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[JAMA发表论文]: 压力支持与T管通气进行自主呼吸试验对机械通气患者成功拔管的影响:一项随机临床试验
2019年06月14日 时讯速递, 进展交流 暂无评论

Original Investigation June 11, 2019

Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

Carles Subirà, Gonzalo Hernández, Antònia Vázquez, et al

JAMA. 2019;321(22):2175-2182. doi:10.1001/jama.2019.7234Key Points

Objective 目的

To evaluate the effect of an SBT consisting of 30 minutes of pressure support ventilation (an approach that is less demanding for patients) vs an SBT consisting of 2 hours of T-piece ventilation (an approach that is more demanding for patients) on rates of successful extubation.

评价采用30分钟压力支持通气(对患者要求较少)或2小时T管通气进行SBT(对患者要求较高)对拔管成功率的影响

Design, Setting, and Participants 试验设计,场景及研究人群

Randomized clinical trial conducted from January 2016 to April 2017 among 1153 adults deemed ready for weaning after at least 24 hours of mechanical ventilation at 18 intensive care units in Spain. Follow-up ended in July 2017.

2016年1月至2017年4月在西班牙18个ICU进行的随机临床试验,纳入1153名接受机械通气至少24小时且具备脱机条件的成年患者。随访截止到2017年7月。

Interventions 干预措施

Patients were randomized to undergo a 2-hour T-piece SBT (n = 578) or a 30-minute SBT with 8-cm H2O pressure support ventilation (n = 557).

患者被随机分组,分别接受2小时T管SBT (n = 578)或8-cm H2O压力支持SBT 30分钟(n = 557)。

Main Outcome and Measures 主要预后指标

The primary outcome was successful extubation (remaining free of mechanical ventilation 72 hours after first SBT). Secondary outcomes were reintubation among patients extubated after SBT; intensive care unit and hospital lengths of stay; and hospital and 90-day mortality.

主要预后指标为成功拔管(首次SBT后无需机械通气72小时)。次要预后指标包括SBT后拔管患者再插管比例;ICU住院日及总住院日;住院及90天病死率。

Results 结果

Among 1153 patients who were randomized (mean age, 62.2 [SD, 15.7] years; 428 [37.1%] women), 1018 (88.3%) completed the trial. Successful extubation occurred in 473 patients (82.3%) in the pressure support ventilation group and 428 patients (74.0%) in the T-piece group (difference, 8.2%; 95% CI, 3.4%-13.0%; P = .001). Among secondary outcomes, for the pressure support ventilation group vs the T-piece group, respectively, reintubation was 11.1% vs 11.9% (difference, −0.8%; 95% CI, −4.8% to 3.1%; P = .63), median intensive care unit length of stay was 9 days vs 10 days (mean difference, −0.3 days; 95% CI, −1.7 to 1.1 days; P = .69), median hospital length of stay was 24 days vs 24 days (mean difference, 1.3 days; 95% CI, −2.2 to 4.9 days; P = .45), hospital mortality was 10.4% vs 14.9% (difference, −4.4%; 95% CI, −8.3% to −0.6%; P = .02), and 90-day mortality was 13.2% vs 17.3% (difference, −4.1% [95% CI, −8.2% to 0.01%; P = .04]; hazard ratio, 0.74 [95% CI, 0.55-0.99]).

1153名患者接受随机分组(平均年龄, 62.2 [SD, 15.7] 岁; 428名 [37.1%] 女性),1018名患者 (88.3%) 完成了临床试验。压力支持组473名患者 (82.3%) 及T管组428名患者 (74.0%) 拔管成功(差异, 8.2%; 95% CI, 3.4%-13.0%; P = .001)。在次要预后指标中,压力支持组与T管组再插管率分别为 11.1% vs 11.9% (差异, −0.8%; 95% CI, −4.8% to 3.1%; P = .63),ICU住院日中位数分别为 9 天 vs 10 天(平均差异, −0.3 天; 95% CI, −1.7 to 1.1 天; P = .69),住院日中位数分别为 24 天 vs 24 天(平均差异, 1.3 天; 95% CI, −2.2 to 4.9 天; P = .45),住院病死率分别为 10.4% vs 14.9% (差异, −4.4%; 95% CI, −8.3% to −0.6%; P = .02),90天病死率分别为 13.2% vs 17.3% (差异, −4.1% [95% CI, −8.2% to 0.01%; P = .04]; 风险比, 0.74 [95% CI, 0.55-0.99])。

Conclusions and Relevance 结论与意义

Among patients receiving mechanical ventilation, a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials.

对于接受机械通气的患者,与2小时T管通气相比,采用30分钟压力支持进行自主呼吸试验显著增加拔管成功率。这些结果支持采用时间更短、对患者要求更少的通气策略进行自主呼吸试验。

Trial Registration 试验注册

ClinicalTrials.gov Identifier: NCT02620358

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