Weaning from a ventilator was defined as the time between the first attempt at separation and successful extubation, resulting in either seven days of continuous spontaneous breathing or discharge from the ICU, whichever comes first and regardless of the use of NIV .
The NIV applied immediately after extubation has been used for some time in several patient groups, including COPD patients and hypercapnic patients with acute to chronic respiratory insufficiency, to prevent respiratory failure after extubation.
Which Resp technique is the best in the ITU?
A more recent guideline could not give any clear recommendations for the use of this procedure in patients with non-hypercapnic hypoxemic acute respiratory insufficiency (hARF) due to the scarcity of data.
Since the guidelines were published, new studies have emerged that clarify whether or not early extubation should be used in hARF patients. Therefore, a new systematic review article published in the journal Critical Care aims to clarify whether NIV after early extubation in patients with non-hypercapnic hypoxemic acute respiratory failure shortens the total duration of invasive mechanical ventilation compared to conventional weaning. [ []
Methods
This systematic review and meta-analysis was carried out in accordance with the PRISMA instructions with the protocol registered on PROSPERO. Articles were considered eligible for inclusion if they were RCTs comparing early extubation plus NIV with standard weaning with an ETT in adults who were not hypercapnic and who received i-MV for more than two days.
Articles were excluded if the respiratory insufficiency was caused by neurological or neuromuscular diseases, patients with asthma, COPD, OSA, pulmonary edema, a tracheal vessel or a BMI over 30.
The databases searched were EMBASE, PubMed and CENTRAL with no language or date restrictions and the search strategies are fully available. Two authors, with a third for consensus, reviewed the articles and applied the inclusion / exclusion criteria.
The data were extracted using a form that was first piloted and refined by the two authors. The Cochrane Risk of Bias Tool was used to assess the quality of the studies included in the review, the results of which were fully available.
The primary outcome measure used in the review was the total duration of ventilation, with secondary measures being the rate of ventilation-associated pneumonia and the mortality rate.
Clinical significance and clinical take-home
A total of six studies were included in the quantitative synthesis, which was reduced from an initial result of 1605 data sets. The full explanation of why articles were excluded is available in the article and visually summarized in the PRISMA-IPD flowchart.
A total of 459 patients were included in the review, 233 in the intervention group and 226 in the control group with a mean age of 62 years, 59% of whom were male.
With regard to the primary result of the study, the patients who received NIV after early extubation showed a shorter duration of invasive mechanical ventilation than the control group. According to a sensitivity analysis, this remained statistically significant with estimates of between -2.7 and -5 days less ventilation.
Brief summary of the NIV after early extubation
The use of NIV after early extubation resulted in a shorter time for invasive mechanical ventilation
The total time that was spent with mechanical ventilation did not differ between the groups
Patients who spend less time on invasive ventilation have lower rates of ventilation-associated pneumonia
The time to discharge from the intensive care unit did not differ between the groups, but the NIV group had a somewhat shorter hospital stay .
Even after adjustment to demographics and severity-dependent variables, the duration of invasive ventilation was shorter in those who received NIV after early extubation ( mean difference of -3.43 days ). However, the total duration of mechanical ventilation was not significant.
The study did not identify any significant differences in mortality between the groups, but there was a lower rate of ventilation-related pneumonia in the NIV group. In addition, the NIV group was discharged from the hospital earlier, but as a control group it had a total length of stay at the ITU.
The systematic review shows some weaknesses, which the authors mitigated as much as possible, but the results suggest that patients who recover from hARF are likely to have early extubation followed by immediate NIV benefit.
