|Year : 2021 | Volume
| Issue : 3 | Page : 123-127
Comparison between continuous positive airway pressure and T piece as spontaneous breathing trial at a tertiary care pediatric intensive care unit: A pilot randomized control trial
Ramesh Chand Bairwa, Hiremath Sagar, Anil Kumar Sapare, Rajiv Aggarwal
Department of Pediatrics, Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India
|Date of Submission||01-Jan-2021|
|Date of Decision||28-Mar-2021|
|Date of Acceptance||14-Apr-2021|
|Date of Web Publication||21-May-2021|
Dr. Hiremath Sagar
Mazumdar Shaw Medical Center, NH Health City, Bommasandra Industrial Area, Anekal Taluk, Bengaluru - 560 099, Karnataka
Source of Support: None, Conflict of Interest: None
Background: A spontaneous breathing trial (SBT) is often used to decide about extubation readiness in mechanically ventilated patients. Studies done to identify the best method of SBT have shown variable results. As there was no published data comparing continuous positive airway pressure (CPAP) and T piece, this study was conducted to compare CPAP and T piece as method of SBT for postextubation outcomes.
Subjects and Methods: This study was a pilot randomized controlled trial conducted at a tertiary care pediatric intensive care unit (PICU) from November 2018 to October 2019. Criteria for starting SBT and to identify trial as failure were predefined. Sixty patients were included in the study and randomly assigned to CPAP and T-piece group, of 30 each. Demographic data, diagnosis, duration of mechanical ventilation (MV), endotracheal tube size, need of inotropes, vasopressors, and sedation were all recorded. The primary outcome of the study was extubation failure within 48 h. The secondary outcomes studied were mortality, need of respiratory support, duration of oxygen requirement, and length of PICU (LOPICU) stay after extubation.
Results: Age, gender, indication of intubation, duration of MV, and number of SBT attempts were similar in both the groups. There was no statistically significant difference in extubation failure within 48 h between the two groups. Four patients were reintubated in both the groups and two patients died in T piece group and one patient in CPAP group. Postextubation respiratory support, duration of oxygen therapy, LOPICU stay, and mortality were not significant different between the two groups.
Conclusion: There was no significant difference in extubation outcomes when CPAP and T piece were used as methods of SBT.
Keywords: Continuous positive airway pressure, pediatric intensive care unit, spontaneous breathing trial, T piece
|How to cite this article:|
Bairwa RC, Sagar H, Sapare AK, Aggarwal R. Comparison between continuous positive airway pressure and T piece as spontaneous breathing trial at a tertiary care pediatric intensive care unit: A pilot randomized control trial. J Pediatr Crit Care 2021;8:123-7
|How to cite this URL:|
Bairwa RC, Sagar H, Sapare AK, Aggarwal R. Comparison between continuous positive airway pressure and T piece as spontaneous breathing trial at a tertiary care pediatric intensive care unit: A pilot randomized control trial. J Pediatr Crit Care [serial online] 2021 [cited 2023 Jun 8];8:123-7. Available from: http://www.jpcc.org.in/text.asp?2021/8/3/123/316595
| Introduction|| |
Mechanical ventilation (MV) is an important life support measure used in pediatric intensive care unit (PICU). Although MV can be life-saving, it has its own complications airway injury, ventilator-associated pneumonia, ventilator-induced lung injury, etc. Hence, it is important to discontinue MV once the patient is able to sustain breathing spontaneously. However, it has been noted that extubation failure is associated with prolonged length of MV, prolonged length of PICU (LOPICU) stay, and higher risk of mortality., Thus, early extubation should be our goal to prevent the complications of MV, but at the same time, premature extubation leading to extubation failure can have serious consequences. Hence, the timing of extubation is critical. A spontaneous breathing trial (SBT) is often used to decide about extubation readiness using methods such as continuous positive airway pressure (CPAP), pressure support (PS) with or without positive end expiratory pressure (PEEP), T piece, automatic tube compensation (ATC), and flow inflating anesthetic bag., Studies done to identify the best method of SBT have shown variable results. A meta-analysis showed patient's undergoing PS SBT were more likely to be extubated successfully, another study concluded T piece as best choice for predicting extubation while some did not find any difference between T piece and PS SBT, ATC, and PS SBT.,,,,,
PS has been used over and above PEEP to compensate for increase in work of breathing induced by endotracheal tube (ET). The PS applied has also been variable in different studies ranging from 5 to 10 cm H2O and is also based on the size of ET.,,,, The imposed work of breathing due to ET has been analyzed and found to be either negligible or even if high was clinically irrelevant.,, Furthermore, the use of PS above CPAP overestimated readiness for extubation contributing to extubation failure and also underestimated postextubation effort of breathing., In a study on 17 children comparing pressure rate product and in turn effort of breathing on T piece, T piece with heliox, CPAP and PS found that T piece best approximated the postextubation effort of breathing while PS and CPAP underestimated the postextubation effort. There have been no subsequent large study comparing the two modes of SBT. We hypothesized T piece would be a better method of SBT as compared to CPAP. During SBT, T piece provides no PS and effort of breathing correlates with postextubation effort leading to reduced extubation failure rates. CPAP, on the other hand, would be underestimating the postextubation effort of breathing leading to higher extubation failure rates. We wanted to find out the difference between CPAP and T piece method of SBT in children with respect to postextubation outcomes in the form of extubation failure within 48 h, mortality, need of respiratory support, duration of oxygen requirement, and LOPICU stay.
| Materials and Methods|| |
This pilot, randomized controlled study was conducted in PICU of tertiary care hospital from November 2018 to October 2019 after Institutional Ethics Committee approval. All patients aged between 1 month and 18 years who were mechanically ventilated for >12 h and judged by the pediatric intensivist as fit to undergo SBT were included in the study after obtaining informed consent from one of the parent or legal guardian. Patients were enrolled if they met the criteria are mentioned in [Table 1]. Patients with tracheostomy, unrepaired congenital heart disease, known neuromuscular disease, and known upper airway anomalies were excluded from the study.
For the included patients following information was collected, age, gender, weight, admission diagnosis, indication of MV, ET size, cuffed or uncuffed ET, and duration of MV. Patients' once included in the study were randomly allotted using random number table into either CPAP with PEEP of ≤5 with FiO2 <0.4 or T piece group. Random number table was generated using online random number table generator. Randomization was done using permuted blocks, with each block being of four patients. SBT was done for 2 h with close monitoring of the patient. If the patient tolerated SBT, he would be extubated. SBT would be terminated if any signs of poor tolerance were noted [Table 2] and patient was put on MV and trialed again after 24 h depending on clinical assessment. The number of SBT attempts needed by the patients for extubation was also noted. Vital parameters, including heart rate, respiratory rate, SpO2, and arterial blood gas (ABG) parameters, were noted prior to and during SBT, also after extubation. Postextubation respiratory support was given in the form of nasal cannula oxygen, high flow nasal cannula (HFNC), or noninvasive ventilation (NIV) depending on respiratory distress. Postextubation, following information was recorded, extubation success or failure, need of oxygen or respiratory support by HFNC or NIV and its duration and LOPICU stay. The primary outcome was extubation failure which was defined as need of reintubation within 48 h after extubation.
As there was no published data comparing CPAP and T piece, a pilot study with sample size of 30 in each group was selected. Continuous variables were expressed as mean and standard deviation and analyzed using the unpaired t-test. Nominal variables were expressed as percentage and analyzed using the Chi-square test. P < 0.05 was considered statistically significant. Statistical analysis was done using Epi Info Version 7.0 (2011) developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US).
| Results|| |
Sixty patients were included in the study, 30 in CPAP group and 30 in T piece group. Baseline characteristics in both the groups were similar including number of SBT attempts needed for extubation [Table 3]. Based on the number of SBT attempts needed to extubate, patients were divided into simple, difficult, and prolonged weaning group. Patients who succeeded initial attempt of SBT and extubated were classified as simple weaning, those who needed 2 or 3 SBTs were classified as difficult weaning group and those who needed >3 SBTs were classified as prolonged weaning. Vitals and ABG parameters did not show any significant difference between the two groups [Table 4] and [Table 5].
There was no difference in mortality or extubation failure as 1 patient died in CPAP group and 2 patients died in T piece group while both groups had 4 extubation failures each. In the CPAP group, extubation failure was due to upper airway obstruction in 2 cases, poor sensorium in 1 case, and respiratory distress in 1 case. In the T piece group, extubation failure was due to respiratory distress in 2 cases, poor sensorium in 1 case, and shock in 1 case. There was no difference in the number of patients needing respiratory support in form of HFNC, NIV, or oxygen. Although the duration of oxygen requirement and LOPICU stay was longer in T piece group, the difference was not statistically significant [Table 6].
| Discussion|| |
Our study did not show any difference in SBT performed by CPAP without PS and T piece with respect to postextubation outcomes, although the oxygen requirement and duration of PICU stay was longer in T piece group, the difference was not significant.
Although many studies have been done on SBT in adults and children, we did not find any study comparing CPAP with T Piece as a method of SBT in children or adults. As T piece does not provide any PS when compared to CPAP, we expected that children in T piece group on would have reduced extubation failure rates and increased respiratory support and extubation failure in CPAP group, as these children might have succeeded SBT due to the CPAP and once extubated, they would lose this respiratory support. PS and CPAP with PS have been used to overcome the increased work of breathing imposed by ET. However, applying physiologic principles and anatomical knowledge, the work of breathing through ET should be reduced in children. In adults, the peak flow rates are 30 L/min and as size of ET reduces resistance increases leading to increased work of breathing. The flow rates in children are less and resistance does not increase significantly as compared to ET size. In children, airway has collapsible nature and the difference between ET size and diameter of natural airway is minimal, making the inspiratory resistance through ET decrease., Based on their study comparing PS of 10/PEEP 5 cmH2O and CPAP of 5 cmH2O, the authors concluded CPAP alone best estimates postextubation effort during SBT., However, another small study suggested best postextubation effort of breathing is predicted by T piece as compared to T piece with heliox, PS with PEEP and CPAP. In our study, we compared T piece and CPAP alone as method of SBT, but did not find any difference with respect to extubation failure. Another finding of our study was that there was no difference in the two groups with respect to number of SBTs needed. A systematic review article suggested pressure support ventilation to be superior with respect to lower failure rates in simple to wean group and T piece was associated with shorter weaning duration in prolonged weaning group but this was based on low quality evidence and at high risk of bias.
Extubation failure rates in children vary between 6% and 33% depending on the study population and the variability in definition of extubation failure.,,,,,,, Our study showed a extubation failure rate of 13.3% which is similar to other studies.
Postextubation respiratory support in the form of NIV was 8.3% in our study while in other studies in ranged from 5% to 26%.,, HFNC is being more commonly used after extubation to reduce the risk of extubation failure as it is shown to be better than conventional oxygen therapy., In our study, 45% patients needed HFNC, whereas in a study by Baudin et al., 36% patients were put on HFNC postextubation.
In our study, PICU stay in both the groups was similar (7 vs. 7.9 days). Similarly, no difference in LOPICU stay was found in the study by Farias et al. where the stay was 11 days in PS group and 12 days in T piece group. Similarly, other adult studies also did not find any difference in ICU LOS between PS and T piece group., An Indian study in postsurgical adult patients evaluating T piece versus PS/CPAP did not find any difference in the duration of oxygen therapy and LOICU stay between the two groups similar to our study findings. Length of stay in PS group was 8 ± 7 days versus T piece 6 ± 5 days which was similar to our study (CPAP 7 days and T piece 7.9 days). Duration of oxygen therapy was 53 ± 36 h in PS/CPAP group and 56 ± 34 h in T piece group. In our study, it was 73.6 ± 57.32 CPAP group and 87.4 ± 69.23 in T piece group.
Our study has following, limitations. First, this is a pilot study with very small sample size was. Second, this was a single-center study. Third, many of our patients were postoperative (35%) and also many were ventilated for between 12 and 48 h (68%). Hence, our study findings cannot be extrapolated to the general population. A multicenter randomized trials on the large number of subjects are needed to identify the best method of SBT in children.
| Conclusion|| |
There was no significant difference in extubation outcomes when CPAP and T piece were used as methods of SBT.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kurachek SC, Newth CJ, Quasney MW, Rice T, Sachdeva RC, Patel NR, et al.
Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes. Crit Care Med 2003;31:2657-64.
Farias JA, Retta A, Alía I, Olazarri F, Esteban A, Golubicki A, et al.
A comparison of two methods to perform a breathing trial before extubation in pediatric intensive care patients. Intensive Care Med 2001;27:1649-54.
Burns KE, Soliman I, Adhikari NK, Zwein A, Wong JT, Gomez-Builes C, et al.
Trials directly comparing alternative spontaneous breathing trial techniques: A systematic review and meta-analysis. Crit Care 2017;21:127.
Chavez A, dela Cruz R, Zaritsky A. Spontaneous breathing trial predicts successful extubation in infants and children. Pediatr Crit Care Med 2006;7:324-8.
Bien MY, Shui Lin Y, Shih CH, Yang YL, Lin HW, Bai KJ, et al.
Comparisons of predictive performance of breathing pattern variability measured during T-piece, automatic tube compensation, and pressure support ventilation for weaning intensive care unit patients from mechanical ventilation. Crit Care Med 2011;39:2253-62.
Esteban A, Alía I, Gordo F, Fernández R, Solsona JF, Vallverdú I, 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;156:459-65.
Kumar L, Meghalakshmi AR, Vasudevan A, Rajan S, Paul J. Comparison of extubation outcomes following T-piece trial versus pressure support/continous positive airway pressure in postsurgical patients. Indian J Respir Care 2018;7:37-41. [Full text]
El-Beleidy AS, Khattab AA, El-Sherbini SA, Al-Gebaly HF. Automatic tube compensation versus pressure support ventilation and extubation outcome in children: A randomized controlled study. ISRN Pediatr 2013;2013:871376.
Faustino EV, Gedeit R, Schwarz AJ, Asaro LA, Wypij D, Curley MA, et al.
Accuracy of an extubation readiness test in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease. Crit Care Med 2017;45:94-102.
Newth CJ, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, et al.
Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009;10:1-11.
Mortamet G, Nardi N, Groleau V, Essouri S, Fauroux B, Jouvet P, et al.
Impact of spontaneous breathing trial on work of breathing indices derived from esophageal pressure, electrical activity of the diaphragm, and oxygen consumption in children. Respir Care 2019;64:509-18.
van Dijk J, Blokpoel RG, Koopman AA, Dijkstra S, Burgerhof JG, Kneyber MC. The effect of pressure support on imposed work of breathing during pediatric extubation readiness testing. Ann Intensive Care 2019;9:78.
Ferguson LP, Walsh BK, Munhall D, Arnold JH. A spontaneous breathing trial with pressure support overestimates readiness for extubation in children. Pediatr Crit Care Med 2011;12:e330-5.
Khemani RG, Hotz J, Morzov R, Flink RC, Kamerkar A, LaFortune M, et al.
Pediatric extubation readiness tests should not use pressure support. Intensive Care Med 2016;42:1214-22.
Willis BC, Graham AS, Yoon E, Wetzel RC, Newth CJ. Pressure-rate products and phase angles in children on minimal support ventilation and after extubation. Intensive Care Med 2005;31:1700-5.
Hiff A, Lee V. Pulse rate, respiratory rate and body temperature of children between 2 months and 18 years of age. Child Dev 1952;23:237-45.
Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al.
Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-56.
Keidan I, Fine GF, Kagawa T, Schneck FX, Motoyama EK. Work of breathing during spontaneous ventilation in anesthetized children: A comparative study among the face mask, laryngeal mask airway and endotracheal tube. Anesth Analg 2000;91:1381-8.8
Khemani RG, Newth CJ. CPAP alone best estimates post-extubation effort during spontaneous breathing trials in children. Intensive Care Med 2017;43:150-1.
Pellegrini JA, Moraes RB, Maccari JG, de Oliveira RP, Savi A, Ribeiro RA, et al.
Spontaneous breathing trials with T-piece or pressure support ventilation. Respir Care 2016;61:1693-703.
Ghaffari S, Ghasempour M, Bilan N. Spontaneous breathing trial: A reliable method for weaning in children. Int J Pediatr, 2015;3:3-2, Serial No.18, Jun.
Foronda FK, Troster EJ, Farias JA, Barbas CS, Ferraro AA, Faria LS, et al.
The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: A randomized controlled trial. Crit Care Med 2011;39:2526-33.
Randolph AG, Wypij D, Venkataraman ST, Hanson JH, Gedeit RG, Meert KL, et al.
Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: A randomized controlled trial. JAMA 2002;288:2561-8.
Akyıldız B, Öztürk S, Ülgen-Tekerek N, Doğanay S, Görkem SB. Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit. Turk J Pediatr 2018;60:126-33.
Hernández G, Vaquero C, González P, Subira C, Frutos-Vivar F, Rialp G, et al
. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA. 2016;315:1354-61.
Baudin F, Gagnon S, Crulli B, Proulx F, Jouvet P, Emeriaud G. Modalities and complications associated with the use of high-flow nasal cannula: Experience in a pediatric ICU. Respir Care 2016;61:1305-10.
Subirà C, Hernández G, Vázquez A, Rodríguez-García R, González-Castro A, García C, et al.
Effect of pressure support vs T-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: A randomized clinical trial. JAMA 2019;321:2175-82.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
|This article has been cited by|
||Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document
| ||Samer Abu-Sultaneh, Narayan Prabhu Iyer, Analía Fernández, Michael Gaies, Sebastián González-Dambrauskas, Justin Christian Hotz, Martin C. J. Kneyber, Yolanda M. López-Fernández, Alexandre T. Rotta, David K. Werho, Arun Kumar Baranwal, Bronagh Blackwood, Hannah J. Craven, Martha A. Q. Curley, Sandrine Essouri, Jose Roberto Fioretto, Silvia M. M. Hartmann, Philippe Jouvet, Steven Kwasi Korang, Gerrard F. Rafferty, Padmanabhan Ramnarayan, Louise Rose, Lyvonne N. Tume, Elizabeth C. Whipple, Judith J. M. Wong, Guillaume Emeriaud, Christopher W. Mastropietro, Natalie Napolitano, Christopher J. L. Newth, Robinder G. Khemani |
| ||American Journal of Respiratory and Critical Care Medicine. 2023; 207(1): 17 |
|[Pubmed] | [DOI]|
||A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial
| ||Kelby E. Knox, Justin C. Hotz, Christopher J.L. Newth, Michael Khoo, Robinder G. Khemani |
| ||Chest. 2022; |
|[Pubmed] | [DOI]|