Respiratory Trials·org

Topic

Ventilation & weaning

Oxygen targets, non-invasive support, high-flow oxygen, extubation, and tracheostomy.

Non-invasive ventilation earns its place in hypercapnic COPD and almost nowhere else with the same confidence. In acute exacerbations it reduced intubation, length of stay and in-hospital mortality (Brochard 1995). In cardiogenic pulmonary oedema it relieves distress and acidosis faster than oxygen but does not reduce mortality (3CPO) — a distinction worth keeping straight.

High-flow nasal oxygen did not reduce intubation in hypoxaemic respiratory failure, its primary endpoint, but produced more ventilator-free days and lower 90-day mortality as secondary findings (FLORALI). The non-invasive ventilation arm fared worst of the three, which is the part of that trial most often forgotten.

Liberation is about sedation as much as ventilation. Pairing a daily spontaneous awakening trial with a daily breathing trial produced more ventilator-free days and better one-year survival than breathing trials alone (Wake up and breathe). How the breathing trial itself is conducted matters less: pressure support and T-piece gave identical ventilator-free days (TIP-EX).

Weaning from the ventilator

Trial Year Therapy Effect Finding
TIP-EX 2022 Pressure-support spontaneous breathing trial Pressure support and T-piece breathing trials produced the same ventilator-free days
Breathe 2018 Early extubation to non-invasive ventilation Extubating early onto non-invasive ventilation did not shorten total time to liberation
Jubran 2013 2013 Tracheostomy collar Unassisted breathing through a tracheostomy collar weaned patients faster than pressure support
Wake up and breathe 2008 Paired sedation interruption and breathing trial Pairing daily sedation interruption with a breathing trial got patients off ventilators sooner and improved survival
Brochard 1994 1994 Pressure support weaning Gradual pressure support weaning outperformed T-piece trials and SIMV in difficult-to-wean patients

Preventing post-extubation failure

Trial Year Therapy Effect Finding
Casey 2021 2021 Protocolised post-extubation support Giving every extubated patient respiratory support prevented no reintubations
Thille 2019 2019 High-flow oxygen plus non-invasive ventilation Adding non-invasive ventilation to high-flow oxygen cut reintubation in the highest-risk patients
Hernandez 2016 2016 High-flow nasal oxygen High-flow nasal oxygen was non-inferior to non-invasive ventilation after extubation, and better tolerated
Ferrer 2009 2009 Prophylactic non-invasive ventilation Prophylactic non-invasive ventilation after extubation prevented respiratory failure and deaths in hypercapnic patients

Oxygenation targets in the ventilated patient

Trial Year Therapy Effect Finding
UK-ROX 2025 Conservative oxygen therapy Conservative oxygen targets changed nothing, in the largest ICU oxygen trial yet run
PILOT 2022 SpO2 target Lower, intermediate and higher oxygen saturation targets gave identical ventilator-free days
ICU-ROX 2020 Conservative oxygen therapy Conservative oxygen therapy made no difference to ventilator-free days

Rehabilitation in the critically ill

Trial Year Therapy Effect Finding
TEAM 2022 Early active mobilisation Pushing mobilisation harder gave no benefit and more than doubled adverse events
Morris 2016 2016 Standardised rehabilitation therapy Standardised rehabilitation did not shorten hospital stay or improve strength
Moss 2016 2016 Intensive physical therapy Nearly five times as much physiotherapy produced no functional gain

Non-invasive support in cardiogenic pulmonary oedema

Trial Year Therapy Effect Finding
3CPO 2008 CPAP or bilevel NIV Non-invasive ventilation made patients with pulmonary oedema feel better faster without saving lives
Bersten 1991 1991 Face-mask CPAP Face-mask CPAP rapidly improved physiology and reduced intubation in cardiogenic pulmonary oedema

Non-invasive ventilation in hypoxaemic failure

Trial Year Therapy Effect Finding
Jaber 2016 2016 Non-invasive ventilation Non-invasive ventilation reduced reintubation after abdominal surgery
Ferrer 2003 2003 Non-invasive ventilation Non-invasive ventilation reduced intubation and mortality in severe hypoxaemic respiratory failure

Timing of tracheostomy

Trial Year Therapy Effect Finding
TracMan 2013 Early tracheostomy Early tracheostomy did not improve survival, and over half the late group never needed one
Terragni 2010 2010 Early tracheostomy Early tracheostomy did not significantly reduce ventilator-associated pneumonia

High-flow nasal oxygen

Trial Year Therapy Effect Finding
FLORALI 2015 High-flow nasal oxygen High-flow oxygen did not reduce intubation but was associated with lower 90-day mortality

Non-invasive ventilation in COPD exacerbation

Trial Year Therapy Effect Finding
Brochard 1995 1995 Non-invasive ventilation Non-invasive ventilation cut intubation, length of stay and mortality in COPD exacerbations

Predicting weaning success

Trial Year Therapy Effect Finding
Yang and Tobin diagnostic accuracy 1991 Rapid shallow breathing index The rapid shallow breathing index outperformed every other weaning predictor

Rescuing established post-extubation failure

Trial Year Therapy Effect Finding
Esteban 2004 2004 Rescue non-invasive ventilation Rescue non-invasive ventilation for established post-extubation failure did not work and delayed reintubation

Routine investigations in the ventilated patient

Trial Year Therapy Effect Finding
Hejblum 2009 2009 On-demand chest radiography Ordering chest films on demand cut radiographs by a third with no loss of safety

Tidal volume without ARDS

Trial Year Therapy Effect Finding
PReVENT 2018 Low tidal volume ventilation Low tidal volumes gave no benefit in ventilated patients who did not have ARDS

Tracheostomy decannulation

Trial Year Therapy Effect Finding
REDECAP 2020 Suctioning-based decannulation Deciding decannulation on suctioning frequency rather than capping trials halved time to decannulation

Key references

Guidelines, standards and reviews for this topic.