2011 Sep 15 - Noninvasive Ventilation and Weaning in Patients with Chronic Hypercapnic Respiratory Failure: A Randomized Multicenter Trial

Christophe Girault1,2, Michael Bubenheim3, Fekri Abroug4, Jean Luc Diehl5, Souheil Elatrous6, Pascal Beuret7, Jack Richecoeur8, Erwan L'Her9, Gilles Hilbert10, Gilles Capellier11, Antoine Rabbat12, Mohamed Besbes13, Claude Guérin14, Philippe Guiot15, Jacques Bénichou3,16, Guy Bonmarchand1,2 and for the VENISE Trial Group*. American Journal of Respiratory and Critical Care Medicine Vol 184. pp. 672-679, (2011)
Rationale: The use of noninvasive ventilation (NIV) as an early weaning/extubation technique from mechanical ventilation remains controversial.

Objectives: To investigate NIV effectiveness as an early weaning/extubation technique in difficult-to-wean patients with chronic hypercapnic respiratory failure (CHRF).

Methods: In 13 intensive care units, 208 patients with CHRF intubated for acute respiratory failure (ARF) who failed a first spontaneous breathing trial were randomly assigned to three groups: conventional invasive weaning group (n = 69), extubation followed by standard oxygen therapy (n = 70), or NIV (n = 69). NIV was permitted as rescue therapy for both non-NIV groups if postextubation ARF occurred. Primary endpoint was reintubation within 7 days after extubation. Secondary endpoints were: occurrence of postextubation ARF or death within 7 days after extubation, use of rescue postextubation NIV, weaning time, and patient outcomes.

Measurements and Main Results: Reintubation rates were 30, 37, and 32% for invasive weaning, oxygen-therapy, and NIV groups, respectively (P = 0.654). Weaning failure rates, including postextubation ARF, were 54, 71, and 33%, respectively (P < 0.001). Rescue NIV success rates for invasive and oxygen-therapy groups were 45 and 58%, respectively (P = 0.386). By design, intubation duration was 1.5 days longer for the invasive group than in the two others. Apart from a longer weaning time in NIV than in invasive group (2.5 vs. 1.5 d; P = 0.033), no significant outcome difference was observed between groups.

Conclusions: No difference was found in the reintubation rate between the three weaning strategies. NIV decreases the intubation duration and may improve the weaning results in difficult-to-wean patients with CHRF by reducing the risk of postextubation ARF. The benefit of rescue NIV in these patients deserves confirmation.

Clinical trial registered with www.clinicaltrials.gov (NCT 00213499).

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