Trials directly comparing alternative spontaneous breathing trial techniques: a systematic review and meta-analysis

Karen E A Burns,Jose Augusto Pellegrini,Amer Zwein,Carolina Gomez-Builes,Neill K J Adhikari,Michael Sklar,Ibrahim Soliman,Jessica T Y Wong,Jan O Friedrich,Lu Chen,Nuttapol Rittayamai,Laurent J Brochard

doi:10.1186/s13054-017-1698-x

Abstract

BackgroundThe effect of alternative spontaneous breathing trial (SBT) techniques on extubation success and other clinically important outcomes is uncertain.MethodsWe searched MEDLINE, EMBASE, CENTRAL, CINAHL, Evidence-Based Medicine Reviews, Ovid Health Star, proceedings of five conferences (1990–2016), and reference lists for randomized trials comparing SBT techniques in intubated adults or children. Primary outcomes were initial SBT success, extubation success, or reintubation. Two reviewers independently screened citations, assessed trial quality, and abstracted data.ResultsWe identified 31 trials (n = 3541 patients). Moderate-quality evidence showed that patients undergoing pressure support (PS) compared with T-piece SBTs (nine trials, n = 1901) were as likely to pass an initial SBT (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.89–1.11; I2 = 77%) but more likely to be ultimately extubated successfully (RR 1.06, 95% CI 1.02–1.10; 11 trials, n = 1904; I2 = 0%). Exclusion of one trial with inconsistent results for SBT and extubation outcomes suggested that PS (vs T-piece) SBTs also improved initial SBT success (RR 1.06, 95% CI 1.01–1.12; I2 = 0%). Limited data suggest that automatic tube compensation plus continuous positive airway pressure (CPAP) vs CPAP alone or PS increase SBT but not extubation success.ConclusionsPatients undergoing PS (vs T-piece) SBTs appear to be 6% (95% CI 2–10%) more likely to be extubated successfully and, if the results of an outlier trial are excluded, 6% (95% CI 1–12%) more likely to pass an SBT. Future trials should investigate patients for whom SBT and extubation outcomes are uncertain and compare techniques that maximize differences in support.

Highlights

The effect of alternative spontaneous breathing trial (SBT) techniques on extubation success and other clinically important outcomes is uncertain
Compared with nonprotocolized care, randomized controlled trials (RCTs) and a systematic review indicate that weaning protocols reduce the duration of mechanical ventilation, weaning time, and intensive care unit (ICU) length of stay (LOS)
Low-quality evidence from three trials (n = 247) suggests that patients were significantly more likely to pass an SBT with Automatic tube compensation (ATC) + continuous positive airway pressure (CPAP) compared with CPAP alone (RR 1.12, 95% Confidence interval (CI) 1.04–1.22; p = 0.005, I2 = 0%)

Summary

Introduction

The effect of alternative spontaneous breathing trial (SBT) techniques on extubation success and other clinically important outcomes is uncertain. Weaning accounts for approximately 40% of the time spent on mechanical ventilation [1, 2]. Compared with nonprotocolized care, randomized controlled trials (RCTs) and a systematic review indicate that weaning protocols reduce the duration of mechanical ventilation, weaning time, and intensive care unit (ICU) length of stay (LOS). Patients may undergo a spontaneous breathing trial (SBT) to assess their ability to breathe spontaneously with minimal or no support. Clinicians conduct SBTs to facilitate decision-making regarding timely extubation and to minimize patients’ exposure to invasive ventilation. Several techniques are commonly used to conduct SBTs, including pressure support (PS) with or without positive end-expiratory pressure (PEEP), continuous positive airway pressure (CPAP), automatic

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