• Gonzalo Hernández Martínez, Patricia Rodriguez, Jesus Soto, Oriol Caritg, Andrea Castellví-Font, Borja Mariblanca, Antonio Maria García, Laura Colinas, Jose Manuel Añon, Francisco Jose Parrilla-Gomez, Jose Alberto Silva-Obregón, Joan Ramon Masclans, Alicia Propin, Alicia Cuadra, Mario Guillermo Dalorzo, Gemma Rialp, Fernando Suarez-Sipmann, and Oriol Roca.
• Complejo Hospitalario Universitario de Toledo, Toledo, Spain. ghernandezm@telefonica.net.
• Intensive Care Med. 2024 Feb 1; 50 (2): 258267258-267.

PurposeThis study aimed to determine the best strategy to achieve fast and safe extubation.MethodsThis multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.ResultsRandomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).ConclusionAmong patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.

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