Extubation With or Without Spontaneous Breathing Trial

Jing Wang, Yingmin Ma and Qiuhong Fang

Crit Care Nurse 2013, 33:50-55. doi: 10.4037/ccn2013580

© 2013 American Association of Critical-Care Nurses
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 Feature

Extubation With or Without

Spontaneous Breathing Trial
JING WANG, MD
YINGMIN MA, MD, PhD
QIUHONG FANG, MD, PhD

PURPOSE—To evaluate whether spontaneous breathing trials (SBTs) are necessary when extubating critical
care patients.
METHODS—A prospective, randomized, double-blind study was performed in adult patients supported by
mechanical ventilation for at least 48 hours in the general intensive care unit of a teaching hospital. Patients
ready for weaning were randomly assigned to either the SBT group (extubation with an SBT) or the no-SBT
group (extubation without an SBT). Patients in the SBT group who tolerated SBT underwent immediate extuba-
tion. Patients in the no-SBT group who met the weaning readiness criteria underwent extubation without an
SBT. The primary outcome measure was a successful extubation or the ability to maintain spontaneous
breathing for 48 hours after extubation.
RESULTS—A total of 139 adult patients were enrolled. No significant difference in the demographic, respi-
ratory, and hemodynamic characteristics was indicated between the groups at the end of weaning readiness
assessment. Successful extubation was achieved in 56 of 61 patients (91.8%) in the SBT group and 54 of 60
patients (90.0%) in the no-SBT group. In the SBT and no-SBT groups, 5 (8.2%) and 6 (10.0%) patients, respec-
tively, needed reintubation; 7 (11.5%) and 9 (15.0%) patients, respectively, required noninvasive ventilation
after extubation. In-hospital mortality did not differ significantly between the groups.
CONCLUSION—Intensive care patients can be extubated successfully without an SBT. (Critical Care Nurse.
2013;33[6]:50-56)

imely weaning from mechanical ventilation of patients in intensive care units (ICUs) is

T intriguing and difficult work. Unnecessary delay in weaning from ventilator support increases
the rate of complications such as pneumonia or airway trauma, as well as costs.1,2 The major fac-
tor in successful weaning is resolution of the precipitating illness. Other factors include comorbid ill-
nesses, cause of acute respiratory failure, protocol, and the method of weaning. Current views suggest
that nurses can be the key players in reducing the duration of mechanical ventilation for patients and
can lead the extubation part of ventilatory weaning.3 Nurses’ involvement in decision making about
ventilator weaning relies on appropriate knowledge and skills in managing ventilation. The method of
weaning is an important variable because it affects the potential to intervene. Accordingly, extensive
efforts have been made to identify predictors of successful extubation or weaning.

©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013580

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 Major weaning studies were conducted by using or weaning.17 The present study evaluated the clinical out-
spontaneous breathing trials (SBTs) through T-piece come of extubation with or without an SBT. We hypoth-
and pressure support (PS) ventilation.4,5 In these studies, esized that an SBT is not an essential process during
readiness to wean was assessed by an initial 2-hour T-piece weaning from ventilation in ICU patients.
trial. Patients who tolerated this trial were extubated,
whereas those whose trial was unsuccessful were ran- Materials and Methods
domized to different weaning methods. Previous data Patients
revealed a shortened discontinuing period when follow- The present study was conducted in an 8-bed adult
ing a standard protocol that includes an SBT trial in general ICU in a 1000-bed primary teaching hospital.
weaning patients from ventilation.6-8 Common practice All patients enrolled in this study had been receiving
currently recommends an SBT for 30 min to 120 min mechanical ventilation via an endotracheal tube for more
before extubation.9 However, the trial may be unsuccess- than 48 hours during the study period. The investigation
ful in some patients before extubation because of the was approved by the hospital’s ethics committee. Written
discomfort and increased labor of breathing caused by informed consent was obtained from the next of kin of
the endotracheal tube.10,11 Consequently, low levels of pos- each patient. The patients were ventilated in PS mode
itive pressure ventilatory support are often applied dur- during the entire weaning period. The levels of inspira-
ing SBTs. Several studies showed the same extubation tory PS and positive-end expiratory pressure were pro-
results between short (30-minute) and long (120-minute) gressively reduced depending on a patient’s clinical
SBTs.12-14 Although work of breathing was not evaluated assessment and blood gas values.
in these studies, use of the shortened SBT, which The patients had to satisfy the following readiness
relieves the patient from endotracheal tube discomfort criteria: significant improvement or resolution of the
sooner and hypothetically reduces the work of breath- underlying cause of acute respiratory failure; full wake-
ing, may improve patients’ tolerance of SBTs. fulness; need for bronchial toilet less than twice within
The potential for reducing the period of SBT and the the 4-hour period preceding the assessment; stable
effect of said reduction on a patient’s spontaneous breath- hemodynamics without further need for vasoactive
ing ability after extubation remain unclear. The effects agents;
of complete elimination of the SBT procedure during extu- ratio of Patients in the no-SBT group who met the
bation should be investigated. Some studies recommend PaO2 to readiness criteria immediately underwent
SBTs, whereas others suggest that SBTs are inaccurate fraction of extubation without an SBT and received
and that approximately 15% of extubation failures are inspired supplemental oxygen via facemask.
unidentified in SBTs.15 The reintubation rates of initial oxygen
SBTs ranged from 10% to 20%. Failure rates for SBTs of (FIO2) greater than 200 at a positive end-expiratory
26% to 42% have been reported.4,5,16 Studies have been pressure of 4.0 cm H2O, with a maximum FIO2 of 0.40;
conducted to identify predictors of successful extubation core temperature less than 38.0°C; systolic blood pres-
sure greater than 90 mm Hg; and respiratory rate/tidal
volume ratio less than 105 breaths/min per liter. The
Authors ratio was calculated after 1 minute of spontaneous
Jing Wang is a physician in the Department of Respiratory Medicine, breathing.13 During the SBT, the maximum inspiratory
the PLA General Hospital, Beijing, China. PS was 12 cm H2O, and no mandatory machine breaths
Yingmin Ma is a director in the Department of Respiratory Medicine, were supplied from the ventilator.
Beijing Shijitan Hospital, Capital Medical University.
Qiuhong Fang is a deputy director in the Department of Respiratory Study Protocol
Medicine, Beijing Shijitan Hospital, Capital Medical University.
We investigated the weaning process with and with-
Corresponding author: Yingmin Ma, MD, PhD, Department of Respiratory Medicine,
Beijing Shijitan Hospital, Capital Medical University, Beijing 100069, China (e-mail: out an SBT. All patients were continuously assessed
[email protected]). according to the readiness criteria and were screened
To purchase electronic or print reprints, contact the American Association of Critical- for enrollment once a day (between 10 AM and noon).
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. As soon as they were ready for weaning, the patients

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 Table 1 Characteristics of patients who underwent a spontaneous breathing trial and patients who did not

Characteristic No trial (n = 60) Trial (n = 61) P

Age, mean (SD), y 64.7 (16.0) 63.9 (16.3) .57
Male, No. of patients 38 40 .92
Acute Physiology and Chronic Health Evaluation II score, mean (SD) 18.3 (6.4) 18.9 (6.7) .45
Days of ventilation before trial, mean (SD) 6.1 (4.1) 5.9 (4.3) .29
Size of endotracheal tube, mean (SD), mm 7.5 (0.4) 7.5 (0.3) .89
Reason for mechanical ventilation, No. of patients
After emergency surgery 7 8 .58
Heart failure 1 3 .34
Shock 9 8 .42
Multitrauma 6 7 .57
Pneumonia 5 4 .44
Sepsis with acute lung injury 4 5 .56
Acute exacerbation of chronic obstructive pulmonary disease 28 26 .79

were randomly assigned to either the SBT group or the (SaO2 <90% for >15 minutes) while receiving supplemen-
no-SBT group. Randomization was conducted in a blinded tal oxygen, respiratory acidosis (arterial pH <7.35 with
fashion by using opaque and sealed envelopes. All patients PaCO2 >45 mm Hg), and respiratory rate greater than
breathed through the ventilator circuit with flow trigger- 25/min for 1 hour. The mode of ventilation was bipha-
ing (2 L/min), positive end-expiratory pressure of 4.0 cm sic positive airway pressure. When such support was
H2O, FIO2 of 0.4, and PS before enrollment. The patients inadequate (hypoxemia, hypercapnea, or respiratory dis-
in the SBT group underwent a 1-hour SBT with inspiratory tress), the patient was reintubated and mechanical venti-
PS of 7 cm H2O and other settings remaining constant lation was resumed.
(FIO2 of 0.4, positive end-expiratory pressure of 4.0 cm The SBT and extubation were performed by 2 physi-
H2O, and trigger sensitivity of 2 L/min). Patients who cians who are members of the research team. Decisions
exhibited poor tolerance to SBT were immediately admin- regarding reintubation were made by the physicians who
istered full were blinded to the treatment groups. Extubation failure
Extubation without an SBT was successful ventilation was defined as reintubation within 48 hours. The reasons
compared with extubation with an SBT, support and for reintubation were prospectively recorded.
which is the standard protocol when continuously
discontinuing ventilation support. assessed for Statistical Analysis
the subse- Results are expressed as mean (SD). Mean values of
quent weaning. Poor tolerance was defined by the fol- selected demographic variables and physiologic parame-
lowing failure criteria: a decrease in oxygen saturation to ters of patients who underwent SBT were compared with
less than 90%; a respiratory rate greater than 35/min for those of patients who underwent extubation directly via
more than 5 minutes in the presence of diaphoresis or Student t tests. Differences in proportions between the 2
thoracoabdominal paradox; and a sustained increase in groups were determined by a χ2 test.
heart rate (>140/min) or a significant change in systolic
blood pressure (>180 or <90 mm Hg). Patients who toler- Results
ated the SBT underwent immediate extubation and Characteristics of Patients
received supplemental oxygen via a facemask. A total of 121 patients satisfied the inclusion criteria
Patients in the no-SBT group who met the readiness for extubation and were randomized (SBT group, n = 61;
criteria immediately underwent extubation without an no-SBT group, n = 60). Table 1 shows the baseline char-
SBT and received supplemental oxygen via facemask. acteristics for patients in the 2 treatment groups. No sig-
Noninvasive ventilatory support was introduced after nificant difference in sex, age, Acute Physiology and
extubation under the following conditions: hypoxemia Chronic Health Evaluation II score at ICU admission,

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 Table 2 Patient parameters measured before extubation
(no-trial group) and at the start of the spontaneous breathing trial (trial group)
Characteristic No trial (n = 60) Trial (n = 61) P
Ratio of respiratory rate to tidal volume, breaths per minute per L 68.6 (22.2) 64.1 (24.3) .59
Paco2, mm Hg 38.8 (4.1) 39.5 (5.1) .17
Pao2, mm Hg 101.7 (23.5) 97.8 (22.4) .81
Ratio of Pao2 to fraction of inspired oxygen 277.7 (72.8) 262.8 (72.8) .67
Heart rate, beats per minute 90.8 (13.3) 99.4 (17.8) .16
Systolic arterial blood pressure, mm Hg 138.8 (16.3) 135.0 (19.8) .40
Body temperature, ºC 37.0 (0.6) 37.2 (0.6) .84
Albumin, g/L 34.4 (4.9) 32.6 (4.3) .44
Hemoglobin, g/L 90.9 (21.1) 87.3 (13.8) .15
a All values in second and third column are mean (SD).

duration of mechanical ventilation, size of endotracheal

tube, and reason for mechanical ventilation was appar- Total = 139
ent between the treatment groups. No significant dif- Mechanical ventilation >48 hours
ference in respiratory measurements, hemodynamic
parameters, level of albumin in the blood, and level of
hemoglobin at the end of weaning readiness assessment Tracheotomy Patients enrolled
n = 18 n = 121
was indicated between the groups (Table 2). In the non-
SBT group, the level of PS was 11.6 (1.1) cm H2O at the
time of extubation. In the SBT group, the level of PS
was 12.1 (1.4) cm H2O before the patient entered the No spontaneous Spontaneous
breathing trial breathing trial
SBT phase. The Figure presents the treatment course n = 60 n = 61
and the outcomes.

Reintubation Successful Reintubation Successful Reintubation

Reintubation was required in 11 patients after nonin- extubation n=6 extubation n=5
n = 54 n = 56
vasive ventilation: 6 of 60 (10.0%) in the no-SBT group
and 5 of 61 (8.2%) in the SBT group (P = .76). Reasons Figure Treatment course and outcomes for patients who
for reintubation included inability to clear secretions underwent a spontaneous breathing trial and patients who
did not.
(n = 6), new sepsis (n = 2), and respiratory distress (due
to acute renal failure, n = 2; due to new hemorrhagic
shock, n = 1). A total of 16 patients required noninvasive could discontinue ventilation without an SBT in future
ventilation after extubation: 9 of 60 (15.0%) in the no-SBT extubation attempts. However, 54 patients (90%) were
group and 7 of 61 (11.5%) in the SBT group (P = .87). A successfully extubated without an SBT, and 56 patients
total of 12 patients died while in the hospital after extu- (91.8%) were successfully extubated with an SBT. No sig-
bation: 7 of 60 (11.7%) in the no-SBT group and 5 of 61 nificant differences in reintubation and requirement for
(8.2%) in the SBT group (P = .78). noninvasive ventilation support after extubation were
found between the 2 groups. These results suggest that
Discussion SBT is not required before extubation.
In this study, we assessed the outcomes of extubation Tolerance of an SBT in the discontinuation of mechan-
with and without an SBT. The results did not indicate ical ventilation has been examined.6-8 Results showed
whether the patients in whom the SBT was unsuccessful successful extubation with an SBT (with PS ventilation,

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continuous positive airway pressure, and T-tube strat- extubated successfully after a further trial with PS.22
egy) and shortened mechanical ventilation by protocol- However, whether patients in whom the SBT is unsuc-
directed weaning with an SBT. One possible reason for cessful can be successfully extubated without the SBT
SBT failure in some patients is the increased ventilatory has not been determined. The need for an SBT with or
muscle work caused by the endotracheal tube. To improve without a supporting procedure (shortening SBT dura-
SBT tolerance, shortened SBT duration (30 minutes) is tion or using automatic tube compensation) to predict
recommended, which has shown extubation outcomes spontaneous breathing ability before extubation has not
similar to the outcomes for longer SBT duration (120 min- been ascertained. Whether SBT failure can be used to
utes) when releasing patients from mechanical ventila- predict the need for ventilator dependence cannot be
tion sooner.12,14,18 Cohen et al19 recently assessed the effect formally assessed because patients in whom the SBT is
of SBT with automatic tube compensation, a ventilatory unsuccessful remain on ventilation support.
mode designed to overcome the imposed work of breath- Extubation without an SBT was successful compared
ing due to artificial airways. Cohen et al observed a with extubation with an SBT, which is the standard pro-
trend exhibiting higher SBT tolerance among patients tocol in discontinuing ventilation support. Data for this
and less need for noninvasive ventilation support after single-center cohort of patients suggest that the effect of
extubation compared with an SBT with continuous and need for an SBT in weaning patients off of mechani-
positive airway pressure. Esteban et al20 compared 2-hour cal ventilation require further research in a general ICU
trials of unassisted breathing with a PS of 7 cm H2O population.
versus a T-piece trial. Failure to tolerate weaning was Studies exploring interprofessional responsibility for
observed in a smaller proportion of patients in the PS decision making related to mechanical ventilation and
group (14%) than in the T-piece trial group (22%). These weaning in Australia and New Zealand revealed that
results suggest that PS decreased breathing load and physicians and nurses actively collaborated in the man-
minimized work of breathing during SBT, which may agement of ventilation and weaning, generally in the
improve SBT tolerance and improve the extubation out- absence of protocols.23 Therefore, physicians and nurses
come. In another study,21 researchers demonstrated a must discuss the weaning process. CCN
significant increase in endocrine stress response, as Financial Disclosures
assessed by plasma levels of cortisol, insulin, and glucose, None reported.
as well as by urinary levels of vanillylmandelic acid,
during an SBT. The magnitude of the response was sig-
Now that you’ve read the article, create or contribute to an online discussion
nificantly larger at the end of a breathing trial with a about this topic using eLetters. Just visit www.ccnonline.org and select the article
T-tube than with PS ventilation. The levels of vanillyl- you want to comment on. In the full-text or PDF view of the article, click
“Responses” in the middle column and then “Submit a response.”
mandelic acid returned to normal in the PS group but
remained elevated in the T-tube group 48 hours after
extubation. All patients requiring reintubation were
To learn more about extubation, read “Influence of Physical Restraint
from the T-tube group. Increased endocrine stress on Unplanned Extubation of Adult Intensive Care Patients: A Case-
response may have elevated oxygen consumption in the Control Study” by Chang et al in the American Journal of Critical Care,
September 2008;17:408-415. Available at www.ajcconline.org.
body during the trial. Although the change in endocrine
stress response could not be assessed in the present
References
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 CCN Fast Facts CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing

Extubation With or Without Spontaneous

Breathing Trial
Facts extubation and received supplemental oxygen via a
• Timely weaning from mechanical ventilation facemask.
of patients in intensive care units is difficult • Patients in the no-SBT group who met the readi-
work. Unnecessary delay in weaning from ven- ness criteria immediately underwent extubation
tilator support increases the rate of complica- without an SBT and received supplemental oxygen
tions such as pneumonia or airway trauma, as via facemask.
well as costs. • A total of 121 patients satisfied the inclusion crite-
• The major factor in successful weaning is reso- ria for extubation and were randomized (SBT group,
lution of the precipitating illness. Other factors n = 61; no-SBT group, n = 60). No significant differ-
include comorbid illnesses, cause of acute res- ence in respiratory measurements, hemodynamic
piratory failure, protocol, and the method of parameters, level of albumin in the blood, and level
weaning. of hemoglobin at the end of weaning readiness
• Nurses can be the key players in reducing the assessment was indicated between the groups.
duration of mechanical ventilation for patients • No significant differences in reintubation and
and can lead the extubation part of ventilatory requirement for noninvasive ventilation support
weaning. Nurses’ involvement in decision after extubation were found between the 2 groups.
making about ventilator weaning relies on These results suggest that SBT is not required
appropriate knowledge and skills in managing before extubation.
ventilation. • Extubation without an SBT was successful com-
• We investigated the weaning process with and pared with extubation with an SBT, which is the
without a spontaneous breathing trial (SBT). standard protocol in discontinuing ventilation sup-
As soon as patients were ready for weaning, port. Data for this single-center cohort of patients
they were randomly assigned to either the SBT suggest that the effect of and need for an SBT in
group or the no-SBT group. weaning patients off of mechanical ventilation require
• The patients in the SBT group underwent a further research in a general intensive care unit
1-hour SBT with inspiratory pressure support population. CCN
of 7 cm H2O and other settings remaining con-
stant (FIO2 of 0.4, positive end-expiratory pres-
sure of 4.0 cm H2O, and trigger sensitivity of
2 L/min). Patients who exhibited poor toler-
ance to SBT were immediately administered
full ventilation support and continuously
assessed for the subsequent weaning. Patients
who tolerated the SBT underwent immediate

Wang J, Ma Y, Fang Q. Extubation With or Without Spontaneous Breathing Trial. Critical Care Nurse. 2013;33(6):50-56.

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