Division of Pulmonary and Critical Care Medicine, Edward Hines Jr VA Hospital, 111N, 5000 Fifth Ave, Hines, IL 60141, USA.
JAMA. 2013 Feb 20;309(7):671-7. doi: 10.1001/jama.2013.159.
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.
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.
DESIGN, SETTING, AND PARTICIPANTS: 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.
Primary outcome was weaning duration. Secondary outcome was survival at 6 and 12 months after enrollment.
Of 316 patients, 4 were withdrawn and not included in analysis.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%).
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.
clinicaltrials.gov Identifier: NCT01541462.
需要长时间机械通气（>21 天）的患者通常在长期急性护理医院（LTACH）进行脱机。尚未研究最有效的脱机方法。
比较压力支持与经气管造口套管无辅助呼吸在转至 LTACH 进行长时间通气脱机的患者中的脱机时间。
设计、地点和参与者：2000 年至 2010 年期间，在一家 LTACH 对因长时间通气而接受气管切开术的患者进行了一项随机研究。在 500 名接受了为期 5 天的筛选程序的患者中，有 316 名患者无法耐受该程序，并被随机分配接受压力支持（n=155）或气管造口套管（n=161）脱机。还确定了 6 个月和 12 个月时的生存情况。
主要观察指标为脱机时间。次要观察指标为纳入后的 6 个月和 12 个月的生存情况。
在 316 名患者中，有 4 名患者被撤出，未纳入分析。在 152 名接受压力支持的患者中，有 68 名（44.7%）成功脱机；22 名（14.5%）死亡。在 160 名接受气管造口套管的患者中，有 85 名（53.1%）成功脱机；16 名（10.0%）死亡。与压力支持相比，气管造口套管的中位脱机时间更短（15 天；四分位间距 [IQR]，8-25），P=.004。调整基线临床协变量后，气管造口套管的成功脱机率高于压力支持（风险比 [HR]，1.43；95%CI，1.03-1.98；P=.033）。在耐受筛选程序 12 至 120 小时的患者中，与压力支持相比，气管造口套管的使用实现了更快的脱机（HR，3.33；95%CI，1.44-7.70；P=.005），而在耐受筛选程序 0 至 12 小时的患者中，两种方法的脱机时间相当。在 6 个月（55.92%比 51.25%；4.67%差异，95%CI，-6.4%至 15.7%）和 12 个月（66.45%比 60.00%；6.45%差异，95%CI，-4.2%至 17.1%）时，压力支持组和气管造口套管组的死亡率相似。
在需要长时间机械通气并在单一长期护理机构接受治疗的患者中，与压力支持相比，经气管造口套管的无辅助呼吸导致中位脱机时间更短，但脱机模式对 6 个月和 12 个月的生存没有影响。
clinicaltrials.gov 标识符：NCT01541462。
