Smit Jim M, Van Bommel Jasper, Gommers Diederik A M P J, Reinders Marcel J T, Van Genderen Michel E, Krijthe Jesse H, Jonkman Annemijn H
Erasmus Medical Center, Department of Intensive Care (internal postal address: Room Ne-411), Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
EEMCS, Pattern Recognition & Bioinformatics Group, Delft University of Technology, Delft, The Netherlands.
Intensive Care Med Exp. 2025 Jul 16;13(1):73. doi: 10.1186/s40635-025-00785-1.
Switching from controlled to assisted ventilation is crucial in the trajectory of intensive care unit (ICU) stay, but no guidelines exist. We described current practices, analyzed patient characteristics associated with switch success or failure, and explored the feasibility to predict switch failure.
In this retrospective study, we obtained highly granular longitudinal ICU data sets from three medical centers, covering demographics, severity scores, vital signs, ventilation, and laboratory parameters. The primary endpoint was switch success, considering a switch attempt to be successful if a patient did not return to controlled ventilation for the next 72 h while alive, and to be failed otherwise. We compared the characteristics of patients with successful vs. failed first switch attempts at ICU admission, immediately before, and 3 h after the attempt. We trained LASSO logistic regression models to predict switch failure.
In 4524/6715 (67%) patients attempting a switch, the first attempt failed. The first switch attempt, regardless of success or failure, was generally made at normalized PaCO and pH levels, with PEEP < 10 cmHO and PaO/FiO indicating mild injury. Despite very similar baseline disease severity, switch failure was associated with significantly worse outcomes, including a 28-day mortality of 27% vs. 16% and median ventilator-free days of 16 vs. 22 (p < 0.001). Failed attempts were initiated significantly earlier than successful ones (median 1.8 vs. 1.3 days, p < 0.001). Before the switch, PaO/FiO, if measured at PEEP > 10 cmHO, and respiratory system compliance was lower in patients with switch failure (median 185 vs. 205 mmHg, p < 0.001; 39 vs. 41 mL/cmHO, P = 0.001), and post-switch, patients with switch failure experienced greater deterioration in gas exchange and minimal improvement in ventilatory parameters post-switch. Contrary to our hypotheses, patient characteristics for failed vs. successful switches were surprisingly similar, resulting in prediction models with limited discriminative performance.
Approximately two-thirds of attempts to switch patients to assisted ventilation fail, which are associated with significantly worse clinical outcomes, despite similar baseline disease severity. Contrary to our hypotheses, patients with successful and failed attempts showed similar characteristics, making switch failure difficult to predict. These findings underscore the importance of preventing switch failures and, given the retrospective nature of this study, highlight the need for prospective studies to better understand the reasons for switch failure and when spontaneous breathing can be safely initiated.
在重症监护病房（ICU）住院过程中，从控制通气转换为辅助通气至关重要，但目前尚无相关指南。我们描述了当前的做法，分析了与转换成功或失败相关的患者特征，并探讨了预测转换失败的可行性。
在这项回顾性研究中，我们从三个医疗中心获取了高度详细的纵向ICU数据集，涵盖人口统计学、严重程度评分、生命体征、通气和实验室参数。主要终点是转换成功，即如果患者在接下来的72小时内存活且未恢复到控制通气，则认为转换尝试成功，否则为失败。我们比较了ICU入院时、转换尝试前即刻以及尝试后3小时首次转换尝试成功与失败患者的特征。我们训练了LASSO逻辑回归模型来预测转换失败。
在4524/6715（67%）尝试转换的患者中，首次尝试失败。首次转换尝试，无论成功与否，通常在PaCO和pH值正常、呼气末正压（PEEP）<10 cmH₂O且动脉血氧分压/吸入氧分数值（PaO₂/FiO₂）表明轻度损伤时进行。尽管基线疾病严重程度非常相似，但转换失败与明显更差的结果相关，包括28天死亡率为27% vs. 16%，以及无呼吸机天数中位数为16天 vs. 22天（p<0.001）。失败的尝试比成功的尝试开始得明显更早（中位数为1.8天 vs. 1.3天，p<0.001）。在转换前，如果在PEEP>10 cmH₂O时测量，转换失败患者的PaO₂/FiO₂和呼吸系统顺应性较低（中位数为185 vs. 205 mmHg，p<0.001；39 vs. 41 mL/cmH₂O，P = 0.001），并且在转换后，转换失败患者的气体交换恶化更严重，转换后通气参数改善极小化。与我们的假设相反，转换失败与成功患者的特征惊人地相似，导致预测模型的判别性能有限。
将患者转换为辅助通气的尝试中约三分之二失败，尽管基线疾病严重程度相似，但这些失败与明显更差的临床结果相关。与我们的假设相反，转换成功与失败的患者表现出相似的特征，使得转换失败难以预测。这些发现强调了预防转换失败的重要性，并且鉴于本研究的回顾性性质，突出了进行前瞻性研究以更好地理解转换失败原因以及何时可以安全启动自主呼吸的必要性。
