Frequency of Screening and Spontaneous Breathing Trial Techniques
Authors: Karen E. A. Burns, Jessica Wong, Leena Rizvi, Myriam Lafreniere-Roula, Kevin Thorpe, John W. Devlin, Deborah J. Cook, Andrew Seely, Peter M. Dodek, Maged Tanios, Thomas Piraino, Audrey Gouskos, Kenneth C. Kiedrowski, Phyllis Kay, Susan Mitchell, George W. Merner, Michael Mayette, Frederick D’Aragon, Francois Lamontagne, Bram Rochwerg, Alexis Turgeon, Ying Tung Sia, Emmanuel Charbonney, Pierre Aslanian, Gerard J. Criner, Robert C. Hyzy, Jeremy R. Beitler, Elias Baedorf Kassis, Demetrios James Kutsogiannis, Maureen O. Meade, Janice Liebler, Santhi Iyer-Kumar, Jennifer Tsang, Robert Cirone, Carl Shanholtz, Nicholas S. Hill, Kim Dawdy, Zana Mariano, Gyan Sandhu, Marlene Santos, Imrana Khalid, Kurtis Salway, Jennifer Hodder, Orla Smith, Jessica Hajj, Samantha Buchanan, Vivianne Severdija, Anna Medvetskaya, Sarah Enriquez, John Michaels, Kanthi Kavikondala, Irene Watpool, Rebecca Porteous, Kaitlyn Montroy, Sydney Miezitis, Jessica Haines, Heather Langlois, Jackie Bastianon, Saba Rawjani, Aaron Nesom, Brigette Gomes, Liane Leclair, Jay Greco, Marie-Hélène Masse, Joannie Marchand, Marie-Pier Bouchard, Elaine Carbonneau, Julie Belisle, Marilène Ladouceur, Karine Grondin, France Clarke, Neala Hoad, Timothy Karachi, Tina Millen, Jennifer Leroux, Jean-Francois Naud, Isabelle Roy, Martin Faucher, Mélissa Bellefeuille, Danielle Tapps Tapps, Mylena Laplante, Cassandra Mailloux, Lea Durocher, Martine Lebrasseur, Marie-Eve Cantin, Dounia Boumahni, Fatna Benettaib Benettaib, Ali Ghamraoui, Maya Salamé, Karine-Candy Gagnon, David Bellemare, Joannie Blais, Marie-Claude Boulanger, Eve Cloutier, Olivier Costerousse, Hélène Côté, Emilie Couillard-Chénard, Marjorie Daigle, Charles Francoeur, Gabrielle Guilbault, Stéphanie Grenier, Francois Lauzier, Guillaume Leblanc, Shany Rodrigue, Isabelle St. Hilaire, Maude St. Onge, Antoine Tremblay, Patrica Thompson, Tayne Hewer, Cynthia Smit, Victoria Alcuaz, Lena Farina, Draga Jichici, Lori Hand, Claudia Poulin, Erick Duan, Mercedes Camargo-Penuela, Lisa Patterson, Jeremy Yue, Anthony (TJ) Fuagno, Mary M. Hayes, Abigail Pires, Grace Kersker, Fernando Martinez Guasch, Adriana Paz Mancia, Courtney Capobianco, Leslie Lussier, Hyunsoon Park, Kelvin Arreola, Kenneth Le, Son Nguyen, Kristi Peters-Fitzpatrick, Amy Blank, Joshua Cosa, Arin Marshall, Cedrik De La Pena, Francine McGonagle, Shubhra Srivastava-Malhotra, Sheril George, Heidi Shore-Brown, Lauren Miller, Linda Ayres, David Miller, Kristine Nelson, Carl Haas, Jose Victor Jimenez, Andy Weirauch, Alexis Serra, Ivan Garcia, Charmaine Wilson, Valerie Goodspeed, Julia (Dwyer) Crane, Andrew Toksoz-Exley, Krystal Capers, Andre De Souza Licht, Lynn Fukushima, Carese Lee, Daniel Motamedi, Thelma Harrington, Olga Kolesnik, Maura Deeley
Journal: JAMA (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;amp;gt;0-≤8 cm H 2 O and a positive end-expiratory pressure [PEEP] level that was &amp;amp;gt;0-≤5 cm H 2 O 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 H 2 O 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