REMI 1927E. Noninvasive positive-pressure ventilation as a weaning strategy

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Original article: Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure.Burns KE, Meade MO, Premji A, Adhikari NK. Cochrane Database Syst Rev 2013; 12: CD004127. [Abstract] [Related articles]
   
Introduction: Many complications related to the use of mechanical ventilation, in particular ventilator-associated pneumonia (VAP), are time dependent. Therefore, weaning should be started as early as possible and can occupy up to 40% of total mechanical ventilation time [1]. Substitution of traditional weaning with non-invasive mechanical ventilation (NIV) weaning can have a significant impact on the duration of invasive mechanical ventilation and thus may reduce the incidence of complications.
   
Abstract: The aim of this review is to compare weaning by means of early extubation followed by immediate application of NIV or continued IPPV weaning in adults with respiratory failure of any cause. The primary outcome was to determine whether NIV reduces mortality compared with invasive positive-pressure ventilation (IPPV) weaning. Secondary outcomes were the differences between the two strategies in terms of weaning failure, NAV incidence, ICU and hospital lenght of stay, total duration of mechanical ventilation and intubation. With this aim, randomized or quasi-randomized clinical trials comparing the two techniques were searched in the Cochrane Central Register of Controlled Trials, Medline and Embase, among other databases. 16 trials with 994 participants, most with Chronic Obstructive Pulmonary Disease (COPD) were identified. In them, mortality was significantly lower with NIV compared to traditional weaning (RR 0.53, 95% CI 0.36 to 0.80, P = 0.002). This benefit was significantly higher in the 9 trials enrolling only COPD patients (RR 0.36, 95% CI 0.24 to 0.56) than in those with mixed population (RR 0.81, 95% CI 0.47 to 1.40). NIV weaning also significantly reduced weaning failure and VAP, shortened ICU and hospital lenght of stay and total time in mechanical ventilation (mean difference -7.44 days, 95% CI -10.34 to -4.55). NIV weaning also reduced the rates of re-intubation and tracheostomy. NIV had no effect on the duration of mechanical ventilation related to weaning.
   
Comments: This review suggests that NIV may be an effective and safe technique of weaning (since it does not increase the failure rate of weaning or reintubation), at least in patients with COPD. However, it must be noted that for patients with IPPV weaning, different ventilatory modes were used in each trial, including SIMV or PSV, with gradual reduction in pressure support that may have delayed the decision to perform the T-tube test. Also, this test lasted for a variable period of time, from half an hour to three hours.
      
Ramón Díaz-Alersi
Hospital U. Puerto Real, Cádiz.
© REMI, http://medicina-intensiva.com. January 2014
   
Links:
  1. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. Esteban A, Frutos F, Tobin MJ, Alía I, Solsona JF, Valverdú I, Fernández R, de la Cal MA, Benito S, Tomás R, et al. N Engl J Med 1995; 332: 345-350.[PubMed] [Full text
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  • Plain Language: Noninvasive positive-pressure ventilation as weaning strategy
  • Syntax: Noninvasive positive-pressure ventilation AND weaning strategy
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