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Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial

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Abstract

Purpose

This study aimed to determine the best strategy to achieve fast and safe extubation.

Methods

This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.

Results

Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).

Conclusion

Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.

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Data availability

Data available after personal communication with a detailed planned analysis.

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Author information

Authors and Affiliations

  1. Complejo Hospitalario Universitario de Toledo, Toledo, Spain

    Gonzalo Hernández Martínez, Patricia Rodriguez, Laura Colinas, Alicia Cuadra & Mario Guillermo Dalorzo

  2. Hospital Universitario La Paz, Madrid, Spain

    Jesus Soto & Jose Manuel Añon

  3. Hospital Universitari Vall d’Hebron, Barcelona, Spain

    Oriol Caritg

  4. Hospital del Mar, Barcelona, Spain

    Andrea Castellví-Font, Francisco Jose Parrilla-Gomez & Joan Ramon Masclans

  5. Hospital Universitario de Guadalajara, Guadalajara, Spain

    Borja Mariblanca & Jose Alberto Silva-Obregón

  6. Hospital Santa Barbara, Puertollano, Spain

    Antonio Maria García

  7. Programa Investigo SESCAM, Palma, Spain

    Alicia Propin

  8. Hospital Universitario Son Llàtzer, Palma, Spain

    Gemma Rialp

  9. Hospital Universitario La Princesa, Madrid, Spain

    Fernando Suarez-Sipmann

  10. Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain

    Gonzalo Hernández Martínez & Jose Manuel Añon

  11. Grupo de Investigación del Paciente Hematológico, Instituto de Investigación Sanitaria Hospital Universitario La Paz (IdiPAZ), Madrid, Spain

    Jose Alberto Silva-Obregón

  12. Vall d’Hebron Institut de Reserca (VHIR), Barcelona, Spain

    Oriol Caritg

  13. Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain

    Andrea Castellví-Font, Francisco Jose Parrilla-Gomez & Joan Ramon Masclans

  14. MELIS, Universitat Pompeu Fabra (UPF), Barcelona, Spain

    Joan Ramon Masclans

  15. Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain

    Oriol Roca

  16. Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain

    Oriol Roca

  17. Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain

    Gonzalo Hernández Martínez & Oriol Roca

Authors
  1. Gonzalo Hernández Martínez
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  2. Patricia Rodriguez
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Contributions

GHM had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept, design, administrative, technical, or material support and study supervision: GHM. Statistical analysis, analysis, and interpretation of data: GHM, OR. Drafting of the manuscript: GHM, LC, and OR. Acquisition and critical revision of the manuscript for important intellectual content: GHM, PR, JS, OC, BM, AMG, LC, JMA, FJPG, JASO, JRM, AP, AC, MGD, GR, and FSS.

Corresponding author

Correspondence to Gonzalo Hernández Martínez.

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Conflicts of interest

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. GHM reported travel expenses and personal fees from Fisher & Paykel Healthcare Ltd. OR reported a research grant from Hamilton Medical AG and Fisher&Paykel Healthcare Ltd, speaker fees from Hamilton Medical AG, Fisher&Paykel Healthcare Ltd, Aerogen Ltd and Ambu, and non-financial research support from Timpel; all outside the study reported here. JRM reported grants, travels and non-financial support from Fisher& Paykel, personal fees from Gilead, Dextro, Chiesi and grants from Linet.

Funding

Fisher&Paykel Healthcare Ltd provided insurance coverage and paid John Giba to correct the English grammar and style of the manuscript. They had no other involvement in the study, including in its design and conduct; the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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Hernández Martínez, G., Rodriguez, P., Soto, J. et al. Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial. Intensive Care Med 50, 258–267 (2024). https://doi.org/10.1007/s00134-024-07330-w

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