title: Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial.
abstract: OBJECTIVE
  Patients requiring prolonged mechanical ventilation (>21 days) are commonly weaned at long-term acute care hospitals (LTACHs). The most effective method of weaning such patients has not been investigated.
  
  
  OBJECTIVE
  To compare weaning duration with pressure support vs unassisted breathing through a tracheostomy collar in patients transferred to an LTACH for weaning from prolonged ventilation.
  
  
  METHODS
  Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation. Of 500 patients who underwent a 5-day screening procedure, 316 did not tolerate the procedure and were randomly assigned to receive weaning with pressure support (n = 155) or a tracheostomy collar (n = 161). Survival at 6- and 12-month time points was also determined.
  
  
  METHODS
  Primary outcome was weaning duration. Secondary outcome was survival at 6 and 12 months after enrollment.
  
  
  RESULTS
  Of 316 patients, 4 were withdrawn and not included in analysis. Of 152 patients in the pressure-support group, 68 (44.7%) were weaned; 22 (14.5%) died. Of 160 patients in the tracheostomy collar group, 85 (53.1%) were weaned; 16 (10.0%) died. Median weaning time was shorter with tracheostomy collar use (15 days; interquartile range [IQR], 8-25) than with pressure support (19 days; IQR, 12-31), P = .004. The hazard ratio (HR) for successful weaning rate was higher with tracheostomy collar use than with pressure support (HR, 1.43; 95% CI, 1.03-1.98; P = .033) after adjusting for baseline clinical covariates. Use of the tracheostomy collar achieved faster weaning than did pressure support among patients who did not tolerate the screening procedure between 12 and 120 hours (HR, 3.33; 95% CI, 1.44-7.70; P = .005), whereas weaning time was equivalent with the 2 methods in patients who did not tolerate the screening procedure within 0 to 12 hours. Mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 months (55.92% vs 51.25%; 4.67% difference, 95% CI, -6.4% to 15.7%) and at 12 months (66.45% vs 60.00%; 6.45% difference, 95% CI, -4.2% to 17.1%).
  
  
  CONCLUSIONS
  Among patients requiring prolonged mechanical ventilation and treated at a single long-term care facility, unassisted breathing through a tracheostomy, compared with pressure support, resulted in shorter median weaning time, although weaning mode had no effect on survival at 6 and 12 months.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01541462.
authors: Division of Pulmonary and Critical Care Medicine, Edward Hines Jr VA Hospital, 111N, 5000 Fifth Ave, Hines, IL 60141, USA. mtobin2@lumc.edu
authors: Amal
authors: A
authors: Jubran
authors: Brydon J B
authors: BJ
authors: Grant
authors: Lisa A
authors: LA
authors: Duffner
authors: Eileen G
authors: EG
authors: Collins
authors: Dorothy M
authors: DM
authors: Lanuza
authors: Leslie A
authors: LA
authors: Hoffman
authors: Martin J
authors: MJ
authors: Tobin
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000379:methods*; D012119:Respiration; D016019:Survival Analysis; D013997:Time Factors; D014139:Tracheostomy / Q000295:instrumentation*; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000379:methods*