<p> NONINVASIVE VENTILATION DURING THE WEANING PROCCESS</p><p>IN CHRONICALLY CRITICALLY ILL PATIENTS</p><p>Online Supplemental Material</p><p>Jesus Sancho1, Emilio Servera1,2, Luis Jara-Palomares3, Emilia Barrot3, Raquel</p><p>Sanchez-Oro-Gómez3, F Javier Gómez de Terreros4,5, M Jesús Martín-Vicente4,5,</p><p>Isabel Utrabo4,5, M Belen Núñez5,6, Alicia Binimelis5,6, Ernest Sala5,6, Enrique</p><p>Zamora7, Gonzalo Segrelles7, Angel Ortega-Gonzalez8, Fernando Masa4,5. Spanish</p><p>Respiratory Intermediate Care Units Group</p><p>1Respiratory Care Unit. Respiratory Medicine Department. Hospital Clínico</p><p>Universitario, Valencia. Spain. INCLIVA Institute of Health Reasearch. Valencia. Spain</p><p>2Universitat de Valencia. Spain</p><p>3Unidad Médico-Quirurgica de Enfermedades Respiratorias. Hospital Virgen del Rocio.</p><p>Sevilla. Spain</p><p>4Servicio de Neumología. Hospital San Pedro Alcántara. Cáceres. Spain</p><p>5Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES). IS</p><p>CIII. Madrid. Spain</p><p>6Servicio de Neumología. Hospital Son Espases. Palma de Mallorca. Spain</p><p>7Intermediate Care Unit. Pulmonology Department. La Princesa Institute for Health</p><p>Research. Hospital Universitario de La Princesa. Madrid. Spain</p><p>8Servicio de Neumología. Hospital Nuestra Señora del Prado. Talavera de la Reina.</p><p>Spain</p><p>Conflict of Interest: authors have no financial relationship with any commercial entity that has an interest in the subject of this manuscript.</p><p>Corresponding Author:</p><p>Jesus Sancho Respiratory Care Unit. Respiratory Medicine Department</p><p>Hospital Clínico Universitario</p><p>Blasco Ibañez 17</p><p>46010 Valencia. Spain [email protected]</p><p>Key words: noninvasive ventilation, prolonged mechanical ventilation, chronic critical illness, weaning, respiratory failure. MATERIAL AND METHOD</p><p>Those patients whose weaning process could not be completed due to the need for</p><p>MV during the night were transferred to NIV. The criteria for transfer to NIV were: when it proved impossible to increase the duration of SBT beyond 18 hours during 5 consecutive days.5 Two different techniques were used to effect the transfer to NIV. In some RCUs, the tracheostomy was replaced by a tracheal button and NIV was initiated; in others, NIV was applied with the tracheostomy tube having been capped, its cuff deflated, and using a fenestrated inner cannula. A tracheal button (Figure S-1) is a stoma maintenance device that fits from the skin to just inside the anterior wall of the trachea; with this device the patient breaths through the upper airway, when is capped, and when necessary a catheter can be passed through the button for secretions removal.</p><p>In both cases, NIV was applied through a nasal or oronasal mask in pressure support mode and with oxygen added if necessary. The ventilator was initially set up so as to attain a tidal volume of about 8-10 mL/Kg. The back-up respiratory rate was set at 12 to</p><p>16 bpm and the inspiratory trigger sensitivity at –1 cmH2O. The ventilatory parameters were then readjusted in order to achieve effective ventilation (PaCO2 <45mmHg and time spent with SpO2 below 90% at night using NIV <5%). Once NIV was tolerated by the patient and effective ventilation had been achieved the tracheal button or tracheostomy tube was removed and the tracheostomy was closed.</p><p>RESULTS</p><p>In 24 patients a capped tracheostomy tube was used to transfer to NIV and in 16 a tracheal button; no statistical differences were found between the two groups in hospital mortality (8.33% vs 6.25%, p=0.760), stay at RCU (34.43+19.81 vs 56.64+43.81 days, p=0.096) and time from NIV initiation to tracheostomy closure (1.42+1.13 vs 2.30+2.18 days, p=0.307). (Table E1, E2) Legends:</p><p>Figure S-1: Tracheal button Tracheal button Capped tracheostomy p n=16 tube n=24 Gender (Male/Female) 8/8 13/19 0.265 Age (years) 67.53+12.04 63.60+15.47 0.972 Cause of Critical illness 11/5 19/5 0.549 (medical/surgical) Charlson Index 1.73+1.22 2.09+1.30 0.087 APACHE II 15.00+3.27 13.11+2.80 0.164 Intensive care stay 43.54+22.46 38.57+20.63 0.643 (days) MV in intensive care 34.81+18.45 35.96+20.69 0.606 (days) Weaning time at RCU 31.33+18.93 43.00+21.73 0.087 (days) pH 7.39+0.04 7.39+0.08 0.972 PaO2 (mmHg) 105.50+28.33 78.28+19.64 0.006 PaCO2 (mmHg) 49.50+0.04 53.60+7.09 0.288 FiO2 0.36+0.07 0.39+0.09 0.413 Leukocytes (per L) 10034.66+2878.06 9810.00+3832.71 0.850 Neutrophils (%) 72.54+12.74 71.75+11.12 0.886 Hemoglobin (g/dL) 9.38+1.54 10.27+1.60 0.205 Hematocrit (%) 28.13+4.92 30.87+5.33 0.230 Platelets (per L) 300600.00+15800.00 234000.00+76967.52 0.278 Sodium (mmol/L) 138.53+6.61 140.62+4.90 0.442 Potassium (mmol/L) 4.08+0.39 4.17+0.77 0.718 Blood urea nitrogen 53.53+40.99 75.25+35.06 0.375 (mg/dL) Creatinine (mg/dL) 0.91+0.85 0.87+0.69 0.908 Serum albumin (g/dL) 3.06+0.69 3.30+0.51 0.347 C-reactive protein 45.66+44.21 22.31+20.80 0.175 (mg/L)</p><p>Table E-1</p><p>Demographic and clinical data at RCU admission</p><p> of the CCI patients who need NIV during weaning process. </p><p>APACHE: Acute Physiology and Chronic Health Evaluation; CCI: Chronically critically Ill; MV: Mechanical ventilation; NIV: Noninvasive ventilation; RCU:</p><p>Respiratory Care Unit</p><p>Tracheal button Capped tracheostomy tube p n=15 n=22 pH 7.42+0.04 7.43+0.03 0.701 PaO2 (mmHg) 80.46+19.98 71.90+10.47 0.209 PaCO2 (mmHg) 41.60+4.32 44.72+6.92 0.169 FiO2 0.21+0.1 0.21+0.01 0.880</p><p>Table E-2</p><p>Arterial Blood Gases at Hospital discharge of the Chronically CritilalIy Ill patients</p><p> who need noninvasive ventilation to achieve weaning success. </p>