Comparative Efficacy of SPONTANEOUS BREATHING TRIAL Techniques in Mechanically Ventilated Adult Patients A Review

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Comparative Efficacy of SPONTANEOUS


BREATHING TRIAL Techniques in Mechanically
Ventilated Adult Patients:
A Review
Hernandez, L. 1, Jaictin, S.1, Jandayan, J.1 & Magarin, KRJ1.
1.
School of Allied Health Sciences, Respiratory Therapy Department, San Pedro College, Davao City, Philippines, 8000

Abstract:- Since the invention of mechanical ventilation intubation times to a minimum. To reduce risk of tracheotomy
and the development of critical care medicine, weaning and delayed weaning, prolonged mechanical breathing,
literature and research have transformed daily patient defined as more than 14 days of intubation, is typically
treatment in intensive care units. More study on weaning avoided unless absolutely required. [2] Early extubation has
trials has become important as our understanding of been proven to improve the patient's prognosis.
mechanical breathing with the use of mechanical
ventilators has grown. Studies tended to concentrate on the The researcher’s objective is to compare the efficacy of
length of mechanical ventilation utilizing different methods spontaneous breathing trial techniques with the use of
for conducting spontaneous breathing trials as a means of synchronized intermittent mandatory ventilation (SIMV),
weaning patients from assisted ventilation. pressure support ventilation, and T-piece/T-tube trials for adult
patients weaning from mechanical ventilation according to
This article review offers a comprehensive look at the mortality, weaning failure, re-intubation, and weaning
effectiveness of weaning using spontaneous breathing trials duration. [3]
with pressure support ventilation (PSV), synchronized
intermittent mandatory ventilation (SIMV), and T-tube or II. METHODS
T-piece trials.
The researchers of this study conducted a systematic
Keywords:- Weaning; Mechanical Ventilation Weaning; literature search on PubMed from their inception until
Mechanical Ventilation; Spontaneous Breathing Trial; SBT; February 28, 2023. No restriction on language was imposed.
Spontaneous Breathing Trial Techniques The search process employed several combinations of specific
keywords based on the principle of combination of medical
I. INTRODUCTION subject heading and text words: “ventilator weaning”,
spontaneous breathing trial”, “mechanical ventilation”, and
Several ventilatory support techniques have been other terms related to weaning modalities. Any disagreements
proposed to assist patients in gradually weaning themselves about the study retrieval were solved based on the consensus
off mechanical ventilation. However, it is unknown how between the 4 authors of this study.
effective these techniques will be when used in a medical
setting. Only a few of the identified ventilatory support III. LITERATURE SEARCH
techniques have passed as a theory.
 Spontaneous Breathing Trials
By quickly identifying patients who are capable of The spontaneous breathing trial (SBT) evaluates the
spontaneous breathing, the duration of mechanical ventilation likelihood that a patient can effectively wean off of invasive
may be reduced, and complications related to artificial mechanical ventilation by using a T-tube or modest
ventilation may also be reduced. [1] Weaning off artificial spontaneous breathing support. [2] If a patient is declared ready
breathing is done in the intensive care unit (ICU) using a step- to breathe independently, this screening technique is routinely
by-step procedure that is well recognized to all primary health performed. Typically, a T-piece is affixed to the patient’s
workers who work closely with the mechanically ventilated endotracheal tube when the patient is taken off the ventilator
patients. Despite the fact the intubation is required to protect to assume all of the work of breathing.
the airways and stop central hypoventilation, the respiratory
therapists face a problem while weaning patients off of
mechanical ventilation because it is important to keep

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Trials of spontaneous breathing can be performed in a patient. For some patient populations who require long-term
variety of ways, with varying levels and types of assistance mechanical ventilation, pressure support mode may be useful.
provided during inhalation and exhalation. One strategy is These patients include those who have chronic muscle
using pressures that typically ranges from 5-7cmH20 of weakness, chronic obstructive lung illness, and narrow
minimal pressure support, which some prefer to partially artificial airways. Because pressure support increases
replace the mechanical ventilator. [1] [2] ventilation and decreases blood carbon dioxide levels, it is a
straightforward and logical concept. Although a rise in airway
 Synchronized Intermittent Mandatory Ventilation (SIMV) resistance or a decline in lung compliance might produce less-
Synchronized intermittent mandatory ventilation (SIMV) than-ideal outcomes, pressure support ventilation performs
is type of ventilation where the ventilator must deliver a best in patients with compliant lungs who can breathe
specified volume and predetermined number of breaths and spontaneously. [6]
permits spontaneous breathing during a certain window.
Spontaneous breathing happens when the airway pressure  T-tube/T-piece Trial
drops below the end-expiratory pressure also known as trigger. After extubation, spontaneous breathing trial aims to as
The ventilator makes an effort to match the patient's nearly resemble the patient’s breathing pattern as possible.
spontaneous efforts with the delivery of necessary breaths. In One of the two main kinds of spontaneous breathing trial, SBT
contrast, SIMV can also supply spontaneous volumes that are with pressure support or SBT with T-piece, is generally
entirely motivated by patient effort through assist control administered to critically ill patients. It is said that SBT using
ventilation (ACV) [4]. One type of breath pattern used to pressure support reduces pressure support to 10 cmH20
categorize a mode of ventilation is intermittent mandatory whether or not a positive end-expiratory pressure (PEEP) is
ventilation (IMV). IMV is described as the capacity for applied.
patient-triggered and patient-cycled spontaneous breaths to
exist in between obligatory breaths (machine triggered or In line to this, the SBT using T-piece entails withdrawing
machine cycled). [3] Patients who have undergone unsuccessful the patient from the ventilator and then connecting the
weaning methods can try a gradual withdrawal from assisted endotracheal tube to a t-piece to provide oxygen, if necessary,
breathing while addressing the root cause of ventilatory without artificial breaths. In a worldwide observational study,
reliance. The most effective method of weaning those who are the type of SBT employed was significantly diverse. It was
deemed tough to wean has been proved to be SIMV. [5] recently proposed that the initial spontaneous breathing trial
 technique should be carried out using pressure support rather
Pressure Support Ventilation than a T-piece trial for hospitalized patient who are ventilated
Patients who can breathe on their own are usually given for longer than 24 hours based on evidence of only fair
pressure support ventilation (PSV), also known as pressure quality. In fact, a study analysis indicates that SBT using
support mode, to aid in ventilator release. Patients pressure support may have higher success rates than using T-
participating in weaning trials have shown to find pressure piece trial. This is also because pressure support technique
support ventilation to be comfortable. Furthermore, it is simple requires less labor to breathe than the use of spontaneous
to titrate in order to regulate patient’s respiration. Without breathing trial using T-piece.[7]
intending to stop the ventilation, it may also be tried on a

Table 1: Comparative Efficacy of Spontaneous Breathing Trial Techniques in Mechanically Ventilated Adult Patients
Author & Year Origin Article Title Results/Discussion

Ye Xiaomei, Waters David & Yu China The Effectiveness of Pressure When all four results of the study were looked
Hong-Jing (2022) Support Ventilation and T-piece at together, those who were thought to be easy
in differing duration among to wean did better after 30 minutes of pressure
weaning patients: A systematic support ventilation. Also, a 120-minute T-
review and network meta- piece trial and 120-minute pressure support
analysis ventilation are more likely to lead to a lower
rate of reintubation. So, weaning time is
thought to be more important for people who
are more likely to need a breathing tube again.
[8]

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Li Yuting, Li Hongxiang & Zhang China Comparison of T-piece and In patients who are very critical, T-piece trial
Dong (2020) pressure support ventilation as and pressure support ventilation as
spontaneous breathing trials in spontaneous breathing trial technique are
critically ill patients; a thought to have the same effect. The authors
systematic review and meta- were firm that there were no clear difference
analysis between the rates of patient being reintubated,
length of stay in the critical care unit and
hospital, or rates of mortality in the critical
care unit and hospital. [9]

Na Soo Jin, Ko Ryoung-Eun, Nam Republic of Comparison Between Pressure In critical patients, spontaneous breathing trial
Jimyoung, Ko Myeong Gyun & Jeon Korea Support Ventilation and T-piece using pressure support was not linked to a
Kyeongnam (2022) in Spontaneous Breathing Trials higher rate of successful weaning than using
T-piece trial. But it was decided that pressure
support ventilation could speed up the
weaning process without increasing the risk of
having to put the tube back in. [10]

Subira Carles, Hernandez Gonzalo, Spain Effect of Pressure Support vs T- A spontaneous breathing test with 30-minutes
Vazquez Antionia, et. al (2019) piece Ventilation Strategies of pressure support ventilation compared to 2
During Spontaneous Breathing hours of T-piece trial led to a huge increase in
Trials on Successful Extubation the number of patients who were able to get
Among Patients Receiving rid of the breathing machines. The results
Mechanical Ventilation: A show that a less difficult way to breathe
Randomized Clinical Trial should be used when testing patients’ ability
to breathe on their own. [11]

Pellegrini Jose Augusto, Boniatti Brazil Pressure-support Ventilation or The study found that trying to breathe on your
Marcio Manozzo, Boniatti Viviane T-piece Spontaneous Breathing own using spontaneous breathing trial
Correa, et. al (2018) Trials for Patients with Chronic technique didn’t change how long you had to
Obstructive Pulmonary Disease use mechanical ventilation. The use of T-piece
– A Randomized Controlled trial may make it longer to get hard-to-wean
Trial patients off of mechanical ventilators. [12]

Mancebo Jordi, Golgher Ewan & Spontaneous Breathing Trials The results of the clinical trial, which was
Borchard Laurent (2019) and Successful Extubation randomized, compared to 30-minute
spontaneous breathing trial using pressure
support mode was less difficult. When
spontaneous breathing trial was done with T-
piece, the rate of successful extubation was
higher. It is thought to be an easier method
that doesn’t increase the risk of reintubation.
[13]

Zein Hossam, Baratloo Alireza, Egypt Ventilator Weaning and Spontaneous breathing trials evaluates the
Negida Ahmed, Safari Saeed, et. al Spontaneous Breathing Trials; patient’s ability to breathe on his or her own
(2016) an Educational Review with minimal to no ventilatory support. The
collective task force stated in 2001 that the
process of breathing trials and weaning should
begin with determining whether or not the
patient’s underlying cause of respiratory
failure has been addressed and resolved.
Weaning predictors are parameters introduced
to assist clinicians in predicting whether or not
weaning attempts will be successful. [14]

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Thille, A. W., Coudroy, R., Gacouin, France T-piece versus pressure-support The experiment was started by the researches
A., Ehrmann, S., Contou, D., ventilation for spontaneous to see if pressure support ventilation could
Dangers, L., Frat, J.-P. (2020) breathing trials before speed up the extubation and reduce the
extubation in patients at high number of high-risk patients who needed to be
risk of reintubation: protocol for re-intubated faster than T-piece. Both of the
a multicentre, randomized techniques mentioned in the experiment have
controlled trial (TIP-EX) never been tested on patients who are at a high
risk for re-intubation which makes the study
very important for making good decisions and
everyday recommendations about extubation
in the intensive care unit. [15]

Chatburn Robert, Lui Ping-Hui, et. al Cleveland, The Evolution of Intermittent Over time, intermittent mandatory ventilation
(2022) Ohio Mandatory Ventilation has changed into four different types with
each of the technique to have its own pros and
cons for achieving the intended objectives of
mechanical ventilation, which are mostly to
keep the patient safe and comfortable. [16]

Dadam, M. M., Gonçalves, A. R. R., Brazil The Effect of Reconnection to The research shows that hooking up the
Mortari, G. L., Klamt, A. P., Hippler, Mechanical Ventilation for 1 patient to the mechanical ventilator for one
A., Lago, J. U., … Westphal, G. A. Hour After Spontaneous hour after a successful spontaneous breathing
(2021) Breathing Trial on Reintubation test didn’t have any statistically significant
Among Patients Ventilated for results or a big effect on the main goal of the
More Than 12 Hours. proponents. The results were good for
reintubation within the first 48 hours when the
patient had been on mechanical ventilation for
more than 72 hours before being taken off the
ventilator. So, it is possible that people who
have been using mechanical ventilation for a
long time may benefit more from this. But this
action needs to be checked with follow-up
research that is the right size and focuses on
the right people. [17]

Thille, A. W., Coudroy, R., Nay, M.- France Pressure-support ventilation The study showed that the first spontaneous
A., Gacouin, A., Demoule, A., versus T-piece during breathing trial using pressure support mode in
Sonneville, R., Frat, J.-P. (2020) spontaneous breathing trials critical patients who are at high risk for
before extubation among extubation failures went by a lot. Using
patients at high-risk of pressure support mode, weaning could speed
extubation failure: a post-hoc up extubation without increasing the risk of
analysis of a clinical trial. having to put the tube back in. This is another
important result that could happen in the
future but more study needs to be done to
confirm these results in high-risk groups
before this can be used as part of the plan to
wean all mechanically ventilated patients in
the intensive care unit. [18]

IV. CONCLUSION ventilation, although it takes longer for patients to be removed


from the mechanical ventilator. This is especially true to
In individuals who are simple to wean from mechanical patients who are difficult to wean. On the other hand,
ventilation, spontaneous breathing trials employing the use synchronized intermittent mandatory ventilation has its own
pressure support ventilation reduces weaning failure rates. benefits and drawbacks in terms of patients’ security, comfort
SBT employing T-tube/T-piece trial also lowers reintubation and freedom from mechanical ventilation. Future research
rates in patients when compared to pressure support should therefore contrast pressure support ventilation and T-

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
piece and T-tube trials with spontaneous breathing trial the SBT-ICU study. Trials. 2022 Dec 12;23(1):993. doi:
techniques using synchronized intermittent mandatory 10.1186/s13063-022-06896-4. PMID: 36503500;
ventilation. PMCID: PMC9742015.
https://pubmed.ncbi.nlm.nih.gov/36503500/
ACKNOWLEDGEMENT [8]. Ye X, Waters D, Yu HJ. The effectiveness of pressure
support ventilation and T-piece in differing duration
The researchers would like to express their deepest among weaning patients: A systematic review and
appreciation to the School of Allied Health Sciences (SAHS) network meta-analysis. Nurs Crit Care. 2023
spearheaded by Dean Fatima May Tesoro for the opportunity Jan;28(1):120-132. doi: 10.1111/nicc.12781. Epub
to learn about the Fundamentals in Journal Review. The 2022 Jun 1. PMID: 35647738.
researchers are also grateful to Dr. Erwin Faller for sharing his https://pubmed.ncbi.nlm.nih.gov/35647738/
expertise and assistance in the field of article writing, as well [9]. Li Y, Li H, Zhang D. Comparison of T-piece and
as to the SAHS Associate Dean, Marie Glen Geronan for her pressure support ventilation as spontaneous breathing
unending support and motivation to the Respiratory Therapy trials in critically ill patients: a systematic review and
faculty. The researchers would also like to thank the cohort meta-analysis. Crit Care. 2020 Feb 26;24(1):67. doi:
members of this article review for keeping the spirits and 10.1186/s13054-020-2764- 3. PMID: 32102693;
motivation high during the entire research process. Above all, PMCID: PMC7045460.
the researchers thank God for His guidance in all their https://pubmed.ncbi.nlm.nih.gov/32102693/
endeavors. [10]. Na SJ, Ko RE, Nam J, Ko MG, Jeon K. Comparison
between pressure support ventilation and T-piece in
CONFLICT OF INTEREST spontaneous breathing trials. Respir Res. 2022 Feb
7;23(1):22. doi: 10.1186/s12931-022-01942-w. PMID:
No conflict of interest among the authors. 35130914; PMCID: PMC8822807.
https://pubmed.ncbi.nlm.nih.gov/35130914/
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