经气管切开套管拔管时高流量吸氧联合封管或吸引。

High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation.

机构信息

From Virgen de la Salud University Hospital (G.H.M., M.-L.R., L.C.) and the Research Unit, Medical Council (R.C.-B.), Toledo, Ramón y Cajal University Hospital (M.-C.V., R.P.) and Ciber Enfermedades Respiratorias, Health Institute Carlos III (O.R.), Madrid, Ciudad Real University Hospital and Ciudad Real University, Ciudad Real (R.O., M.-C.E.), Medical Research Mar Institute (J.-R.M.), the Critical Care Department, Autònoma de Barcelona University (J.-R.M., M.G.-A.), Del Mar University Hospital (J.-R.M., C.C.), Vall d'Hebron Research Institute (O.R.), and Vall d'Hebron University Hospital (O.R., M.G.A.), Barcelona, and Alcala University, Alcalá de Henares (R.P.) - all in Spain.

出版信息

N Engl J Med. 2020 Sep 10;383(11):1009-1017. doi: 10.1056/NEJMoa2010834.

DOI:10.1056/NEJMoa2010834

PMID:32905673

Abstract

BACKGROUND

When patients with a tracheostomy tube reach a stage in their care at which decannulation appears to be possible, it is common practice to cap the tracheostomy tube for 24 hours to see whether they can breathe on their own. Whether this approach to establishing patient readiness for decannulation leads to better outcomes than one based on the frequency of airway suctioning is unclear.

METHODS

In five intensive care units (ICUs), we enrolled conscious, critically ill adults who had a tracheostomy tube; patients were eligible after weaning from mechanical ventilation. In this unblinded trial, patients were randomly assigned either to undergo a 24-hour capping trial plus intermittent high-flow oxygen therapy (control group) or to receive continuous high-flow oxygen therapy with frequency of suctioning being the indicator of readiness for decannulation (intervention group). The primary outcome was the time to decannulation, compared by means of the log-rank test. Secondary outcomes included decannulation failure, weaning failure, respiratory infections, sepsis, multiorgan failure, durations of stay in the ICU and hospital, and deaths in the ICU and hospital.

RESULTS

The trial included 330 patients; the mean (±SD) age of the patients was 58.3±15.1 years, and 68.2% of the patients were men. A total of 161 patients were assigned to the control group and 169 to the intervention group. The time to decannulation was shorter in the intervention group than in the control group (median, 6 days [interquartile range, 5 to 7] vs. 13 days [interquartile range, 11 to 14]; absolute difference, 7 days [95% confidence interval, 5 to 9]). The incidence of pneumonia and tracheobronchitis was lower, and the duration of stay in the hospital shorter, in the intervention group than in the control group. Other secondary outcomes were similar in the two groups.

CONCLUSIONS

Basing the decision to decannulate on suctioning frequency plus continuous high-flow oxygen therapy rather than on 24-hour capping trials plus intermittent high-flow oxygen therapy reduced the time to decannulation, with no evidence of a between-group difference in the incidence of decannulation failure. (REDECAP ClinicalTrials.gov number, NCT02512744.).

摘要

背景

当气管切开患者的护理达到脱管阶段时，通常会将气管切开管盖上 24 小时，以观察患者是否能够自主呼吸。目前尚不清楚这种确定患者脱管准备情况的方法是否比基于气道抽吸频率的方法更能带来更好的结果。

方法

在五家重症监护病房（ICU）中，我们招募了意识清醒、患有气管切开管的危重症成人患者；患者在机械通气撤机后符合条件。在这项非盲试验中，患者被随机分配至接受 24 小时封管试验加间歇性高流量吸氧治疗（对照组）或接受持续高流量吸氧治疗，以抽吸频率作为脱管准备的指标（干预组）。通过对数秩检验比较主要结局（脱管时间）。次要结局包括脱管失败、撤机失败、呼吸道感染、败血症、多器官衰竭、ICU 和医院住院时间以及 ICU 和医院死亡率。

结果

试验纳入了 330 例患者；患者的平均（±SD）年龄为 58.3±15.1 岁，68.2%的患者为男性。共有 161 例患者被分配至对照组，169 例患者被分配至干预组。与对照组相比，干预组的脱管时间更短（中位数，6 天[四分位距，5 至 7] vs. 13 天[四分位距，11 至 14]；绝对差异，7 天[95%置信区间，5 至 9]）。干预组的肺炎和气管支气管炎发病率较低，住院时间较短。两组的其他次要结局相似。