The REVA trial, published in the New England Journal of Medicine in 2022, addresses a critical question in the management of mechanically ventilated patients: Which strategy for spontaneous breathing trials (SBTs)—Pressure-Support Ventilation (PSV) or a T-piece—offers better outcomes?
Objective of the Trial
The study aimed to compare the number of ventilator-free days within 28 days following the first spontaneous breathing trial between the two approaches. Specifically, it sought to determine whether one strategy could improve outcomes for patients at high risk of extubation failure.
Trial Design and Inclusion Criteria
This multicenter, open-label randomized trial enrolled 969 patients. Participants were adults aged 65 years or older or had chronic cardiac or lung diseases. Patients were eligible if they met the following criteria:
- Ventilated >24 hours before the first SBT.
- Respiratory rate (RR) ≤35.
- SpO₂ ≥90% (FiO₂ ≤0.4).
- PaO₂/FiO₂ ratio ≥150.
- Positive end-expiratory pressure (PEEP) ≤8.
- Adequate cough, stable hemodynamics, and minimal sedation (RASS +1 to -2).
Participants were randomized into two groups:
- PSV Group (n = 484): Spontaneous-breathing trials with pressure-support ventilation.
- T-Piece Group (n = 485): Trials using a T-piece.
Primary Outcome
At day 28, the median number of ventilator-free days was 27 days in both groups. There was no significant difference between the groups:
- Difference: 0 days (95% CI, -0.5 to 1; P=0.31).
Secondary Outcomes
- Extubation Success (within 24 hours):
- PSV: 77.7%
- T-piece: 72.2%
- Difference: 5.5% points (95% CI, 0.01 to 10.9).
- Reintubation Rate (within 7 days):
- PSV: 14.9%
- T-piece: 13.6%
- Difference: 1.3% points (95% CI, -3.1 to 5.8).
Key Conclusion
The trial concluded that among patients at high risk of extubation failure, performing SBTs with PSV did not result in significantly more ventilator-free days at day 28 compared to SBTs with a T-piece. While the extubation rate within 24 hours was slightly higher in the PSV group, there was no significant impact on the rate of reintubation.
Clinical Implications
The REVA trial highlights that both PSV and T-piece are viable strategies for conducting spontaneous breathing trials, with neither showing clear superiority in terms of long-term ventilator-free days. Clinicians can make decisions based on patient-specific factors, institutional protocols, and available resources without fear of compromising outcomes.
Takeaway for Healthcare Providers
For patients at high risk of extubation failure, choosing between PSV and T-piece trials should be guided by clinical judgment. The slight improvement in extubation rates with PSV may offer benefits in select populations, but the choice ultimately depends on patient tolerance and team expertise.