Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial.
BACKGROUND
Non-invasive ventilation can prevent respiratory failure after extubation in individuals at increased risk of this complication, and enhanced survival in patients with hypercapnia has been recorded. We aimed to assess prospectively the effectiveness of non-invasive ventilation after extubation in patients with hypercapnia and as rescue therapy when respiratory failure develops.


METHODS
We undertook a randomised controlled trial in three intensive-care units in Spain. We enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia after a successful spontaneous breathing trial. We randomly allocated participants by computer to receive after extubation either non-invasive ventilation for 24 h (n=54) or conventional oxygen treatment (n=52). The primary endpoint was avoidance of respiratory failure within 72 h after extubation. Analysis was by intention to treat. This trial is registered with clinicaltrials.gov, identifier NCT00539708.


RESULTS
Respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation than in those allocated conventional oxygen therapy (8 [15%] vs 25 [48%]; odds ratio 5.32 [95% CI 2.11-13.46]; p<0.0001). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was independently associated with a lower risk of respiratory failure after extubation (adjusted odds ratio 0.17 [95% CI 0.06-0.44]; p<0.0001). 90-day mortality was lower in patients assigned non-invasive ventilation than in those allocated conventional oxygen (p=0.0146).


CONCLUSIONS
Early non-invasive ventilation after extubation diminished risk of respiratory failure and lowered 90-day mortality in patients with hypercapnia during a spontaneous breathing trial. Routine implementation of this strategy for management of mechanically ventilated patients with chronic respiratory disorders is advisable.


BACKGROUND
IDIBAPS, CibeRes, Fondo de Investigaciones Sanitarias, European Respiratory Society.
Ferrer
Miquel
M
Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain. miferrer@clinic.ub.es
Sellarés
Jacobo
J
Valencia
Mauricio
M
Carrillo
Andres
A
Gonzalez
Gumersindo
G
Badia
Joan Ramon
JR
Nicolas
Josep Maria
JM
Torres
Antoni
A
D000368:Aged; D002908:Chronic Disease; D020878:Device Removal; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006935:Hypercapnia / Q000150:complications; D007442:Intubation, Intratracheal; D007902:Length of Stay; D008297:Male; D011175:Positive-Pressure Respiration / Q000009:adverse effects; D012121:Respiration, Artificial / Q000009:adverse effects; D012131:Respiratory Insufficiency / Q000097:blood / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D015300:Ventilator Weaning