Spontaneous breathing trials should be adapted for each patient according to the critical illness. A new individualised approach: the GLOBAL WEAN study

Purpose

Spontaneous breathing trials (SBT) evaluate the patient's capacity to maintain inspiratory effort after extubation. SBT practices are heterogeneous and not individualised. The objective of this study was to assess which SBT best reproduces inspiratory effort after extubation in five critical illnesses.

Methods

In this multicentre randomized cross-over study, adult intensive care unit patients under invasive mechanical ventilation for at least 24-h and ready for extubation, underwent three 15-min SBTs in random order: pressure support ventilation level of 7-cmH₂O with positive end-expiratory pressure (PEEP) level of 0-cmH₂O (PSV7PEEP0), PSV 0-cmH₂O with PEEP 0-cmH₂O (PSV0PEEP0) and T-piece trial. Primary outcome was the variation of pressure–time-product per minute (PTPmin) between each SBT and 20-min after extubation. Five categories of critical illnesses were selected: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease (COPD) and miscellaneous.

Results

Five hundred measures of effort from 100 patients were analysed. PTPmin (cmH₂O s/min, median and interquartile range, IQR) was 256 (208–321) after extubation, 192 (127–281) at the end of PSV7PEEP0 (p < 0.001 in comparison to after extubation), 291 (235–347) at the end of PSV0PEEP0 and 262 (198–338) at the end of T-piece (both no different from after extubation). One method of SBT in patients with brain injury (PSV0PEEP0), two in abdominal surgery (PSV0PEEP0 and T-piece) and miscellaneous patients (PSV7PEEP0 and T-piece) and all three methods in chest trauma and COPD exacerbation patients replicated reasonably accurately the postextubation effort to breathe.

Conclusion

Unassisted SBTs, namely PSV0PEEP0 and T-piece trial, are the most appropriate to replicate the postextubation effort to breathe.