About this trial
This is a randomized, open, multicenter, pragmatic, adaptive clinical trial with intention-to-treat analysis. The study will compare two weaning strategies from mechanical ventilation in critically ill patients admitted to intensive care units, with more than 72 hours of mechanical ventilation and with a successful spontaneous breathing trial on T-piece. Immediately after a successful spontaneous breathing trial, eligible patients will be randomized into 2 groups that will be treated according to one of the following interventions:
1. One-hour positive pressure ventilation: as soon as the success of the spontaneous breathing trial is confirmed, the patient is submitted to mechanical ventilation for 1 hour using the previous ventilatory parameters and, afterwards, extubated. 2. Immediate extubation: the patient is extubated immediately after the success of the spontaneous breathing trial.
Eligibility criteria
This trial does not accept healthy volunteersQualifiers
Patients aged > 18 years.
Admitted to the intensive care unit (surgical or medical).
With endotracheal intubation.
Mechanical ventilation for more than 72 hours.
Disqualifiers
Patients unable to obey commands.
With non-planned extubation.
Neuromuscular disease and cervical spinal cord injury.
Tracheostomy.
Trial design
Parallel
Treatments tested in this trial
One-hour positive pressure ventilation
Other interventionAs soon as the success of the spontaneous breathing trial is confirmed, the patient is submitted to mechanical ventilation for 1 hour using the previous ventilatory parameters and, afterwards, extubated.
Immediate extubation
Other interventionThe patient is extubated immediately after the success of the spontaneous breathing trial.
Treatment groups
Trial outcomes
Primary outcomes
Number of Participants With Extubation Failure Within 7 Days
Extubation failure is defined as a composite endpoint of reintubation or death within 7 days after randomization.
Secondary outcomes
Ventilator-Free Days Through Day 28
Ventilator-free days are defined as the number of days alive and free from invasive mechanical ventilation from randomization through Day 28 after randomization. If a patient dies before day 28, the ventilator-free days will be counted as zero. If a patient is reintubated and returns to mechanical ventilation and later is extubated again and remains in unassisted breathing until day 28, the ventilator-free days will be counted from the end of the last period of assisted breathing until day 28. An invasive mechanical ventilation period of less than 24 hours for surgical purposes will count as 1 ventilator-free day. Patients discharged from the hospital in unassisted breathing before 28 days will be considered alive and free from mechanical ventilation for the remaining days up to 28 days. Patients transferred to another hospital or healthcare unit will be followed up until day 28 to assess this outcome.
Hospital-Free Days Through Day 28
Hospital-free days are defined as the number of days alive and out of the hospital from randomization through Day 28 after randomization. If a patient dies before day 28, the hospital-free days will be counted as zero. Patients discharged from the hospital in unassisted breathing before 28 days will be considered alive and free from hospital for the remaining days up to 28 days. Patients transferred to another hospital or healthcare unit will be followed through day 28 to ascertain this outcome.
Number of Participants Who Died Within 28 Days
All-cause mortality from randomization through day 28
Other outcomes
Ventilatory Support-Free Days Through Day 28
Ventilatory support-free days are defined as the number of days alive and free from any ventilatory support (invasive or noninvasive) from randomization through day 28. Any use of invasive mechanical ventilation for any duration during a calendar day will count as 1 day with ventilatory support (i.e., not free). Use of noninvasive ventilatory support (noninvasive ventilation or high-flow nasal cannula) for ≥6 hours in any calendar day will count as 1 day with ventilatory support. Participants who die before day 28 will be assigned 0 ventilatory support-free days. If reintubation occurs and the participant later achieves unassisted spontaneous breathing again, ventilatory support-free days will be counted from the end of the last assisted-breathing period through day 28, provided the participant remains alive and free from ventilatory support.
Number of Participants With Extubation Failure Within 2 Days
Extubation failure is defined as a composite endpoint of reintubation or death within 2 days after randomization
Number of Participants With Death or Reintubation Within 28 Days
Composite endpoint of reintubation or death within 28 days after randomization
Intensive Care Unit-Free Days Through Day 28
ICU-free days are defined as the number of days alive and out of the intensive care unit from randomization through day 28. If a patient dies before day 28, the ICU-free days will be counted as zero. Patients discharged from the hospital in unassisted breathing before 28 days will be considered as alive and free from ICU for the remaining days up to 28 days. Patients transferred to another hospital or healthcare unit will be followed up until day 28 to assess this outcome.
Locations
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