Andy , Serra Alexis , Garcia Ivan , Wilson Charmaine , Goodspeed Valerie , (Dwyer) Crane Julia , Toksoz-Exley Andrew , Capers Krystal , De Souza Licht Andre , Fukushima Lynn , Lee Carese , Motamedi Daniel , Harrington Thelma , Kolesnik Olga , Deeley Maura 
Published: October 2024

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 &amp;gt;0-≤8 cm H2O and a positive end-expiratory pressure [PEEP] level that was &amp;gt;0-≤5 cm H2O vs T-piece SBT) on the time to successful extubation.

Design, Setting, and Participants

Randomized clinical trial with a 2 × 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