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Andres Esteban, MD, PhD; Fernando Frutos-Vivar, MD; for the Ventila Group
Author and Funding Information

From the Intensive Care Unit, Hospital Universitario de Getafe; and CIBER Enfermedades Respiratorias from Instituto Carlos III, Madrid, Spain.

Correspondence to: Andres Esteban, MD, PhD, Intensive Care Unit, Hospital Universitario de Getafe, Caretera de Toledo km 12,500, Madrid, 28905, Spain; e-mail: aesteban@ucigetafe.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1284-1285. doi:10.1378/chest.10-1662
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To the Editor:

We thank Drs Díaz-Lobato and Mayoralas for their interest in our article in CHEST (June 2010)1 on the use of synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control ventilation as the primary mode of ventilatory support. Although the topic of their letter has a marginal relationship with our article, which is not an analysis of methods for weaning, we are interested in the controversy about the use of noninvasive positive-pressure ventilation (NIPPV) as a weaning method.

As the authors reference in their letter, there are now 13 reported randomized, controlled trials of NIPPV to facilitate weaning in ventilated patients.2 Among these studies, three have been presented only in abstract form, one is an unpublished dissertation, and four are studies published in Chinese. An additional study included intubated patients with COPD and pneumonia who were randomized to NIPPV vs SIMV-PS, but the patients had not failed a spontaneous breathing trial before being randomized. Therefore, there would only be four accessible studies3-6 to assess the role of NIPPV as a weaning method. These studies have some design and methodologic flaws worth mentioning.

First, it is surprising that significant differences in the evaluated outcomes are found in studies with such small sample sizes (<70 patients per study in all studies). Second, all the studies except the trial by Trevisan et al6 were carried out in respiratory units admitting mostly patients with COPD. This is not the rule in most ICUs.7 Third, the control groups (invasive weaning) in these studies do not reflect current clinical practice. For instance, in the study most favorable to NIPPV,5 outcomes in patients assigned to invasive weaning were: rate of nosocomial pneumonia, 59%; rate of reintubation, 21%; need for tracheostomy, 59%; and ICU mortality, 41%. To try to compare those data with the real world, we have searched in the databases of two international studies on mechanical ventilation.7 In these databases, we have selected patients with COPD who required mechanical ventilation for >3 days and had a duration of weaning >3 days. This patient population would be similar to that in the study by Ferrer et al.5 From a total cohort of 10,151 patients who were mechanically ventilated, we found 160 patients meeting the above-mentioned criteria. The outcomes of this cohort were: rate of nosocomial pneumonia, 7%; rate of reintubation, 21%; need for tracheostomy, 9%; and ICU mortality, 10% (data not previously published). Last, the withdrawal of the endotracheal tube for patients failing a spontaneous breathing trial could raise ethical issues.

Ortiz G, Frutos-Vivar F, Ferguson ND, et al; for the Ventila Group for the Ventila Group Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support: a comparative propensity score study. Chest. 2010;1376:1265-1277. [CrossRef] [PubMed]
 
Burns KEA, Adhikari NKJ, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. [CrossRef] [PubMed]
 
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;1289:721-728. [PubMed]
 
Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med. 1999;1601:86-92. [PubMed]
 
Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;1681:70-76. [CrossRef] [PubMed]
 
Trevisan CE, Vieira SR. Research Group in Mechanical Ventilation Weaning Research Group in Mechanical Ventilation Weaning Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial. Crit Care. 2008;122:R51. [CrossRef] [PubMed]
 
Esteban A, Ferguson ND, Meade MO, et al; VENTILA Group VENTILA Group Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;1772:170-177. [CrossRef] [PubMed]
 

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References

Ortiz G, Frutos-Vivar F, Ferguson ND, et al; for the Ventila Group for the Ventila Group Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support: a comparative propensity score study. Chest. 2010;1376:1265-1277. [CrossRef] [PubMed]
 
Burns KEA, Adhikari NKJ, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. [CrossRef] [PubMed]
 
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;1289:721-728. [PubMed]
 
Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G. Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med. 1999;1601:86-92. [PubMed]
 
Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;1681:70-76. [CrossRef] [PubMed]
 
Trevisan CE, Vieira SR. Research Group in Mechanical Ventilation Weaning Research Group in Mechanical Ventilation Weaning Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial. Crit Care. 2008;122:R51. [CrossRef] [PubMed]
 
Esteban A, Ferguson ND, Meade MO, et al; VENTILA Group VENTILA Group Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;1772:170-177. [CrossRef] [PubMed]
 
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