Immediate versus gradual noninvasive ventilatory pressure-or-duration step-down in chronic obstructive pulmonary disease patients: a randomized trial

Despite the proven role of noninvasive ventilation (NIV) as an effective treatment for acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD), no clear agreement has been reached regarding the ideal weaning strategy. This study aimed to compare three NIV weaning strategies in terms of efficiency and safety among COPD patients with AHRF. A total of 105 COPD patients stabilized on NIV were enrolled in this randomized clinical trial and equally distributed into three groups (n=35 each): duration step-down (group A), pressure step-down (group B), and immediate withdrawal (group C). The primary endpoint was successful weaning within 48 hours. Secondary outcomes included duration of NIV use, lengths of ICU and hospital stay, predictors of weaning failure, and complication rates. The results of this study indicated that successful weaning rates differed significantly among the groups, being highest in group A (82.9%), followed by group B (74.3%), and lowest in group C (54.3%) (p<0.01). Compared with other strategies, immediate withdrawal was associated with higher rates of weaning failure. Although NIV duration was significantly shorter in group C (p<0.001), complication rates and post-discharge outcomes were similar across the three groups. In this trial, gradual duration- and pressure-based step-down strategies were associated with higher rates of successful NIV weaning than immediate withdrawal, with the highest observed success rate in the duration-based step-down group.