Study protocol: The Intensive Care Outcome Network ('ICON') study Causes and Characteristics of Death in Intensive Care Units: A Prospective Multicenter Study Risk factors for extubation failure in patients following a successful spontaneous breathing trial. [Study of timing of invasive and noninvasive sequential ventilation in patients with acute respiratory distress syndrome]. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Differences in Clinical Outcomes According to Weaning Classifications in Medical Intensive Care Units [Time for extubation and sequential noninvasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation]. Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: An Indian experience Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Implications of COPD in patients admitted to the intensive care unit by community-acquired pneumonia Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial Core Outcomes in Ventilation Trials (COVenT): protocol for a core outcome set using a Delphi survey with a nested randomised trial and observational cohort study Causes of death and determinants of outcome in critically ill patients Early onset pneumonia: a multicenter study in intensive care units [Application of sequential noninvasive following invasive mechanical ventilation in COPD patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window]. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Pulmonary infection control window in treatment of severe respiratory failure of chronic obstructive pulmonary diseases: a prospective, randomized controlled, multi-centred study. Comparison of invasive and noninvasive positive pressure ventilation delivered by means of a helmet for weaning of patients from mechanical ventilation. The effect of postal questionnaire burden on response rate and answer patterns following admission to intensive care: a randomised controlled trial Epidemiology of Weaning Outcome according to a New Definition. The WIND Study [Prospective randomized controlled clinical study of early use of noninvasive positive pressure ventilation in the treatment for acute exacerbation of chronic obstructive pulmonary disease]. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. [An investigation of the efficacy of invasive-noninvasive sequential mechanical ventilation in senile patients with severe community-acquired pneumonia]. Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial Prevalence and prognosis of COPD in critically ill patients between 1998 and 2008 Weaning of mechanically ventilated chronic obstructive pulmonary disease patients by using non-invasive positive pressure ventilation: A prospective study Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial.
Background Extended follow-up of survivors of ICU treatment  has shown many patients suffer long-term physical and psychological consequences that affect their health-related quality of life . The current lack of rigorous longitudinal studies means that the true prevalence of these physical and psychological problems remains undetermined . Methods / Design The ICON ( Intensive Care Outcome Network ) study is a multi-centre , longitudinal study of survivors of critical illness . Patients will be recruited prior to hospital discharge from 20–30 ICUs in the UK and will be assessed at 3 , 6 , and 12 months following ICU discharge for health-related quality of life as measured by the Short Form-36 ( SF-36 ) and the EuroQoL ( EQ-5D ) ; anxiety and depression as measured by the Hospital Anxiety and Depression Scale ( HADS ) ; and post traumatic stress disorder ( PTSD ) symptoms as measured by the PTSD Civilian Checklist ( PCL-C ) . Postal question naires will be used . Discussion The ICON study will create a valuable UK data base detailing the prevalence of physical and psychological morbidity experienced by patients as they recover from critical illness . Knowledge of the prevalence of physical and psychological morbidity in ICU survivors is important because research to generate models of causality , prognosis and treatment effects is dependent on accurate determination of prevalence . The results will also inform economic modelling of the long-term burden of critical illness . Trial Registration IS RCT Background : Different modes of death are described in selected population s , but few data report the characteristics of death in a general intensive care unit population . This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts . Methods : An observational multicenter cohort study was performed in 96 intensive care units . During 1 yr , each intensive care unit was r and omized to participate during a 1-month period . Demographic data , characteristics of organ failures ( Sequential Organ Failure Assessment subscore greater than or equal to 3 ) , and organ supports were collected on all patients who died in the intensive care unit . Modes of death were defined as anticipated ( after withdrawal or withholding of treatment or brain death ) or unexpected ( despite engagement of full-level care or sudden refractory cardiac arrest ) . Results : A total of 698 patients were included during the study period . At the time of death , 84 % had one or more organ failures ( mainly hemodynamic ) and 89 % required at least one organ support ( mainly mechanical ventilation ) . Deaths were considered unexpected and anticipated in 225 and 473 cases , respectively . Compared to its anticipated counterpart , unexpected death occurred earlier ( 1 day vs. 5 days ; P < 0.001 ) and had fewer organ failures ( 1 [ 1 to 2 ] vs. 1 [ 1 to 3 ] ; P < 0.01 ) and more organ supports ( 2 [ 2 to 3 ] vs. 1 [ 1 to 2 ] ; P < 0.01 ) . Withdrawal or withholding of treatments accounted for half of the deaths . Conclusions : In a general intensive care unit population , the majority of patients present with at least one organ failure at the time of death . Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms BACKGROUND To assess the factors associated with reintubation in patients who had successfully passed a spontaneous breathing trial . METHODS We used logistic regression and recursive partitioning analyses of  prospect ively collected clinical data from adults admitted to ICUs of 37 hospitals in eight countries , who had undergone invasive mechanical ventilation for > 48 h and were deemed ready for extubation . RESULTS Extubation failure occurred in 121 of the 900 patients ( 13.4 % ) . The logistic regression analysis identified the following associations with reintubation : rapid shallow breathing index ( RSBI ) [ odds ratio ( OR ) , 1.009 per unit ; 95 % confidence interval ( CI ) , 1.003 to 1.015 ] ; positive fluid balance ( OR , 1.70 ; 95 % CI , 1.15 to 2.53 ) ; and pneumonia as the reason for initiating mechanical ventilation ( OR , 1.77 ; 95 % CI , 1.10 to 2.84 ) . The recursive partitioning analysis allowed the separation of patients into different risk groups for extubation failure : ( 1 ) RSBI of > 57 breaths/L/min and positive fluid balance ( OR , 3.0 ; 95 % CI , 1.8 to 4.8 ) ; ( 2 ) RSBI of < 57 breaths/L/min and pneumonia as reason for mechanical ventilation ( OR , 2.0 ; 95 % CI , 1.1 to 3.6 ) ; ( 3 ) RSBI of > 57 breaths/L/min and negative fluid balance ( OR , 1.4 ; 95 % CI , 0.8 to 2.5 ) ; and ( 4 ) RSBI of < 57 breaths/L/min ( OR , 1 [ reference value ] ) . CONCLUSIONS Among routinely measured clinical variables , RSBI , positive fluid balance 24 h prior to extubation , and pneumonia at the initiation of ventilation were the best predictors of extubation failure . However , the combined predictive ability of these variables was weak OBJECTIVE To investigate the timing and value of noninvasive ventilation ( NIV ) as a weaning tool immediately after early extubation in patients with acute respiratory distress syndrome ( ARDS ) . METHODS A prospect i ve r and omized controlled trial was conducted . The ARDS patients with surgical diseases admitted to Department of Respiratory Intensive Care Unit ( RICU ) of the First Affiliated Hospital of Xinjiang Medical University were enrolled . The patients were r and omly divided into sequential group and control group . All patients underwent endotracheal intubation and were mechanically ventilated . Every 12 hours during the first 3 days , the lung recruitment maneuver was performed during pressure control ventilation ( PCV ) . After lung recruitment , all patients were ventilated with synchronized intermittent m and atory ventilation ( SIMV ) + pressure support ventilation ( PSV ) + positive end-expiratory pressure ( PEEP ) or assistant/control ventilation ( A/C ) . The objects in sequential group who met the following criteria including those with oxygen index ( PaO2/FiO2 ) reaching 200 - 250 mmHg ( 1 mmHg=0.133 kPa ) under PEEP of 8 cmH2O ( 1 cmH2O=0.098 kPa ) , and pressure support of 12 cmH2O , and most acute infiltrating lesions having resolved on chest imaging , received noninvasive ventilation ( NIV ) immediately after extubation , and patients in control group continued to have invasive mechanical ventilation via intubation or tracheostomy with an endotracheal tube . The baseline data in both groups and the number of re-intubation in the sequential group were recorded . The duration of invasive mechanical ventilation and total duration of mechanical ventilation , ICU length of stay , the incidence of ventilator-associated pneumonia ( VAP ) , and mortality rate were compared between the two groups . RESULTS 53 consecutive adult patients were enrolled , including 26 in sequential group and 27 cases in control group . The period of endotracheal intubation was 7.0 ( 6.8 , 9.5 ) days , and 7.7 % ( 2/26 ) patients underwent re-intubation in sequential group . There were significant difference in respiratory and circulatory indicators before extubation spontaneous breathing trial ( SBT ) ≤10 minutes in sequential group , indicating that the patients were still in the early stage of extubation sequential NIV . There was no significant difference in indices reflecting respiratory function and circulation between the two groups , except that respiratory rate at 1 hour was slightly increased in sequential group as compared with that of control group , indicating that sequential NIV could maintain invasive ventilation function . There was significant difference in duration of invasive mechanical ventilation [ 7.0 ( 6.8 , 9.5 ) days vs. 21.0 ( 17.0 , 25.0 ) days , Z=-6.048 , P=0.000 ] , duration of total mechanical ventilation ( 18.0±4.1 days vs. 22.0±7.3 days , t=-2.805 , P=0.008 ) , and length of ICU stay ( 21.0±4.1 days vs. 28.0±8.1 days , t=-4.012 , P=0.000 ) between sequential group and control group , but there was no significant differences in the incidence of VAP [ 15.4 % ( 4/26 ) vs. 29.6 ( 8/27 ) , χ(2)=1.535 , P=0.215 ] and mortality rate [ 7.7 % ( 2/26 ) vs. 18.5 % ( 5/27 ) , P=0.420 ] . CONCLUSIONS When PaO2/FiO2 reached 200 - 250 mmHg under the condition of low ventilation , sequential NIV facilitates the early discontinuation of mechanical ventilation in ARDS patients with surgical diseases , with shortening of duration of invasive mechanical ventilation , total mechanical ventilation , and the length of ICU stay BACKGROUND Global epidemiological data regarding outcomes for patients in intensive care units ( ICUs ) are scarce , but are important in underst and ing the worldwide burden of critical illness . We , therefore , did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of ICU mortality . METHODS 730 participating centres in 84 countries prospect ively collected data on all adult ( > 16 years ) patients admitted to their ICU between May 8 and May 18 , 2012 , except those admitted for fewer than 24 h for routine postoperative monitoring . Participation was voluntary . Data were collected daily for a maximum of 28 days in the ICU and patients were followed up for outcome data until death or hospital discharge . In-hospital death was analysed using multilevel logistic regression with three levels : patient , hospital , and country . FINDINGS 10,069 patients were included from ICUs in Europe ( 5445 patients ; 54·1 % ) , Asia ( 1928 ; 19·2 % ) , the Americas ( 1723 ; 17·1 % ) , Oceania ( 439 ; 4·4 % ) , the Middle East ( 393 ; 3·9 % ) , and Africa ( 141 ; 1·4 % ) . Overall , 2973 patients ( 29·5 % ) had sepsis on admission or during the ICU stay . ICU mortality rates were 16·2 % ( 95 % CI 15·5 - 16·9 ) across the whole population and 25·8 % ( 24·2 - 27·4 ) in patients with sepsis . Hospital mortality rates were 22·4 % ( 21·6 - 23·2 ) in the whole population and 35·3 % ( 33·5 - 37·1 ) in patients with sepsis . Using a multilevel analysis , the unconditional model suggested significant between-country variations ( var=0·19 , p=0·002 ) and between-hospital variations ( var=0·43 , p<0·0001 ) in the individual risk of in-hospital death . There was a stepwise increase in the adjusted risk of in-hospital death according to decrease in global national income . INTERPRETATION This large data base highlights that sepsis remains a major health problem worldwide , associated with high mortality rates in all countries . Our findings also show a significant association between the risk of death and the global national income and suggest that ICU organisation has an important effect on risk of death . FUNDING None Background Although the weaning classification based on the difficulty and duration of the weaning process has been evaluated in the different type of intensive care units ( ICUs ) , little is known about clinical outcomes and validity among the three groups in medical ICU . The objectives of this study were to evaluate the clinical relevance of weaning classification and its association with hospital mortality in a medical ICU with a protocol -based weaning program . Methods All consecutive patients admitted to the medical ICU and requiring mechanical ventilation ( MV ) for more than 24 hours were prospect ively registered and screened for weaning readiness by a st and ardized weaning program between July 2010 and June 2013 . Baseline characteristics and outcomes were compared across weaning classifications . Results During the study period , a total of 680 patients were weaned according to the st and ardized weaning protocol . Of these , 457 ( 67 % ) were classified as simple weaning , 136 ( 20 % ) as difficult weaning , and 87 ( 13 % ) as prolonged weaning . Ventilator-free days within 28 days decreased significantly from simple to difficult to prolonged weaning groups ( P < 0.001 , test for trends ) . In addition , reintubation within 48 hours after extubation ( P < 0.001 ) and need for tracheostomy during the weaning process ( P < 0.001 ) increased significantly across weaning groups . Finally , ICU ( P < 0.001 ) , post-ICU ( P = 0.001 ) , and hospital ( P < 0.001 ) mortalities significantly increased across weaning groups . In a multiple logistic regression model , prolonged weaning but not difficult weaning was still independently associated with ICU ( adjusted OR 8.265 , 95 % CI 3.484–19.605 , P < 0.001 ) , and post-ICU ( adjusted OR 3.180 , 95 % CI 1.349–7.497 , P = 0.005 ) , and hospital ( adjusted OR 5.528 , 95 % CI 2.801–10.910 , P < 0.001 ) mortalities . Conclusions Weaning classification based on the difficulty and duration of the weaning process may provide prognostic information for mechanically ventilated patients who undergo the weaning process OBJECTIVE To discuss the optimal time for extubation and sequential non-invasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation .  METHODS 24 patients received invasive ventilation for 3 days were r and omly assigned to receive noninvasive ventilation ( study group ) or to continue the weaning process with invasive ventilation ( control group ) . The incidence of ventilator-associated pneumonia ( VAP ) , the incidence of death , the duration of ventilation , the hospitalization were analyzed in two groups . RESULTS Between study group and control group , the incidence of VAP was 0/12 vs 7/12 , P = 0.027 ; the incidence of death was 0/12 vs 3/12 , P = 0.217 ; the continued duration of ventilation after invasive ventilation for 3 days was ( 7 + /- 5 ) days vs ( 15 + /- 12 ) days , P < 0.05 ; the hospitalization was ( 16 + /- 6 ) days vs ( 25 + /- 12 ) days , P < 0.05 , respectively . CONCLUSIONS In COPD patients with exacerbated respiratory failure who received invasive ventilation  , invasive ventilation for 3 days followed by noninvasive ventilation may decrease the incidence of VAP , shorten the duration of ventilation and hospitalization Background : Endotracheal intubation and mechanical ventilation ( MV ) are often needed in patients of chronic obstructive pulmonary disease ( COPD ) with acute hypercapnic respiratory failure . The rate of weaning failure is high and prolonged MV increases intubation associated complications . Objective : To evaluate the role of Noninvasive ventilation ( NIV ) in weaning patients of chronic obstructive pulmonary disease ( COPD ) from MV , after T piece trial failure . Design : A prospect i ve , r and omized , controlled study was conducted in a tertiary care centre . 30 patients of acute exacerbation of COPD with acute on chronic hypercapnic respiratory failure , who were mechanically ventilated , were included in the study A T-piece weaning trial was attempted once the patients achieved satisfactory clinical and biochemical parameters . After T-piece failure , defined as pH < 7.35 , PaCO2 > 50 mmHg , PaO2 < 50 mmHg , HR > 100/min , RR > 35 , patients were r and omized to receive either NIV or PSV . Results : Demography , severity of disease and clinical profiles were similar in both groups . No significant difference between the two groups in duration of MV ( 6.20 ± 5.20 days vs. 7.47 ± 6.38 days , P > 0.05 ) , duration of weaning ( 35.17 ± 16.98 and 47.05 ± 20.98 hours , P > 0.05 ) or duration of ICU stay ( 8.47 ± 4.79 and 10.80 ± 5.28 days , P > 0.05 ) in Gp I and Gp II , respectively . Five patients developed VAP in the PSV group , where as only one patient had pneumonia in the NIV group . Lesser number of deaths in the NIV group at discharge from ICU ( 3 vs. 5 patients , respectively ) and at 30 days ( 5 vs. 9 patients , respectively ) , it did not achieve statistical significance ( P > 0.05 ) . Conclusion : NIV is as useful as PSV in weaning and can be better in weaning failure especially in COPD for earlier weaning , decrease ICU stay , complications and mortality Purpose The use of noninvasive ventilation ( NIV ) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure ( hypoxemic ARF ) has never been explored . This pilot study aims to assess the feasibility of early extubation followed by immediate NIV , compared conventional weaning , in patients with resolving hypoxemic ARF . Methods Twenty consecutive hypoxemic patients were r and omly assigned to receive either conventional weaning or NIV . The changes in arterial blood gases and respiratory rate were compared between the two groups at 1 , 12 , 24 and 48 h. Differences in the rate of extubation failure , ICU and hospital mortality , number of invasive-ventilation-free-days at day 28 , septic complications , number of tracheotomies , days and rates of continuous intravenous sedation , and ICU length of stay were also determined . Results No patient interrupted the study protocol . Arterial blood gases were similar during invasive mechanical ventilation , 1 h after NIV application following extubation , and after 12 , 24 and 48 h. Respiratory rate was higher after 1 h in the NIV group , but no different after 12 , 24 and 48 h. The number of invasive-ventilation-free-days at day 28 was 20 ± 8 ( min = 0 , max = 25 ) days in the treatment group and 10 ± 9 ( min = 0 , max = 25 ) days in the control group ( p = 0.014 ) . The rate of extubation failure , ICU and hospital mortality , tracheotomies , septic complications , days and rates of continuous sedation , and ICU length of stay were not significantly different between the two groups . Conclusions In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF Prolonged duration of endotracheal mechanical ventilation ( ETMV )  is associated with an increased morbidity and mortality in intensive care unit ( ICU ) patients . The aim of this study was to assess the usefulness of noninvasive ventilation ( NIV ) as a systematic extubation and weaning technique to reduce the duration of ETMV in acute-on-chronic respiratory failure ( ACRF ) . Among 53 consecutively intubated patients admitted for ACRF , we conducted a prospect i ve , r and omized controlled trial of weaning in 33 patients who failed a 2-h T-piece weaning trial ( 2 h-WT ) although they met simple criteria for weaning . Conventional invasive pressure support ventilation ( IPSV ) was used as the control weaning technique in 16 patients ( IPSV group ) , and NIV was applied immediately after extubation in 17 patients ( NIV group ) . The two weaning groups were similar for type of chronic respiratory failure ( CRF ) , pulmonary function data , age , Simplified Acute Physiology Score ( SAPS II ) , and severity of ACRF on admission . The characteristics of the two groups were also similar at r and omization . In the IPSV group , 12 of 16 patients ( 75 % ) were successfully weaned and extubated , versus 13 of 17 ( 76.5 % ) in the NIV group ( p = NS ) . NIV like IPSV significantly and similarly improved gas exchange in relation to that achieved during 2 h-WT ( p < 0.05 ) . The duration of ETMV was significantly shorter in the NIV ( 4.56 + /- 1.85 d ) than in the IPSV group ( 7.69 + /- 3.79 d ) ( p = 0 . 004 ) . NIV also reduced the mean period of daily ventilatory support , but increased the total duration of ventilatory support related to weaning ( 3.46 + /- 1.42 d , versus 11.54 + /- 5.24 d with NIV ; p = 0 . 0001 ) . Most patients in the IPSV group developed complications related to ETMV and /or the weaning process , but the difference was not significant ( nine of 16 versus six of 17 ) . The duration s of ICU and hospital stays and the 3-mo survival were similar in the two groups . In conclusion , NIV permits earlier removal of the endotracheal tube than with conventional IPSV , and reduces the duration of daily ventilatory support without increasing the risk of weaning failures .  NIV should be considered as a new and useful systematic approach to weaning in patients with ACRF who are difficult to wean To assess the efficacy of noninvasive ventilation ( NIV ) in patients with persistent weaning failure , we conducted a prospect i ve , r and omized , controlled trial in 43 mechanically ventilated patients who had failed a weaning trial for 3 consecutive days . This trial was stopped after a planned interim analysis . Patients were r and omly extubated , receiving NIV ( n = 21 ) , or remained intubated following a conventional-weaning approach consisting of daily weaning attempts ( n = 22 ) . Compared with the conventional-weaning group , the noninvasive-ventilation group had shorter periods of invasive ventilation ( through tracheal intubation ) ( 9.5 + /- 8.3 vs. 20.1 + /- 13.1 days , p = 0.003 ) and intensive care unit ( ICU ) ( 14.1 + /- 9.2 vs. 25.0 + /- 12.5 days , p = 0.002 ) and hospital stays ( 27.8 + /- 14.6 vs. 40.8 + /- 21.4 days , p = 0.026 ) , less need for tracheotomy to withdraw ventilation ( 1 , 5 % vs. 13 , 59 % , p < 0.001 ) , lower incidence of nosocomial pneumonia ( 5 , 24 % vs. 13 , 59 % , p = 0.042 ) and septic shock ( 2 , 10 % vs. 9 , 41 % , p = 0.045 ) , and increased ICU ( 19 , 90 % vs. 13 , 59 % , p = 0.045 ) and 90-day survival ( p = 0.044 ) . The conventional-weaning approach was an independent risk factor of decreased ICU ( odds ratio : 6.6 ; p = 0.035 ) and 90-day survival ( odds ratio : 3.5 ; p = 0.018 ) . Earlier extubation with NIV results in shorter mechanical ventilation and length of stay , less need for tracheotomy , lower incidence of complications , and improved survival in these patients The mortality rate of chronic obstructive pulmonary disease ( COPD ) patients with community-acquired pneumonia ( CAP ) is reported to be low . However , studies carried out to date have included < 20 % of critically ill patients . The current authors performed a secondary analysis of a prospect i ve study evaluating 428 immunocompetent patients admitted to the intensive care unit ( ICU ) for severe CAP . In total , 176 COPD patients were compared with 252 non- COPD patients . In COPD patients , ICU mortality ( odds ratio ( OR ) 1.58 ; 95 % confidence interval ( CI ) 1.01–1.43 ) and  mechanical ventilation  ( OR 2.78 ; 95 % CI 1.63–4.74 ) rates were higher than in non- COPD patients . The ICU mortality was 39 % for COPD patients initially intubated and 50 % for those who failed noninvasive ventilation . The proportion of patients who were males , aged ≥70 yrs , smokers and who had chronic heart disease or Pseudomonas aeruginosa were higher in COPD patients .  Inappropriate empirical antibiotic therapy was associated with higher mortality ( OR 3.8 ; 95 % CI 1.19–12.6 ) . ICU mortality in COPD patients with adequate therapy was associated with bilateral pneumonia ( OR 2.32 ; 95 % CI 1.18–4.53 ) and shock ( OR 3.53 ; 95 % CI 1.31–9.71 ) . In conclusion , chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia in the intensive care unit had higher mortality and need of mechanical ventilation when compared with patients without chronic obstructive pulmonary disease Introduction The use of noninvasive positive-pressure mechanical ventilation ( NPPV ) has been investigated in several acute respiratory failure situations . Questions remain about its benefits when used in weaning patients from invasive mechanical ventilation ( IMV ) .  The objective of this study was to evaluate the use of bi-level NPPV for patients who fail weaning from IMV .  Methods This experimental r and omized clinical trial followed up patients undergoing IMV weaning , under ventilation for more than 48 hours , and who failed a spontaneous breathing T-piece trial . Patients with contraindications to NPPV were excluded . Before T-piece placement , arterial gases , maximal inspiratory pressure , and other parameters of IMV support were measured . During the trial , respiratory rate , tidal volume , minute volume , rapid shallow breathing index , heart rate , arterial blood pressure , and peripheral oxygen saturation were measured at 1 and 30 minutes . After failing a T-piece trial , patients were r and omly divided in two groups : ( a ) those who were extubated and placed on NPPV and ( b ) those who were returned to IMV . Group results were compared using the Student t test and the chi-square test . Results Of 65 patients who failed T-piece trials , 28 were placed on NPPV and 37 were placed on IMV .  The ages of patients in the NPPV and IMV groups were 67.6 ± 15.5 and 59.7 ± 17.6 years , respectively .  Heart disease , post-surgery respiratory failure , and chronic pulmonary disease aggravation were the most frequent causes of IMV use . In both groups , ventilation time before T-piece trial was 7.3 ± 4.1 days . Heart and respiratory parameters were similar for the two groups at 1 and 30 minutes of T-piece trial . The percentage of complications in the NPPV group was lower ( 28.6 % versus 75.7 % ) , with lower incidences of pneumonia and tracheotomy . Length of stay in the intensive care unit and mortality were not statistically different when comparing the groups . Conclusion The results suggest that NPPV is a good alternative for ventilation of patients who fail initial weaning attempts . NPPV reduces the incidence of pneumonia associated with mechanical ventilation and the need for tracheotomy . Trial registration CEP HCPA ( 02–114 ) Background Among clinical trials of interventions that aim to modify time spent on mechanical ventilation for critically ill patients there is considerable inconsistency in chosen outcomes and how they are measured . The Core Outcomes in Ventilation Trials ( COVenT ) study aims to develop a set of core outcomes for use in future ventilation trials in mechanically ventilated adults and children . Methods / design We will use a mixed methods approach that incorporates a r and omised trial nested within a Delphi study and a consensus meeting . Additionally , we will conduct an observational cohort study to evaluate uptake of the core outcome set in published studies at 5 and 10 years following core outcome set publication . The three-round online Delphi study will use a list of outcomes that have been reported previously in a review of ventilation trials . The Delphi panel will include a range of stakeholder groups including patient support groups . The panel will be r and omised to one of three feedback methods to assess the impact of the feedback mechanism on subsequent ranking of outcomes . A final consensus meeting will be held with stakeholder representatives to review outcomes . Discussion The COVenT study aims to develop a core outcome set for ventilation trials in critical care , explore the best Delphi feedback mechanism for achieving consensus and determine if participation increases use of the core outcome set in the long term Introduction Whereas most studies focus on laboratory and clinical research , little is known about the causes of death and risk factors for death in critically ill patients . Methods Three thous and seven hundred patients admitted to an adult intensive care unit ( ICU ) were prospect ively evaluated . Study endpoints were to evaluate causes of death and risk factors for death in the ICU , in the hospital after discharge from ICU , and within one year after ICU admission . Causes of death in the ICU were defined according to st and ard ICU practice , whereas deaths in the hospital and at one year were defined and grouped according to the ICD-10 ( International Statistical Classification of Diseases and Related Health Problems ) score . Stepwise logistic regression analyses were separately calculated to identify independent risk factors for death during the given time periods . Results Acute , refractory multiple organ dysfunction syndrome was the most frequent cause of death in the ICU ( 47 % ) , and central nervous system failure ( relative risk [ RR ] 16.07 , 95 % confidence interval [ CI ] 8.3 to 31.4 , p < 0.001 ) and cardiovascular failure ( RR 11.83 , 95 % CI 5.2 to 27.1 , p < 0.001 ) were the two most important risk factors for death in the ICU . Malignant tumour disease and exacerbation of chronic cardiovascular disease were the most frequent causes of death in the hospital ( 31.3 % and 19.4 % , respectively ) and at one year ( 33.2 % and 16.1 % , respectively ) . Conclusion In this primarily surgical critically ill patient population , acute or chronic multiple organ dysfunction syndrome prevailed over single-organ failure or unexpected cardiac arrest as a cause of death in the ICU . Malignant tumour disease and chronic cardiovascular disease were the most important causes of death after ICU discharge A prospect i ve multicenter study concerning the incidence , onset time , risk factors and mortality of pneumonia  was carried out by the Intensive Care Units Collaborative Group for Infection Control in Lombardy , Northern Italy . Out of 1304 patients admitted over 3 months in 16 intensive care units ( ICUs ) , 441 met the criteria for the protocol ( no previous pulmonary infection or irreversible terminal illness , ICU stay>48 h ) . The incidence of  acquired pneumonia was 21.3 % ( 94/441 ) , with 54.2 % of cases diagnosed within 4 days of admission ( early onset pneumonia ) . Impairment of airway reflexes on admission and more than 24h respiratory assistance were shown as significant risk ractors ( RR ) for early onset pneumonia ( respectively RR=12.4 , with 95 % confidence interval (CI)=5.3–28.9 and RR=3.3 , with 95 % CI=1.8–5.9 ) . A suggested pathogenetic mechanism is aspiration of oropharyngeal contents at the onset of acute illness , due to depression of protective reflexes with delayed clearance of bacterial contamination . No protection was offered by routinely applied prophylactic antibiotic therapy OBJECTIVE To evaluate the application of sequential noninvasive following invasive mechanical ventilation in chronic obstructive pulmonary disease ( COPD ) patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window . METHODS From November 2001 to October 2004 , 76 case of COPD patients with severe respiratory failure due to pulmonary infection were intubated and recruited in the study . When the pulmonary infection was significantly controlled ( the time of pulmonary infection control was called PIC window ) by the antibiotic and comprehensive therapy , all cases were r and omized into noninvasive veatiation group ( NIV ) and control group . The early extubation was conducted and followed by noninvasive mechanical ventilation via facial mask with bilevel positive airway pressure mode immediately in the NIV group . Conventional invasive synchronized intermittent m and atory ventilation ( SIMV ) plus pressure support ventilation ( PSV ) was used as the weaning technique in the control group . RESULTS Thirty eight cases among 76 patients were in the NIV group , and the rest in the control group . The NIV group and the control group had similar age , sex , APACHE scores , RR , HR , MAP , PaO2 and PaCO2 at the time of commencement and PIC window ( P > 0.05 ) . The time of PIC window was ( 7.5 + /- 1.9 ) d in the NIV group , and ( 8.0 + /- 2.5 ) d in the control group ( P > 0.05 ) . In the NIV group , the duration s of invasive mechanical ventilation ( MV ) and total MV were ( 7.5 + /- 1.9 ) d and ( 12.5 + /- 4.0 ) d respectively , while the duration s were ( 23.5 + /- 9.5 ) d in the control group ( P < 0.05 ) . The duration s of RICU stay and hospital stay were shorter than that in the control group . The incidence of ventilation associated pneumonia ( VAP ) was 18.4 % ( 7/38 ) in the NIV group , 39.5 % ( 15/38 ) in the control group respectively ( P < 0.05 ) . The incidence of reintubation was 13.2 % ( 5/38 ) in the NIV group , 34.2 % ( 13/38 ) in the control group respectively ( P < 0.05 ) . Hospital mortality was 7.9 % ( 3/38 ) in the NIV group , and 28.9 % ( 11/38 ) in the control group ( P < 0.05 ) . CONCLUSION In those COPD patients requiring intubation and mechanical ventilantion who have severe respiratory failure due to pulmonary infection , sequential noninvasive following invasive mechanical ventilation at the appearance of PIC window can significantly reduce the MV duration , the length of RICU stay and hospital stay , and decrease the occurrence of VAP , reintubation and hospital mortality as well . So it is an efficient strategy to be generalized BACKGROUND After patients recovering from respiratory failure have successfully completed a spontaneous breathing trial ( SBT ) , clinicians must determine whether an artificial airway is still required . We hypothesized that cough strength and the magnitude of endotracheal secretions affect extubation outcomes . METHODS We conducted a prospect i ve study of 91 adult patients treated in medical-cardiac ICUs who were recovering from respiratory failure , had successfully completed an SBT , and were about to be extubated . A number of demographic and physiologic parameters were recorded with the patient receiving full ventilatory support and during the SBT , just prior to extubation . Cough strength on comm and was measured with a semi objective scale of 0 to 5 , and the magnitude of endotracheal secretions was measured as none , mild , moderate , or abundant by a single observer . In addition , patients were asked to cough onto a white card held 1 to 2 cm from the endotracheal tube ; if secretions were propelled onto the card , it was termed a positive white card test ( WCT ) result . All patients were then extubated from T-piece or continuous positive airway pressure breathing trials . If 72 h elapsed and patients did not require reintubation , they were defined as successfully extubated . RESULTS Ninety-one patients with a mean ( + /- SE ) age of 65.2 + /- 1.6 years , ICU admission APACHE ( acute physiology and chronic health evaluation ) II score of 17.7 + /- 0.7 , and duration of mechanical ventilation of 5.0 + /- 0.5 days were studied over 100 extubations . Sixteen patients could not be extubated , and 2 patients underwent two unsuccessful extubation attempts , for a total of 18 unsuccessful extubations . Age , severity of illness , duration of mechanical ventilation , oxygenation , rapid shallow breathing index , and vital signs during SBTs did not differ between patients with successful extubations vs patients with unsuccessful extubations . The WCT result was highly correlated with cough strength . Patients with weak ( grade 0 to 2 ) coughs were four times as likely to have unsuccessful extubations , compared to those with moderate-to-strong ( grade 3 to 5 ) coughs ( risk ratio [ RR ] , 4.0 ; 95 % confidence interval [CI],1.8 to 8.9 ) . Patients with moderate-to-abundant secretions were more than eight times as times as likely to have unsuccessful extubations as those with no or mild secretions ( RR , 8.7 ; 95 % CI , 2.1 to 35.7 ) . Patients with negative WCT results were three times as likely to have unsuccessful extubations as those with positive WCT results ( RR , 3.0 ; 95 % CI , 1.3 to 6.7 ) . Poor cough strength and endotracheal secretions were synergistic in predicting extubation failure ( Rothman synergy index , 3.7 ; RR , 31.9 ; 95 % CI , 4.5 to 225.3 ) . Patients with PaO(2)/fraction of inspired oxygen ( P : F ) ratios of 120 to 200 ( receiving mechanical ventilation ) were not less likely to be successfully extubated than those with P : F ratios of > 200 , but those with hemoglobin levels < or = 10 g/dL were more than five times as likely to have unsuccessful extubations as those with hemoglobin levels > 10 g/dL. CONCLUSIONS After patients recovering from respiratory failure have successfully completed an SBT , factors affecting airway competence , such as cough strength and amount of endotracheal secretions , may be important predictors of extubation outcomes . Also , a majority ( 89 % ) of medically ill patients with P : F ratios of 120 to 200 ( four of five patients with P : F ratios from 120 to 150 ) , values sometimes used to preclude weaning , were extubated successfully BACKGROUND Early withdraw from invasive mechanical ventilation ( MV ) followed by noninvasive MV is a new strategy for changing modes of treatment . This study was conducted to estimate the feasibility and the efficacy of early extubation and sequential noninvasive MV commenced at beginning of pulmonary infection control window in patients with exacerbated hypercapnic respiratory failure caused by chronic obstructive pulmonary diseases ( COPD ) . METHODS A prospect i ve , r and omized controlled study was conducted in eleven teaching hospitals ; respiratory or medical intensive care units in China . Ninety intubated COPD patients with severe hypercapnic respiratory failure triggered by pulmonary infection ( pneumonia or purulent bronchitis ) were involved in the study . When the pulmonary infection had been controlled by antibiotics and comprehensive therapy , the " pulmonary infection control window ( PIC window ) " has been reached . Each case was r and omly assigned to study group ( extubation and noninvasive MV via facial mask immediately ) or control group ( invasive MV was received continuously after PIC window by using conventional weaning technique ) . RESULTS Study group ( n = 47 ) and control group ( n = 43 ) had similar clinical characteristics initially and at the time of PIC window . Compared with control group , study group had shorter duration of invasive MV  [ ( 6.4 + /- 4.4 ) days vs ( 11.3 + /- 6.2 ) days , P = 0.000 ] , lower rate of ventilator associated pneumonia ( VAP ) ( 3/47 vs 12/43 , P = 0.014 ) , fewer days in ICU [ ( 12 + /- 8) days vs ( 16 + /- 11 ) days , P = 0.047 ] and lower hospital mortality ( 1/47 vs 7/43 , P = 0.025 ) . CONCLUSIONS In COPD patients requiring intubation and invasive MV for hypercapnic respiratory failure , which is exacerbated by pulmonary infection , early extubation followed by noninvasive MV initiated at the start of PIC window may decrease significantly the duration of invasive MV , the risk of VAP and hospital mortality PURPOSE The effectiveness of noninvasive positive pressure ventilation delivered by helmet ( H-NPPV ) as a weaning approach in patients with acute respiratory failure is unclear . PATIENTS AND METHODS We r and omly and evenly assigned 64 patients intubated for acute respiratory failure to conventional weaning with invasive mechanical ventilation ( IMV ) or H-NPPV . The primary end point was a reduction in  IMV duration by 6 days between the 2 groups . Secondary end points were the occurrence of ventilator-associated pneumonia and major complications , duration of mechanical ventilation and weaning , intensive care unit and hospital length of stay , and survival . RESULTS The mean duration of IMV  was significantly reduced in the H-NPPV group compared with the IMV group ( P<.0001 ) , without significant difference in duration of weaning ( P=.26 ) and total ventilatory support ( P=.45 ) . In the H-NPPV group , the incidence of major complications was less than the IMV group ( P=.032 ) . Compared with the H-NPPV group , the IMV group was associated with a greater incidence of VAP ( P=.018 ) and an increased risk of nosocomial pneumonia ( P=.049 ) . The mortality rate was similar between the groups , with no significant difference in overall intensive care unit ( P=.47 ) or hospital length of stay ( P=.37 ) . CONCLUSIONS H-NPPV was well tolerated and effective in patients who were difficult to wean Background The effects of postal question naire burden on return rates and answers given are unclear following treatment on an intensive care unit ( ICU ) . We aim ed to establish the effects of different postal question naire burdens on return rates and answers given . Methods Design : A parallel group r and omised controlled trial . We assigned patients by computer-based r and omisation to one of two question naire packs ( Group A and Group B ) . Setting : Patients from 26 ICUs in the United Kingdom . Inclusion criteria : Patients who had received at least 24 h of level 3 care and were 16 years of age or older . Patients did not know that there were different question naire burdens . The study included 18,490 patients . 12,170 were eligible to be sent a question naire pack at 3 months . We sent 12,105 question naires ( 6112 to group A and 5993 to group B ) . Interventions : The Group A pack contained demographic and EuroQol group 5 Dimensions 3 level ( EQ-5D-3 L ) question naires , making four question naire pages . The Group B pack also contained the  Hospital Anxiety and Depression Score ( HADS ) and the  Post-Traumatic Stress Disorder Check List-Civilian ( PCL-C ) question naires , making eight question naire pages in total . Main outcome measure : Question naire return rate 3 months after ICU discharge by group . Results In group A , 2466/6112 ( 40.3 % ) participants responded at 3 months . In group B 2315/ 5993 ( 38.6 % ) participants responded ( difference 1.7 % CI for difference 0–3.5 % p = 0.053).Group A reported better functionality than group B in the EQ-5D-3 L mobility ( 41 % versus 37 % reporting no problems p = 0.003 ) and anxiety/depression ( 59 % versus 55 % reporting no problems p = 0.017 ) domains . Conclusions In survivors of intensive care , question naire burden had no effect on return rates . However , question naire burden affected answers to the same question naire ( EQ-5D-3 L).Trial registration IS RCT N69112866 ( assigned 02/05/2006 ) Rationale : The weaning process concerns all patients receiving mechanical ventilation .  A previous classification into simple , prolonged , and difficult weaning ignored weaning failure and presupposed the use of spontaneous breathing trials . Objectives : To describe the weaning process , defined as starting with any attempt at separation from mechanical ventilation and its prognosis , according to a new operational classification working for all patients under ventilation . Methods : This was a multinational prospect i ve multicenter observational study over 3 months of all patients receiving mechanical ventilation in 36 intensive care units , with daily collection of ventilation and weaning modalities . Pragmatic definitions of separation attempt and weaning success allowed us to allocate patients in four groups . Measurements and Main Results : A total of 2,729 patients were enrolled . Although half of them could not be classified using the previous definition , 99 % entered the groups on the basis of our new definition as follows : 24 % never started a weaning process , 57 % had a weaning process of less than 24 hours ( group 1 ) , 10 % had a difficult weaning  of more than 1 day and less than 1 week ( group 2 ) , and 9 % had a prolonged weaning duration of 1 week or more ( group 3 ) . Duration of ventilation , intensive care unit stay , and mortality ( 6 , 17 , and 29 % for the three groups , respectively ) all significantly increased from one group to the next . The unadjusted risk of dying was 19 % after the first separation attempt and increased to 37 % after 10 days . Conclusions : A new classification allows us to categorize all weaning situations . Every additional day without a weaning success after the first separation attempt increases the risk of dying OBJECTIVE To evaluate the effect of the early use of noninvasive positive pressure ventilation ( NIPPV ) on gas exchange , rate of endotracheal intubation and in-hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease ( COPD ) . METHODS Thirty-six patients with acute exacerbation of COPD [ 7.25 < or = arterial blood pH (pHa)<7.35 , partial pressure of carbon dioxide in artery ( PaCO(2))>45 mm Hg , 1 mm Hg=0.133 kPa ] were enrolled in the study . The patients were divided r and omly into st and ard therapy group ( group A , n=18 ) and st and ard therapy+NIPPV group ( group B , n=18 ) . The patients in group A were treated with st and ard therapy only and those in group B were treated with both st and ard therapy and NIPPV with Bi-level positive airway pressure ( BiPAP ) mode . NIPPV should be maintained over 2 hours in the first time . In the first 3 days , the duration of NIPPV should not be less than 8 hours per day . In each group , heart rate ( HR ) , respiratory rate ( RR ) , parameters of gas exchange , and scale for accessory muscle use were measured at the time of enrollment ( 0 hour ) , 2 hours , 24 hours and 72 hours after r and omization . In group B , the foregoing parameters were also observed at 24 hours after the end of NIPPV . Rate of endotracheal intubation and in-hospital mortality were recorded in each group . RESULTS The general conditions were similar in both groups at 0 hour . Compared with that of 0 hour , marked improvement in HR , RR , pHa , PaCO(2 ) and scale for accessory muscle use was found only at 72 hours after treatment in group A. In group B , significant improvement in HR , RR , PaCO(2 ) , partial pressure of oxygen in artery ( PaO(2 ) ) and scale for accessory muscle use was found 2 hours after the treatment . In this group , the foregoing parameters were improved continuously in the course of the treatment , and they showed no deterioration 24 hours after termination of NIPPV . The rate of endotracheal intubation in group B ( 11.1 % ) was significantly lower than that in group A ( 44.4 % , P<0.05 ) . In group B , the in-hospital mortality was slightly lower than that in group A ( 5.6 % vs. 16.7 % , P>0.05 ) . CONCLUSION Early use of NIPPV can improve gas exchange , lessen respiratory muscle fatigue and decrease the need for intubation in patients with acute exacerbation of COPD CONTEXT The outcome of patients receiving mechanical ventilation for particular indications has been studied , but the outcome in a large number of unselected , heterogeneous patients has not been reported . OBJECTIVE To determine the survival of patients receiving mechanical ventilation  and the relative importance of factors influencing survival . DESIGN , SETTING , AND SUBJECTS Prospect i ve cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1 , 1998 , and March 31 , 1998 . Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days . MAIN OUTCOME MEASURE All-cause mortality during intensive care unit stay . RESULTS Of the 15 757 patients admitted , a total of 5183 ( 33 % ) received mechanical ventilation  for a mean ( SD ) duration of 5.9 ( 7.2 ) days . The mean ( SD ) length of stay in the intensive care unit was 11.2 ( 13.7 ) days . Overall mortality rate in the intensive care unit was 30.7 % ( 1590 patients ) for the entire population , 52 % ( 120 ) in patients who received ventilation because of acute respiratory distress syndrome , and 22 % ( 115 ) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease . Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69 % . The main conditions independently associated with increased mortality were ( 1 ) factors present at the start of mechanical ventilation ( odds ratio [ OR ] , 2.98 ; 95 % confidence interval [ CI ] , 2.44 - 3.63 ; P<.001 for coma ) , ( 2 ) factors related to patient management ( OR , 3.67 ; 95 % CI , 2.02 - 6.66 ; P<.001 for plateau airway pressure > 35 cm H(2)O ) , and ( 3 ) developments occurring over the course of mechanical ventilation ( OR , 8.71 ; 95 % CI , 5.44 - 13.94 ; P<.001 for ratio of PaO(2 ) to fraction of inspired oxygen < 100 ) . CONCLUSION Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation , but also on the development of complications and patient management in the intensive care unit OBJECTIVE To investigate the efficacy of invasive-noninvasive sequential mechanical ventilation ( MV ) in senile patients with severe community-acquired pneumonia ( CAP ) . METHODS A prospect i ve study was conducted . The patients with severe CAP aged ≥75 years admitted to Department of Respiratory Intensive Care Unit ( RICU ) of the First Affiliated Hospital of Xinjiang Medical University from November 2012 to July 2014 , with refusal to have tracheostomy , were enrolled . All patients meeting the diagnostic criteria of CAP and severe CAP were first admitted into the Department of Emergency , and they were found to need MV without absolute contraindication for noninvasive ventilation ( NIV ) in RICU . The patients were mechanically ventilated via endotracheal intubation ( ETI ) , and they were r and omly divided into invasive-noninvasive sequential MV group ( sequential MV group ) and conventional MV group . NIV was initiated immediately when patients matched the conditions for early extubation in the sequential MV group . Oxygen therapy ( 5 L/min ) via a Venturi mask was provided when the indications of conventional extubation were met . The baseline data and clinical characteristics were recorded , the risk factors of death were analyzed by logistic regression analysis , and 60-day survival rate was analyzed by Kaplan-Meier curve . RESULTS Ninety-one senile patients with severe CAP were enrolled , among them 28 patients died within 60 days , with a mortality rate of 30.77 % . No significant difference in 60-day mortality was found between sequential MV group ( n=44 ) and conventional MV group [ n=47 , 25.0 % ( 11/44 ) vs. 36.2 % ( 17/47 ) , χ2=1.331 , P=0.249 ] . In the sequential MV group , the incidence of ventilator-associated pneumonia ( VAP ) was significantly decreased [ 27.3 % ( 12/44 ) vs. 55.3 % ( 26/47 ) , χ2=7.350 , P=0.007 ] , and the rate of ETI≥2 times was increased [ 59.1 % ( 26/44 ) vs. 29.8 % ( 14/47 ) , χ2=5.095 , P=0.024 ] as compared with conventional MV group . Compared with survival group , the patients in non-survival group showed a higher incidence of cerebrovascular disease ( 60.7 % vs. 25.4 % , P=0.002 ) , higher acute physiology and chronic health evaluation II ( APACHEII ) score ( 26.46±2.59 vs. 24.41±2.47 , P=0.001 ) , British Thoracic Society confusion , uremia , respiratory rate , blood pressure , ≥75 years ( CURB-75 score , 4.00±0.47 vs. 3.68±0.53 , P=0.013 ) , a longer total duration of MV ( days : 21.18±10.02 vs. 14.56±7.62 , P=0.002 ) , and a higher ratio of ETI≥2 times ( 53.6 % vs. 33.3 % , P<0.001 ) . It was revealed by multivariate logistic regression analysis that ETI≥2 times and comorbidity of cerebrovascular infa rct ion were independent predictors of a worse outcome in the senile patients [ odds ratio (OR)=9.677 , 95 % confidence interval (95%CI)=3.075 - 30.457 , P<0.001 ; OR=5.386 , 95%CI=1.781 - 6.284 , P=0.003 ] . It was showed by Kaplan-Meir survival analysis that ETI times and concurrent cerebrovascular infa rct ion imparted significant effects on the 60-day survival rate ( χ2=40.805 , P=0.000 ; χ2=4.425 , P=0.035 ) . CONCLUSIONS Invasive-noninvasive sequential MV may not improve the outcome of senile patients with severe CAP , and ETI≥2 times and concurrent cerebrovascular disorders drastically lowered the survival rate Importance In adults in whom weaning from invasive mechanical ventilation is difficult , noninvasive ventilation may facilitate early liberation , but there is uncertainty about its effectiveness in a general intensive care patient population . Objective To investigate among patients with difficulty weaning the effects of protocol ized weaning with early extubation to noninvasive ventilation on time to liberation from ventilation compared with protocol ized invasive weaning . Design , Setting , and Participants R and omized , allocation-concealed , open-label , multicenter clinical trial enrolling patients between March 2013 and October 2016 from 41 intensive care units in the UK National Health Service . Follow-up continued until April 2017 . Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed were enrolled . Interventions Patients were r and omized to receive either protocol ized weaning via early extubation to noninvasive ventilation ( n = 182 ) or protocol ized st and ard weaning ( continued invasive ventilation until successful spontaneous breathing trial , followed by extubation ) ( n = 182 ) . Main Outcomes and Measures Primary outcome was time from r and omization to successful liberation from all forms of mechanical ventilation among survivors , measured in days , with the minimal clinical ly important difference defined as 1 day . Secondary outcomes were duration of invasive and total ventilation ( days ) , reintubation or tracheostomy rates , and survival . Results Among 364 r and omized patients ( mean age , 63.1 [ SD , 14.8 ] years ; 50.5 % male ) , 319 were evaluable for the primary effectiveness outcome ( 41 died before liberation , 2 withdrew , and 2 were discharged with ongoing ventilation ) . The median time to liberation was 4.3 days in the noninvasive group vs 4.5 days in the invasive group ( adjusted hazard ratio , 1.1 ; 95 % CI , 0.89 - 1.40 ) . Competing risk analysis accounting for deaths had a similar result ( adjusted hazard ratio , 1.1 ; 95 % CI , 0.86 - 1.34 ) . The noninvasive group received less invasive ventilation  ( median , 1 day vs 4 days ; incidence rate ratio , 0.6 ; 95 % CI , 0.47 - 0.87 ) and fewer total ventilator days ( median , 3 days vs 4 days ; incidence rate ratio , 0.8 ; 95 % CI , 0.62 - 1.0 ) . There was no significant difference in reintubation , tracheostomy rates , or survival . Adverse events occurred in 45 patients ( 24.7 % ) in the noninvasive group compared with 47 ( 25.8 % ) in the invasive group . Conclusions and Relevance Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed , early extubation to noninvasive ventilation did not shorten time to liberation from any ventilation . Trial Registration IS RCT N Identifier : IS RCT The epidemiology of chronic obstructive pulmonary disease ( COPD ) in critically ill patients is largely unknown . The aims of the study were : 1 ) to determine whether COPD , either as the cause of intensive care unit ( ICU ) admission or as a comorbid condition , is an independent risk factor for increased morbidity and mortality ; and 2 ) to investigate time trends in proportion and outcome of acute respiratory failure in patients with COPD admitted to ICUs . Prospect ively recorded data from 194 453 adults consecutively admitted to 87 Austrian ICUs over a period of 11 years ( 1998–2008 ) were retrospectively analysed . COPD was present in 8.6 % of all patients . The risk-adjusted mortality of patients with COPD was higher than in patients without COPD . The presence of COPD was an independent risk factor for increased mortality and was associated with prolonged mechanical ventilation and prolonged weaning . During the course of the 11 years , the proportion of acute respiratory failure due to COPD increased by about two-thirds , and the use of noninvasive ventilation  within the COPD cohort more than doubled . Simultaneously , the risk-adjusted mortality of patients with COPD improved . In critically ill patients , the presence of COPD is increasing and is an independent risk factor for mortality and morbidity Background : Chronic obstructive pulmonary disease ( COPD ) patients frequently pose difficulty in weaning from invasive mechanical ventilation ( MV ) . Prolonged invasive ventilation brings along various complications . Non-invasive positive pressure ventilation ( NIPPV ) is proposed to be a useful weaning modality in such cases . Objective : To evaluate the usefulness of NIPPV in weaning COPD patients from invasive MV , and compare it with weaning by conventional pressure support ventilation ( PSV ) . Material s and Methods : For this prospect i ve r and omized controlled study , we included 50 COPD patients with type II respiratory failure requiring initial invasive MV .  Upon satisfying weaning criteria and failing a t-piece weaning trial , they were r and omized into two groups : Group I ( 25 patients ) weaned by NIPPV , and group II ( 25 patients ) weaned by conventional PSV . The groups were similar in terms of disease severity , demographic , clinical and biochemical parameters . They were compared in terms of duration of MV , weaning duration , length of intensive care unit ( ICU ) stay , occurrence of nosocomial pneumonia and outcome . Results : Statistically significant difference was found between the two groups in terms of duration of MV , weaning duration , length of ICU stay , occurrence of nosocomial pneumonia and outcome . Conclusion : NIPPV appears to be a promising weaning modality for mechanically ventilated COPD patients and should be tried in re source -limited setting s especially in developing countries 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 r and omly assigned to three groups : conventional invasive weaning group ( n = 69 ) , extubation followed by st and ard 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
Abstract Purpose A systematic review and meta- analysis was conducted to answer the question ‘ In adults with respiratory failure requiring invasive ventilation for more than 24 h , does a weaning strategy with early extubation to non-invasive ventilation ( NIV ) compared to invasive ventilation weaning reduce all-cause hospital mortality ? ’