Effect of alternate invasive and noninvasive ventilation on duration of mechanical ventilation in patients with tracheotomy: a multicenter randomized controlled trial

<bold>Background:</bold> Difficult weaning is common and is associated with poor prognosis. The efficacy of alternate invasive-noninvasive ventilation in difficult-to-wean patients remains to be demonstrated. We aimed to evaluate the effect of alternate invasive-noninvasive ventilation on the duration of MV in difficult-to-wean tracheotomy patients. <bold>Methods:</bold> Difficult-to-wean tracheotomy patients were randomized to receive invasive weaning or alternate invasive-noninvasive ventilation. The primary outcome was time from enrollment to wean. Main secondary outcomes included VAP rate, mortality, survival time and diaphragmatic function. <bold>Results:</bold> A total of 88 participants were included, 45 in the control group and 43 in the intervention group. The median duration of MV was shorter in the alternate invasive-noninvasive ventilation group than in the control group. The VAP rate was lower in patients receiving alternate invasive-noninvasive ventilation than those receiving invasive weaning (OR, 0.37; 95%CI, 0.14-0.98). Participants treated with alternate invasive-noninvasive ventilation had lower 60-d and 90-d mortality (OR, 0.38; 95%CI, 0.16-0.92; OR, 0.35; 95%CI, 0.15-0.85) and longer 90-d survival time compared with controls (adjusted hazard ratio, 0.51; 95% CI, 0.27-0.95). Maximal inspiratory pressure and diaphragm thickness fraction improved significantly over time in the alternate invasive-noninvasive ventilation group. <bold>Conclusion:</bold> Alternate invasive-noninvasive ventilation shortened the total duration of MV, decreased diaphragmatic dysfunction, and improved respiratory muscle strength in difficult-to-wean tracheotomy patients.