The Frequency of Screening and SBT Technique Trial: The FAST Trial
NCT ID: NCT02969226
Last Updated: 2018-12-05
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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UNKNOWN
NA
760 participants
INTERVENTIONAL
2018-01-18
2021-03-31
Brief Summary
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Patients: Adults in North American ICUs who are on ventilators for at least 24 hours and who can take breaths on their own.
Interventions: Patients in our study will receive one type of screening and one type of weaning test at random. In the 'once daily' screening groups, clinicians will screen patients each morning. In the 'two or more times daily screening' groups, patients will be screened in the morning, afternoon, and whenever else clinicians wish to screen. When screening criteria are met, patients will undergo one of two weaning tests with low ventilator support or no support.
Outcomes: The main outcome of this study will be the time for patients to be successfully removed from the ventilator.
Relevance: For patients, this study will clarify the best way to remove them from ventilators in a timely and safe manner. For clinicians and our health care systems, this study holds promise to improve how critically ill patients are weaned from breathing machines.
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Detailed Description
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1. To identify the best strategy to wean patients from ventilators.
2. To fully engage patients and family members (PFM) in our trial.
Rationale: Nearly 40% of the time on invasive ventilation is spent weaning. In minimizing patients' exposure to invasive ventilation, clinicians are challenged by a trade-off between the complications associated with protracted ventilation and the risks \[ventilator-associated pneumonia (VAP), mortality\] of premature, failed attempts at extubation. Although randomized trials have been conducted to evaluate different screening practices and spontaneous breathing trial (SBT) techniques, most trials were small, predated daily screening, and have limited generalizability to the North American (NA) context where weaning involves respiratory therapists (RTs) and physicians.
In a systematic review of 17 trials (n=2,434), we found that screening protocols, compared to usual care, were associated with a 26% reduction in total duration of ventilation, a 70% reduction in weaning time, and an 11% reduction in ICU stay. Only 1 trial (n=385) compared twice daily screening to usual care and found that patients screened twice daily spent significantly less time on ventilators. Once daily screening is poorly aligned with the continuous care ICU environment. In our international survey, Pressure Support (PS) with positive end-expiratory pressure (PEEP) and T-piece were the most commonly used SBT techniques. Concerns exist that PS and T-piece SBTs may over and underestimate, respectively, patients' ability to breathe after extubation. Only 1 trial (n=484) has compared T-piece and PS SBTs and found no difference in outcomes. This trial was conducted in Europe, predated daily screening, and was underpowered.
Design: The investigators will conduct a factorial design trial involving 760 patients in 20 NA ICUs.
Population: The investigators will enroll critically ill adults receiving invasive ventilation for \> 24 hours who can initiate or trigger breaths on commonly used weaning modes.
Comparators: Patients will be randomized to undergo a screening frequency (once vs. at least twice daily) AND an SBT technique (T-piece vs. PS ± PEEP).
Outcomes: The primary outcome will be the time to successful extubation. Secondary outcomes will include general and ventilation-specific outcomes that are important to citizens. We expect that more frequent screening, regardless of SBT technique, will reduce time to successful extubation.
This trial will identify the best strategy to reduce the time patients spend on ventilators and in ICUs, clarify best weaning practices, enhance care delivery, and launch a new paradigm of engagement into our research.
Conditions
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Study Design
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RANDOMIZED
FACTORIAL
SCREENING
NONE
Study Groups
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Once daily screening + PS SBTs
In this arm, RTs will screen patients between approximately 06:00 - 08:00 hrs daily. If a screening period is missed inadvertently or due to an investigation or intervention (operation/procedure) necessitating absence from the ICU, it may be conducted later on the same day and ideally within 6 hrs of the scheduled screening period. Regardless of group assignment, if the SBT screening assessment is passed, an SBT will be conducted as per protocol. RTs will conduct SBTs using only PS\> 0 and =\< 8 cm H2O with PEEP\> 0 and =\< 5 cm H2O.
Once daily screening
RTs will screen invasively ventilated patients between approximately 06:00 - 08:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
PS SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted on PS \>0 and =\< 8 cm H2O with PEEP\>0 and =\< 5 cm H2O
At least twice daily screening + PS SBTs
In this arm patients will be screened at a minimum between approximately 06:00 - 08:00 hours and 13:00 - 15:00 hs daily. If a screening period is missed inadvertently or due to an investigation or intervention (operation/procedure) necessitating absence from the ICU, it may be conducted later on the same day and ideally within 6 hrs of the scheduled screening period. Additional screening trials in the 'at least twice daily' screening arm will be permitted at the discretion of the clinical team \[RTs and physicians\]. Regardless of group assignment, if the SBT screening assessment is passed, an SBT will be conducted as per protocol. RTs will conduct SBTs using only PS\>0 and =\< 8 cm H2O with PEEP\>0 and =\< 5 cm H2O.
Twice daily screening
In the 'at least twice daily' screening arm patients will be screened at a minimum between approximately 6:00-8:00 hours and 13:00-15:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
PS SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted on PS \>0 and =\< 8 cm H2O with PEEP\>0 and =\< 5 cm H2O
Once daily screening + T-piece SBTs
In this arm + PS SBT' arm, RTs will screen invasively ventilated patients between approximately 06:00 - 08:00 hrs daily. If a screening period is missed inadvertently or due to an investigation or intervention (operation/procedure) necessitating absence from the ICU, it may be conducted later on the same day and ideally within 6 hrs of the scheduled screening period. Regardless of group assignment, if the SBT screening assessment is passed, an SBT will be conducted as per protocol. RTs will conduct SBTs using only T-piece (off the ventilator).
Once daily screening
RTs will screen invasively ventilated patients between approximately 06:00 - 08:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
T-piece SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted with T-piece (off the ventilator)
At least twice daily screening + T-piece SBTs
In this arm, RTs will screen invasively ventilated patients between approximately 06:00 - 08:00 hours daily. If a screening period is missed inadvertently In the 'at least twice daily + PS SBT' screening arm patients will be screened at a minimum between approximately 06:00 - 08:00 hrs and 13:00 - 15:00 hrs daily. If a screening period is missed inadvertently or due to an investigation or intervention (operation/procedure) necessitating absence from the ICU, it may be conducted later on the same day and ideally within 6 hours of the scheduled screening period. Additional screening trials in the 'at least twice daily' screening arm will be permitted at the discretion of the clinical team (RTs and physicians). Regardless of group assignment, if the SBT screening assessment is passed, an SBT will be conducted as per protocol. RTs will conduct SBTs using only T-piece (off the ventilator).
Twice daily screening
In the 'at least twice daily' screening arm patients will be screened at a minimum between approximately 6:00-8:00 hours and 13:00-15:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
T-piece SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted with T-piece (off the ventilator)
Interventions
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Once daily screening
RTs will screen invasively ventilated patients between approximately 06:00 - 08:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
Twice daily screening
In the 'at least twice daily' screening arm patients will be screened at a minimum between approximately 6:00-8:00 hours and 13:00-15:00 hours daily. To pass the 'readiness to wean screen' and undergo an SBT, specific criteria must be met.
PS SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted on PS \>0 and =\< 8 cm H2O with PEEP\>0 and =\< 5 cm H2O
T-piece SBTs
Patients are assigned a SBT technique. All SBTs for these patients must be conducted with T-piece (off the ventilator)
Eligibility Criteria
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Inclusion Criteria
2. Capable of initiating spontaneous breaths or triggering the ventilator to give a breath on ventilator modes commonly used in the ICU.
3. Fractional concentration of inspired oxygen (FiO2) \< or = 70%.
4. Positive End-Expiratory pressure (PEEP) \< or = 12 cm H2O.
Exclusion Criteria
2. Evidence of myocardial ischemia in the 24 hour period before enrollment. Except if current trend in troponin is downward AND it has been \> or = 24 hours since last troponin peak or the patient has undergone a revascularization procedure and attending physician has no concerns regarding ongoing ischemia.
3. Received continuous invasive mechanical ventilation for \> or = 2 weeks.
4. Tracheostomy in situ at the time of screening.
5. Receiving a sedative infusion(s) for seizures or alcohol withdrawal.
6. Require escalating doses of sedative agents.
7. Receiving neuromuscular blockers or who have known quadriplegia, paraplegia or 4 limb weakness or paralysis preventing active mobilization.
8. Moribund (e.g., at imminent risk for death) or who have limitations of treatment.
9. Profound neurologic deficits (e.g., post cardiac or respiratory arrest, large intracranial stroke or bleed) or Glasgow Coma Scale (GCS) \< or = 6.
10. Use of ventilator modes that automate SBT conduct.
11. Currently enrolled in a confounding study that includes a weaning protocol.
12. Previous enrollment in this trial.
13. Previous SBT or are already on T-piece, or CPAP alone (without PS), or PS \< or equal 8 cm H2O regardless of PEEP, or other 'SBT equivalent' settings immediately before randomization.
14. Previous extubation \[planned, unplanned (e.g. self, accidental)\] during the same ICU admission.
16 Years
ALL
No
Sponsors
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Unity Health Toronto
OTHER
Responsible Party
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Principal Investigators
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Karen Burns, MD, FRCPC
Role: PRINCIPAL_INVESTIGATOR
St. Michael's Hospital (Toronto, Canada)
Locations
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Longbeach Memorial Hospital
Long Beach, California, United States
Keck Hospital of USC
Los Angeles, California, United States
Tufts Medical Center
Boston, Massachusetts, United States
University of Michigan Health System
Ann Arbor, Michigan, United States
Temple University Hospital
Philadelphia, Pennsylvania, United States
Royal Alexandra Hospital
Edmonton, Alberta, Canada
St. Paul's Hospital
Vancouver, British Columbia, Canada
Hamilton Health Sciences Hamilton General Hospital
Hamilton, Ontario, Canada
Juravinski Hospital Cancer Centre
Hamilton, Ontario, Canada
St. Joseph's Hospital
Hamilton, Ontario, Canada
Niagara Health - St. Catharines
Niagara, Ontario, Canada
Ottawa General Hospital
Ottawa, Ontario, Canada
St. Michael's Hospital
Toronto, Ontario, Canada
St. Joseph's Health Centre
Toronto, Ontario, Canada
St. Michael's Hospital
Toronto, Ontario, Canada
Universite de Sherbooke
Sherbrooke, Quebec, Canada
Ciusss McQ
Trois-Rivières, Quebec, Canada
Countries
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Central Contacts
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Facility Contacts
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Leena Rizvi
Role: primary
References
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Burns KEA, Wong J, Rizvi L, Lafreniere-Roula M, Thorpe K, Devlin JW, Cook DJ, Seely A, Dodek PM, Tanios M, Piraino T, Gouskos A, Kiedrowski KC, Kay P, Mitchell S, Merner GW, Mayette M, D'Aragon F, Lamontagne F, Rochwerg B, Turgeon A, Sia YT, Charbonney E, Aslanian P, Criner GJ, Hyzy RC, Beitler JR, Kassis EB, Kutsogiannis DJ, Meade MO, Liebler J, Iyer-Kumar S, Tsang J, Cirone R, Shanholtz C, Hill NS; Canadian Critical Care Trials Group. Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial. JAMA. 2024 Dec 3;332(21):1808-1821. doi: 10.1001/jama.2024.20631.
Other Identifiers
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FAST-002
Identifier Type: -
Identifier Source: org_study_id
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