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Daniel R. Ouellette, MD, FCCP; Sheena Patel, MPH; Timothy D. Girard, MD; Gregory A. Schmidt, MD, FCCP; Jonathon D. Truwit, MD, FCCP; John P. Kress, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

aDivision of Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, MI

bCHEST, Glenview, IL

cDepartment of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA

dDivision of Pulmonary Diseases, Critical Care and Occupational Medicine, University of Iowa, Iowa City, IA

eDivision of Pulmonary and Critical Care Medicine, Froedtert and Medical College of Wisconsin, Milwaukee, WI

fSection of Pulmonary and Critical Care, University of Chicago, Chicago, IL

CORRESPONDENCE TO: Daniel R. Ouellette, MD, FCCP, 2799 W Grand Blvd, Detroit, MI 48202


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):1400-1401. doi:10.1016/j.chest.2017.03.051
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We thank Goligher et al for their interest in our manuscript. They raise concerns about our conditional recommendation in favor of using pressure augmentation (PA) during a spontaneous breathing trial (SBT) compared with T-piece/CPAP.

Goligher et al are correct that because conducting the SBT with PA is more often successful, both the rates of extubation success and extubation failure could be higher (using the entire population as the denominator). However, if this were the only basis for higher extubation success rates, one would expect patients extubated following a successful PA SBT to have higher rates of subsequent reintubation. In the two studies that we cited that contain relevant data,, when using a T-piece, SBT was successful in 216 patients, but extubation failed in 41 patients (19.0%), whereas with PA, SBT was successful in 259 patients and extubation failed in 49 patients (18.9%). Thus, conducting the SBT with PA does not appear to falsely predict extubation success and Goligher et al’s hypothesis is, at least, incomplete. Because PA leads to more patients being successfully extubated with a shortened duration of mechanical ventilation, we stand by our recommendation.

A key to this debate involves the comparison of the burden of extubation failure and the risk of prolonging mechanical ventilation. It is well known that patients in whom extubation fails have worse outcomes than those in whom it is successful. Reintubation in the ICU certainly is not risk free: however, death around the time of reintubation is extremely rare, particularly with modern intubation approaches.,, It appears that in the majority of patients, reintubation identifies a cohort with a higher severity of illness or acquisition of new problems associated with ongoing mechanical ventilation. At the same time, not extubating also confers risk. As the declaration of SBT failure occurs more commonly with T-piece or CPAP than with PA, it follows that the population assessed with T-piece SBT will have prolonged mechanical ventilation and its attendant risks., We believe that most clinicians and most patients favor strategies that lead to earlier extubation.

References

Ouellette D.R. .Patel S. .Girard T.D. .et al Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation. Chest. 2017;151:166-180 [PubMed]journal. [CrossRef] [PubMed]
 
Esteban A. .Alia I. .Gordo F. .et al Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459-465 [PubMed]journal. [CrossRef] [PubMed]
 
Haberthur C. .Mols G. .Elsasser S. .Bingisser R. .Stocker R. .Guttman J. . Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation. Acta Anaesthesiol Scand. 2002;46:973-979 [PubMed]journal. [CrossRef] [PubMed]
 
Frutos-Vivar F. .Esteban A. .Apezteguia C. .et al Outcome of reintubated patients after scheduled extubation. J Crit Care. 2011;26:502-509 [PubMed]journal. [CrossRef] [PubMed]
 
Jaber S. .Jung B. .Corne P. .et al An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36:248-255 [PubMed]journal. [CrossRef] [PubMed]
 
Jaber S. .Amraoui J. .Lefrant J.Y. .et al Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355-2361 [PubMed]journal. [CrossRef] [PubMed]
 
Menon N. .Joffe A.M. .Deem S. .et al Occurrence and complications of tracheal reintubation in critically ill adults. Respir Care. 2012;57:1555-1563 [PubMed]journal. [CrossRef] [PubMed]
 
Unroe M. .Kahn J.M. .Carson S.S. .et al One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010;153:167-175 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Ouellette D.R. .Patel S. .Girard T.D. .et al Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation. Chest. 2017;151:166-180 [PubMed]journal. [CrossRef] [PubMed]
 
Esteban A. .Alia I. .Gordo F. .et al Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459-465 [PubMed]journal. [CrossRef] [PubMed]
 
Haberthur C. .Mols G. .Elsasser S. .Bingisser R. .Stocker R. .Guttman J. . Extubation after breathing trials with automatic tube compensation, T-tube, or pressure support ventilation. Acta Anaesthesiol Scand. 2002;46:973-979 [PubMed]journal. [CrossRef] [PubMed]
 
Frutos-Vivar F. .Esteban A. .Apezteguia C. .et al Outcome of reintubated patients after scheduled extubation. J Crit Care. 2011;26:502-509 [PubMed]journal. [CrossRef] [PubMed]
 
Jaber S. .Jung B. .Corne P. .et al An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36:248-255 [PubMed]journal. [CrossRef] [PubMed]
 
Jaber S. .Amraoui J. .Lefrant J.Y. .et al Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355-2361 [PubMed]journal. [CrossRef] [PubMed]
 
Menon N. .Joffe A.M. .Deem S. .et al Occurrence and complications of tracheal reintubation in critically ill adults. Respir Care. 2012;57:1555-1563 [PubMed]journal. [CrossRef] [PubMed]
 
Unroe M. .Kahn J.M. .Carson S.S. .et al One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010;153:167-175 [PubMed]journal. [CrossRef] [PubMed]
 
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