西班牙Manresa大学Carles Subirà研究团队开展了一项随机临床试验，探究了压力支持与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。该成果于2019年6月发表在《美国医学会杂志》上。

研究表明每日自主呼吸试验(SBTs)是确定患者是否准备好脱离机械通气的最佳方法，但SBT的模式和持续时间仍存在争议。

本试验比较采用30分钟压力支持通气与2小时T管通气进行SBT对拔管成功率的影响。

2016年1月至2017年4月对西班牙18个重症监护病房内1153名至少接受了24小时的机械通气且具备脱机条件的成年人进行了随机临床试验，随访于2017年7月结束。患者随机接受2小时T管SBT（n = 578）或30分钟8-cm H₂O压力支持通气SBT（n = 557）。主要预后指标是拔管成功（首次SBT后72小时无需进行机械通气）。次要预后指标包括SBT后拔管患者的重新插管比例，重症监护病房和住院总时间，住院和90天的死亡率。在随机分组的1153例患者中（平均年龄62.2 [SD，15.7]年; 428例[37.1％]女性），1018例（88.3％）完成了试验。其中接受30分钟压力支持通气的患者成功拔管的比例为82.3%，而接受2小时t片通气的患者成功拔管的比例为74%，差异具有统计学意义。在次要预后指标中，压力支持通气组和T管组的再插管率分别为11.1％和11.9％（差异，-0.8％; 95％CI，-4.8％至3.1％; P = 0.63），重症监护室中位住院时间为9天和10天（平均差异，-0.3天; 95％CI，-1.7至1.1天; P =0 .69），住院时间中位数分别为24天vs 24天（平均差异1.3天; 95％CI，-2.2至4.9天; P = 0.45），住院死亡率分别为10.4％和14.9％（差异，-4.4％; 95％CI，-8.3％至-0.6％; P =0 .02），90天死亡率为13.2％对17.3％（差异，-4.1％[95％CI，-8.2％至0.01％; P = 0.04]；风险比，0.74 [95％CI，0.55- 0.99]）。

在接受机械通气的患者中，30分钟的压力支持通气自发呼吸试验与2小时的T管通气相比，拔管成功率显着提高。该结论支持使用需时更短、要求更低的通气策略进行自主呼吸试验。

附：英文原文

Title: 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

Author: Carles Subirà, Gonzalo Hernández, Rafael Fernández

Issue&Volume:Vol 321, No. 22,2019

Abstract：

Importance Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial.

Objective 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.

Design, Setting, and Participants 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.

Interventions 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).

Main Outcome and Measures 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.

Results 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]).

Conclusions and Relevance 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.

DOI: doi:10.1001/jama.2019.7234

Source: https://jamanetwork.com/journals/jama/article-abstract/2735502