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Intensive Care Medicine

, Volume 43, Issue 12, pp 1793–1807 | Cite as

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study)

  • René Robert
  • Amélie Le Gouge
  • Nancy Kentish-Barnes
  • Alice Cottereau
  • Bruno Giraudeau
  • Mélanie Adda
  • Djillali Annane
  • Juliette Audibert
  • François Barbier
  • Patrick Bardou
  • Simon Bourcier
  • Jeremy Bourenne
  • Alexandre Boyer
  • François Brenas
  • Vincent Das
  • Arnaud Desachy
  • Jérôme Devaquet
  • Marc Feissel
  • Frédérique Ganster
  • Maïté Garrouste-Orgeas
  • Guillaume Grillet
  • Olivier Guisset
  • Rebecca Hamidfar-Roy
  • Anne-Claire Hyacinthe
  • Sebastien Jochmans
  • Mercé Jourdain
  • Alexandre Lautrette
  • Nicolas Lerolle
  • Olivier Lesieur
  • Fabien Lion
  • Philippe Mateu
  • Bruno Megarbane
  • Sybille Merceron
  • Emmanuelle Mercier
  • Jonathan Messika
  • Paul Morin-Longuet
  • Bénédicte Philippon-Jouve
  • Jean-Pierre Quenot
  • Anne Renault
  • Xavier Repesse
  • Jean-Philippe Rigaud
  • Ségolène Robin
  • Antoine Roquilly
  • Amélie Seguin
  • Didier Thevenin
  • Patrice Tirot
  • Isabelle Vinatier
  • Elie Azoulay
  • Jean ReignierEmail author
Original

Abstract

Purpose

The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives.

Methods

This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff.

Results

We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, −1.9; 95% confidence interval, −5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group.

Conclusions

Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation.

Trial registration: ClinicalTrials.gov identifier: NCT01818895.

Keywords

Critical care Treatment limitation Terminal weaning Immediate extubation Mechanical ventilation Ethics 

Notes

Acknowledgements

We are indebted to Celine Deletage, Carole Guignon, Stéphanie Martin, and Vanessa Zinzoni who monitored the study; Isabelle Treillet and Cedric Colombo, the psychologists who performed the interviews; and A. Wolfe, MD, who helped to prepare and review the manuscript. We are grateful to all medical staff, staff nurses, and research nurses at the 43 sites for their valuable contribution to the success of the study.

Additional contributions

Centre Hospitalier Annecy Genevois, Service de Réanimation Polyvalente, Pringy, France: Renaud Chouquer MD, Michel Muller MD; CHU Bordeaux, service de Réanimation Médicale, Bordeaux, France: Frédéric Guérin RN, Didier Gruson, MD, PhD; CHU de la Cavale Blanche, Service de Réanimation Médicale, Brest, France: Amélie Bazire MD, Gwenael Prat, MD; CHU Côte de Nacre, Service de Réanimation Médicale, Caen, France: Xavier Valette MD, Damien Du Cheyron, MD, PhD; CH de Charleville-Mézières, Service de Réanimation polyvalente, Charleville-Mézières, France: Bernard Just MD; CH de Chartres, Service de Réanimation Polyvalente, Chartres, France: A Ben Salah, Pierre Kalfon, MD, PhD; CHU Gabriel Montpied, Service de Réanimation Médicale, Clermont-Ferrand, France: Mireille Adda, Laure Calvet, MD; CH de Dieppe, Service d’Anesthésie-Réanimation, Dieppe, France: Stéphanie Gélinotte MD, Julien Dehay MD; CHU Dijon, service de Réanimation Médicale, France, Dijon, France: Nicolas Meunier-Beillard, Auguste Dargent, MD; CHU Albert Michallon, Clinique de la Réanimation Médicale, Grenoble, France; INSERM U 1039, laboratoire des radiopharmaceutiques biocliniques, La Tronche, France: Carole Schwebel, MD, PhD; Agnès Bonadona, MD; CHD de la Vendée, Service de Réanimation Polyvalente, La Roche-sur-Yon, France: Christine Lebert, MD; Laurent Martin-Lefevre, MD; CH de La Rochelle, Service de Réanimation Polyvalente, La Rochelle, France: Nicolas Girard, CRA; Maxime Leloup, MD; CH du Mans, Service de Réanimation Médico-chirurgicale, Le Mans, France: Dominique Vivier MD, Thomas Rossignol MD; CH de Lens, Service de Réanimation Polyvalente, Lens, France: Johanna Temime MD, Stéphanie Barrailler MD; CH Bretagne Sud, Service de Réanimation Polyvalente, Lorient, France: Guillaume Belliard, MD; APHM, Hôpital La Timone, Réanimation et surveillance continue, Marseille, France: Béatrice Eon, MD; APHM, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France: Christophe Guervilly, MD; Sami Hraiech, MD; CH Marc Jacquet, Service de Réanimation Médicale, Melun, France: Jonathan Chelly, MD; Claire-Marie Weyer, MD; CHU Hôtel-Dieu, Département d’Anesthésie et Réanimation, Nantes, France: Karim Asehnoune MD, PhD; Raphael Cinotti, MD, PhD; CHR d’Orléans, Service de Réanimation Polyvalente, Orléans, France: Thierry Boulain, MD; Grégoire Muller, MD; CHU Cochin, service de Réanimation Médicale, Assistance Publique des Hôpitaux de Paris, Paris, France: Jean-Paul Mira, MD, PhD; Hôpital Foch, Service de Réanimation Polyvalente, Suresnes, France: Charles Cerf, MD; Justine Delesalle; Hôpital Européen Georges Pompidou; Service d’Anesthésie-Réanimation, Paris, France: Arnaud Follin MD, Nadège Rutter RN; CHU Louis Mourier, Service de Réanimation Médico-chirurgicale, Paris, France: Clément Leclaire, MD; Stéphane Gaudry, MD; Institut Gustave Roussy, Service de Réanimation Médico-Chirurgicale, Paris Villejuif, France: François Blot, MD; Annabelle Stoclin, MD; Hôpital Paris Saint Joseph, Service de Réanimation Médicale, Paris, France: Benoit Misset, MD; Lilia Soufir, MD, CHU Saint-Louis, Service de Réanimation Médicale, Paris, France: Emmanuel Canet, MD; CHU Poitiers, service de Réanimation Médicale, Poitiers, France: Rémi Coudroy MD, Arnaud Thille, MD; CHU Lariboisière, Assistance-Publique-Hopitaux de Paris, Service de Réanimation Médicale et Toxicologique, Paris, France: Isabelle Malissin, MD; Lamia Kerdjana, MD; Hôpital Raymond Poincaré, Service de Réanimation Médicale, Assistance Publique des Hôpitaux de Paris, Garches, France: Diane Friedman, MD; CH de Roanne, Réanimation médico-chirurgicale, Roanne, France: P. Beuret, MD; K Hamdi.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Funding

The ARREVE study was supported by grants from three non-profit organisations: the Fondation de France (#000332577), La Roche-sur-Yon Departmental Hospital, and Programme Hospitalier de Recherche Clinique National 2012 of the French Ministry of Health (#13-0142).

Supplementary material

134_2017_4891_MOESM1_ESM.doc (443 kb)
Supplementary material 1 (DOC 443 kb)

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Copyright information

© Springer-Verlag GmbH Germany and ESICM 2017

Authors and Affiliations

  • René Robert
    • 1
    • 2
    • 3
  • Amélie Le Gouge
    • 4
    • 5
    • 6
  • Nancy Kentish-Barnes
    • 7
    • 8
    • 9
  • Alice Cottereau
    • 10
  • Bruno Giraudeau
    • 4
    • 5
    • 6
  • Mélanie Adda
    • 11
  • Djillali Annane
    • 12
    • 13
  • Juliette Audibert
    • 14
  • François Barbier
    • 15
  • Patrick Bardou
    • 16
  • Simon Bourcier
    • 17
    • 18
  • Jeremy Bourenne
    • 19
  • Alexandre Boyer
    • 20
    • 21
  • François Brenas
    • 22
  • Vincent Das
    • 10
  • Arnaud Desachy
    • 23
  • Jérôme Devaquet
    • 24
  • Marc Feissel
    • 25
  • Frédérique Ganster
    • 26
  • Maïté Garrouste-Orgeas
    • 27
    • 28
    • 29
  • Guillaume Grillet
    • 30
  • Olivier Guisset
    • 20
    • 31
  • Rebecca Hamidfar-Roy
    • 32
    • 33
  • Anne-Claire Hyacinthe
    • 34
  • Sebastien Jochmans
    • 35
  • Mercé Jourdain
    • 36
    • 37
    • 38
  • Alexandre Lautrette
    • 39
    • 40
  • Nicolas Lerolle
    • 41
    • 42
  • Olivier Lesieur
    • 43
  • Fabien Lion
    • 44
  • Philippe Mateu
    • 45
  • Bruno Megarbane
    • 7
    • 46
  • Sybille Merceron
    • 7
    • 8
    • 9
  • Emmanuelle Mercier
    • 5
    • 47
    • 48
  • Jonathan Messika
    • 49
  • Paul Morin-Longuet
    • 50
  • Bénédicte Philippon-Jouve
    • 51
  • Jean-Pierre Quenot
    • 52
    • 53
    • 54
  • Anne Renault
    • 55
    • 56
  • Xavier Repesse
    • 57
  • Jean-Philippe Rigaud
    • 58
  • Ségolène Robin
    • 17
    • 59
    • 60
  • Antoine Roquilly
    • 61
    • 62
  • Amélie Seguin
    • 63
  • Didier Thevenin
    • 64
  • Patrice Tirot
    • 65
  • Isabelle Vinatier
    • 66
  • Elie Azoulay
    • 7
    • 8
    • 9
  • Jean Reignier
    • 61
    • 67
    • 68
    Email author
  1. 1.Inserm CICPoitiersFrance
  2. 2.Université de PoitiersPoitiersFrance
  3. 3.Service de Réanimation MédicaleCHU PoitiersPoitiersFrance
  4. 4.Inserm CIC 1415ToursFrance
  5. 5.Université de ToursToursFrance
  6. 6.CHU ToursToursFrance
  7. 7.Université Paris DiderotParisFrance
  8. 8.Service de Réanimation MédicaleCHU Saint-LouisParisFrance
  9. 9.Groupe de Recherche FamiréaParisFrance
  10. 10.Service de Réanimation polyvalenteCHI André GrégoireMontreuilFrance
  11. 11.Aix-Marseille Université, APHM, URMITE, UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections SévèresMarseilleFrance
  12. 12.Inserm U 1173, Université de Versailles-Saint Quentin en YvelinesVersaillesFrance
  13. 13.Service de Réanimation MédicaleHôpital Raymond Poincaré, Assistance Publique des Hôpitaux de ParisGarchesFrance
  14. 14.Service de Réanimation PolyvalenteCH de ChartresChartresFrance
  15. 15.Service de Réanimation MédicaleCHR d’OrléansOrléansFrance
  16. 16.Service de Réanimation Médico-ChirurgicaleCH de MontaubanMontaubanFrance
  17. 17.Université Paris-DescartesParisFrance
  18. 18.Service de Réanimation MédicaleCHU Cochin, Assistance Publique des Hôpitaux de ParisParisFrance
  19. 19.Aix-Marseille Université, APHM, Hôpital La Timone, Réanimation et surveillance continueMarseilleFrance
  20. 20.Université de BordeauxBordeauxFrance
  21. 21.Service de Réanimation MédicaleCHU BordeauxBordeauxFrance
  22. 22.Service de Réanimation PolyvalenteCH Emile RouxLe Puy En VelayFrance
  23. 23.Service de Réanimation PolyvalenteCH d’AngoulêmeAngoulêmeFrance
  24. 24.Service de Réanimation PolyvalenteHôpital FochSuresnesFrance
  25. 25.Service de Réanimation PolyvalenteCH de Belfort-MontbéliardBelfortFrance
  26. 26.Service de Réanimation MédicaleHôpital Emile MullerMulhouseFrance
  27. 27.Service de médecine intensive et de réanimationGroupe Hospitalier Paris Saint JosephParisFrance
  28. 28.Groupe de recherche OutcomereaParisFrance
  29. 29.IAME, UMR 1137, INSERM Université Paris Diderot, Département de biostatistiques-HUPNVS-AP-HP, UFR de Médecine-BichatParisFrance
  30. 30.Service de Réanimation PolyvalenteCH Bretagne SudLorientFrance
  31. 31.Service de Réanimation MédicaleCHU Bordeaux, Hôpital Saint-AndréBordeauxFrance
  32. 32.Université Grenoble-AlpesGrenobleFrance
  33. 33.CHU Albert Michallon, Clinique de la Réanimation MédicaleGrenobleFrance
  34. 34.Service de Réanimation PolyvalenteCentre Hospitalier Annecy GenevoisPringyFrance
  35. 35.Service de Réanimation MédicaleCH Marc JacquetMelunFrance
  36. 36.Université de LilleLilleFrance
  37. 37.Inserm U1190LilleFrance
  38. 38.Service de Réanimation PolyvalenteCHRU de Lille-Hôpital Roger SalengroLilleFrance
  39. 39.Université de Clermont-FerrandClermont-FerrandFrance
  40. 40.Service de Réanimation MédicaleCHU Gabriel MontpiedClermont-FerrandFrance
  41. 41.Université d’AngersAngersFrance
  42. 42.Département de Réanimation médicale et Médecine hyperbareCHU AngersAngersFrance
  43. 43.Service de Réanimation PolyvalenteCH de La RochelleLa RochelleFrance
  44. 44.Service de Réanimation Médico-ChirurgicaleInstitut Gustave RoussyParis VillejuifFrance
  45. 45.Service de Réanimation polyvalenteCH de Charleville-MézièresCharleville-MézièresFrance
  46. 46.Service de Réanimation Médicale et Toxicologique, Assistance-Publique-Hopitaux de ParisCHU LariboisièreParisFrance
  47. 47.Service de Réanimation MédicaleCHU de Tours, Hôpital BretonneauToursFrance
  48. 48.Réseau CRICSToursFrance
  49. 49.IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Service de Réanimation médico-chirurgicale, Hôpital Louis Mourier, AP-HPColombesFrance
  50. 50.Service de Réanimation PolyvalenteCH Saint NazaireSaint NazaireFrance
  51. 51.Service de Réanimation Médico-chirurgicaleCH de RoanneRoanneFrance
  52. 52.Service de Réanimation MédicaleUniversité de Bourgogne Franche ComtéCHU DijonFrance
  53. 53.Equipe Lipness, UMR 866DijonFrance
  54. 54.INSERM CIC 1432DijonFrance
  55. 55.Equipe de recherche EPS (Ethique, professionnalisme et santé) EA 686Université de Bretagne OccidentaleBrestFrance
  56. 56.Service de Réanimation MédicaleCHU de la Cavale BlancheBrestFrance
  57. 57.Service de Réanimation Médico-ChirurgicaleAssistance publique-hôpitaux de Paris, CHU Ambroise ParéBoulogne-BillancourtFrance
  58. 58.Service d’Anesthésie-RéanimationCH de DieppeDieppeFrance
  59. 59.Hôpital Européen Georges PompidouParisFrance
  60. 60.Service d’Anesthésie-RéanimationParisFrance
  61. 61.Université de NantesNantesFrance
  62. 62.Département d’Anesthésie et RéanimationCHU de NantesNantesFrance
  63. 63.Service de Réanimation MédicaleCHU Côte de NacreCaenFrance
  64. 64.Service de Réanimation PolyvalenteCH de LensLensFrance
  65. 65.Service de Réanimation Médico-chirurgicaleCH du MansLe MansFrance
  66. 66.Service de Réanimation PolyvalenteCHD de la VendéeLa Roche-Sur-YonFrance
  67. 67.Service de Médecine Intensive RéanimationCHU de NantesNantesFrance
  68. 68.Service de Médecine Intensive RéanimationCentre Hospitalier Universitaire Hotel-DieuNantes Cedex 1France

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