Early vs. Standard Extubation in Hypoxemic Patients: a randomised clinical trial.

Vaschetto R, et al. Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med. 2018 Dec 10. doi: 10.1007/s00134-018-5478-0.

Reducing mechanical ventilation duration and preventing all the complications related to this life-saving but nevertheless invasive procedure is one of the main challenges of critical care. Non-invasive ventilation has already been proved to be an efficient way to reduce or delay the implementation of invasive mechanical ventilation, both in immunocompromised patients [1] or in non-immunocompromised patients [2], but there are few studies evaluating its efficiency in allowing early extubation.

The study proposed by Vaschetto et al. is a parallel group, international, multi-centre randomised clinical trial concerning early extubation with the help of immediate NIV in non-hypercapnic hypoxemic patients recovering from an acute respiratory failure. It was conducted from 13 October 2013 to 19 October 2016 in nine ICUs of academic hospitals, six in the Chinese Republic and three in Italy. To be included in this trial, patients still had to be dependent on a PEEP level of between 8 and 13cm H2O and inspiratory support; 130 patients were enrolled, 65 randomised to undergo early extubation and immediate NIV, and 65 following standard extubation procedures.

Patients in the intervention group did not perform spontaneous breathing trials (SBT) before extubation, and NIV was immediately applied with the same PEEP and inspiratory support levels.

In the control group, if the PaO2/FiO2 reached > 250mmHg, a partially supported SBT was performed and patients could be extubated if they met standard criteria.

STUDY STRENGTHS & LIMITATIONS

The study obtained encouraging results: NIV after early extubation significantly reduced the days spent on i-MV, [5.5 (4.0–9.0) vs. 4.0 (3.0–7.0) days, p=0.004] in particular in surgical patients, as they showed a shorter length of i-MV compared with controls [3.0 (2.0–6.0) days vs. 5.4 (3.8–8.9) days, p=0.004], and shorter ICU LOS [6.0 (5.0–8.3) vs. 8.5 (6.3–13.5) days, p=0.036].

There are some significant limitations in this study: it concerns a highly-specific group of patients which reduces generalisability; it does not take into account the possibility to use HFOT; and there was a wide variability of interfaces, humidifiers, and ventilators used. Nevertheless, it confirmed the results of the previous pilot study conducted by the same team [3], meaning that NIV after early extubation can reduce i-MV duration and its complications, even if it does not affect ICU length of stay.

TAKE HOME MESSAGE

• NIV may facilitate the process of withdrawing mechanical ventilation in non-hypercapnic hypoxemic patients, and consequently reduce main complications (VAT, VAP, need for sedation, hospital LOS).
• Besides, there is a trend showing that surgical patients could benefit more from this process, opening new perspectives to future research.

This article review was prepared and submitted by Silvia Calvino Günther, Nurse Educator, Centre Hospitalier Universitaire Grenoble Alpes, Medical Intensive Care Unit, and Member of the ESICM N&AHP Committee, on behalf of the ESICM Journal Review Club.

3) Rosanna Vaschetto, Emilia Turucz, Fabrizio Dellapiazza, Stefania Guido, Davide Colombo, Gianmaria Cammarota, Francesco Della Corte, Massimo Antonelli, Paolo Navalesi. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Int Crit Care Volume 38, Number 10 / October, 2012.