Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study

BACKGROUND

Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity.

METHODS

This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score.

RESULTS

Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs.

CONCLUSION

This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.

Post-extubation laryngitis in children: diagnosis, management and follow-up

OBJECTIVES

To describe the occurrence of post-extubation laryngitis, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes.

METHODS

Retrospective study including children up to 13 years old at a tertiary hospital between March 2020 and March 2022 with diagnosis of post-extubation laryngitis confirmed by endoscopic examination. Exclusion criteria were prior history of intubation or anatomical airway abnormalities. Medical records were reviewed to characterize patients, underlying diagnosis, laryngeal lesions, treatment, and outcomes at 12-month follow-up.

RESULTS

The study included 38 endoscopically confirmed post-extubation laryngitis cases, corresponding to 86.4% of suspected cases. The mean age was 13.24 months, and 60.5% were male. Acute respiratory failure was the leading cause of intubation. Initial treatment was clinical, and initial diagnosis was defined by nasopharynoglaryngoscopy and/or Microlaryngoscopy and Bronchoscopy (MLB) findings. Initial diagnostic MLB was performed in 65.7% of the patients. Approximately half (53%) of the patients exhibited moderate or severe laryngeal lesions. When compared to mild cases, these patients experienced a higher rate of extubation failures (mean of 1.95 vs. 0.72, p = 0.0013), underwent more endoscopic procedures, and faced worse outcomes, such as the increased need for tracheostomy (p = 0.0001) and the development of laryngeal stenosis (p = 0.0450). Tracheostomy was performed in 14 (36.8%) children. Patients undergoing tracheostomy presented more extubation failures and longer intubation periods. Eight (21%) developed laryngeal stenosis, and 17 (58.6%) had complete resolution on follow-up.

CONCLUSION

Post-extubation laryngitis is a frequent diagnosis among patients with clinical symptoms or failed extubation. The severity of laryngeal lesions was linked to a less favorable prognosis observed at one-year follow-up. Otolaryngological evaluation, follow-up protocols, and increased access to therapeutic resources are essential to manage these children properly.

LEVEL OF EVIDENCE

Level 4.

Noninvasive Ventilation in the Cardiac Intensive Care Unit

Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.

Ventilator Weaning and Extubation

Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.

Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study

Background

Since weaning failure is multifactorial, comprehensive weaning scores encompassing not only the respiratory component but also nonrespiratory aspects are quintessential for successful weaning prediction.

Materials and methods

This was a single-center prospective observational study on 128 intensive care unit (ICU) patients undergoing spontaneous breathing trials (SBT). The extubation prediction score (ExPreS), heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR), and weaning parameters, endotracheal tube size, arterial blood gas analysis, nutrition, secretions, neuromuscular affecting agents, obstructive airway problems and wakefulness (WEANSNOW) scores were compared for their diagnostic accuracy for successful weaning prediction.

Results

Out of 128 patients, 49 (38.3%) patients had weaning failure, and 79 (61.7%) had weaning success. The patients in the weaning failure group had significantly higher APACHE II scores, WEANSNOW scores, HACOR scores, MV days, and significantly lower ExPreS scores as compared to the successful weaning group. Multivariable regression analysis showed that ExPreS score p = 0.015, adjusted OR 0.960, 95% CI (0.929-0.992) and HACOR score p < 0.001, adjusted OR 1.357, 95% CI (1.176-1.567) were independent predictors of weaning failure. The HACOR score had an AUC of 0.830, cut-off ≥5, p < 0.001, sensitivity 76%, specificity 68%, diagnostic accuracy 70% to predict weaning failure. The ExPreS score had an AUC of 0.735, cut-off ≥69, p < 0.001, sensitivity of 70.9%, specificity of 69.4%, and diagnostic accuracy of 70.3% to predict weaning success. Both the HACOR and ExPreS scores were good models for predicting weaning outcomes (model quality 0.76 and 0.64 respectively).

Conclusion

The parsimonious HACOR score is comparable to the ExPreS score for the prediction of weaning outcomes in critically ill patients.

How to cite this article

Nayak G, Chaudhuri S, Ravindranath S, Todur P. Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study. Indian J Crit Care Med 2024;28(3):273-279.

Derivation and validation of a quantitative risk prediction model for weaning and extubation in neurocritical patients

Background

Patients with severe neurological conditions are at high risk during withdrawal and extubation, so it is important to establish a model that can quantitatively predict the risk of this procedure.

Methods

By analyzing the data of patients with traumatic brain injury and tracheal intubation in the ICU of the affiliated hospital of Hangzhou Normal University, a total of 200 patients were included, of which 140 were in the modeling group and 60 were in the validation group. Through binary logistic regression analysis, 8 independent risk factors closely related to the success of extubation were screened out, including age ≥ 65 years old, APACHE II score ≥ 15 points, combined chronic pulmonary disease, GCS score < 8 points, oxygenation index <300, cough reflex, sputum suction frequency, and swallowing function.

Results

Based on these factors, a risk prediction scoring model for extubation was constructed with a critical value of 18 points. The AUC of the model was 0.832, the overall prediction accuracy was 81.5%, the specificity was 81.6%, and the sensitivity was 84.1%. The data of the validation group showed that the AUC of the model was 0.763, the overall prediction accuracy was 79.8%, the specificity was 84.8%, and the sensitivity was 64.0%.

Conclusion

These results suggest that the extubation risk prediction model constructed through quantitative scoring has good predictive accuracy and can provide a scientific basis for clinical practice, helping to assess and predict extubation risk, thereby improving the success rate of extubation and improving patient prognosis.

The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients

Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room

BACKGROUND

Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings.

METHODS

A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality.

RESULTS

A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002).

CONCLUSION

Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

Predictors of Extubation Failure in Very Low Birth Weight Infants at a Tertiary Care Hospital in Al Ain: A Retrospective Study

OBJECTIVES

To identify and analyze the factors leading to extubation failure among very low birth weight infants in a specific tertiary care setting in Al Ain, emphasizing clinical and demographic variables. The study used medical data of Very Low Birth Weight (VLBW) infants admitted to the Neonatal Intensive Care Unit (NICU) from 1st January 2015 to 31st December 2019, and evaluated the incidence and risk factors associated with extubation failure.

METHODS

Data was collected from the hospital's electronic records and tabulated in Excel sheets, with extubation failure defined as reintubation due to deterioration of respiratory condition within seven days post-extubation. The data was collected from the period of 1st January 2015 to 31st December 2019. Inclusion criteria included babies admitted to the NICU with a gestational age of ≤ 32 weeks, or of birth weight ≤1500 grams who were intubated within the first seven days of life. Results were analyzed using SPSS software, version 9.0 (SPSS Inc., Chicago) to determine the risk factors for extubation failure and short-term outcomes.

RESULTS

Gestational age, birth weight, antenatal steroids, mode of delivery, number of Survanta® (beractant intratracheal suspension) doses, Positive End-Expiratory Pressure (PEEP), Mean Airway Pressure (MAP), Mean Arterial Pressure (Blood Pressure (BP)), and Infectious Diseases (ID) (indicated by a positive blood culture) were found to be the key predictors of extubation failure in very low birth weight infants at a tertiary care hospital in Al Ain. The most common reasons for reintubation were FiO2 > 50% (23.53%), followed by Respiratory Acidosis (20.59%). Other factors, including maternal chorioamnionitis, Apgar scores, indication for intubation, caffeine, and pre-and post-extubation laboratory values, comorbidities, and hemoglobin (Hgb), creatinine and sodium levels were found to have no effect on the success of extubations.

CONCLUSIONS

The results of this research indicate that factors such as gestational age, birth weight, prenatal steroid use, delivery method, the quantity of Survanta® doses, PEEP, MAP, MAP (BP), and ID (+ve blood culture) were the primary determinants of unsuccessful extubation in VLBW babies at a tertiary healthcare facility in Al Ain. The predominant cause for needing reintubation was a FiO2 level above 50%, followed by Respiratory Acidosis. Additional ®®investigations are required to validate these findings and pinpoint other potential predictors of extubation failure within this demographic.

Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

RESULTS

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSIONS

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Risk factors for long-term invasive mechanical ventilation: a longitudinal study using German health claims data

BACKGROUND

Long-term invasive mechanical ventilation (IMV) is a major burden for those affected and causes high costs for the health care system. Early risk assessment is a prerequisite for the best possible support of high-risk patients during the weaning process. We aimed to identify risk factors for long-term IMV within 96 h (h) after the onset of IMV.

METHODS

The analysis was based on data from one of Germany's largest statutory health insurance funds; patients who received IMV ≥ 96 h and were admitted in January 2015 at the earliest and discharged in December 2017 at the latest were analysed. OPS and ICD codes of IMV patients were considered, including the 365 days before intubation and 30 days after discharge. Long-term IMV was defined as evidence of invasive home mechanical ventilation (HMV), IMV ≥ 500 h, or readmission with (re)prolonged ventilation.

RESULTS

In the analysis of 7758 hospitalisations, criteria for long-term IMV were met in 38.3% of cases, of which 13.9% had evidence of HMV, 73.1% received IMV ≥ 500 h and/or 40.3% were re-hospitalised with IMV. Several independent risk factors were identified (p < 0.005 each), including pre-diagnoses such as pneumothorax (OR 2.10), acute pancreatitis (OR 2.64), eating disorders (OR 1.99) or rheumatic mitral valve disease (OR 1.89). Among ICU admissions, previous dependence on an aspirator or respirator (OR 5.13), and previous tracheostomy (OR 2.17) were particularly important, while neurosurgery (OR 2.61), early tracheostomy (OR 3.97) and treatment for severe respiratory failure such as positioning treatment (OR 2.31) and extracorporeal lung support (OR 1.80) were relevant procedures in the first 96 h after intubation.

CONCLUSION

This comprehensive analysis of health claims has identified several risk factors for the risk of long-term ventilation. In addition to the known clinical risks, the information obtained may help to identify patients at risk at an early stage. Trial registration The PRiVENT study was retrospectively registered at ClinicalTrials.gov (NCT05260853). Registered at March 2, 2022.

Independent predictors and clinical predictive score of postanesthetic reintubation after general anesthesia: A time-matched, case control study

Background and Aims

Postanesthetic reintubation is associated with increased morbidities and mortality; however, it can be reduced with defined predictors and using a score as a tool. This study aimed to identify independent predictors and develop a reliable predictive score.

Material and Methods

A retrospective, time-matched, case control study was conducted on patients who underwent general anesthesia between October 2017 and September 2021. Using stepwise multivariable logistic regression analysis, predictors were determined and the predictive score was developed and validated.

Results

Among 230 patients, 46 were in the reintubated group. Significant independent predictors included age >65 years (odds ratio [OR] 2.96 [95% confidence interval {CI} 1.23, 7.10]), the American Society of Anesthesiologists physical status III-IV (OR 6.60 [95%CI 2.50 17.41]), body mass index (BMI) ≥30 kg/m2 (OR 4.91 [95% CI 1.55, 15.51]), and head and neck surgery (OR 4.35 [95% CI 1.46, 12.87]). The predictive model was then developed with an area under the receiver operating characteristic curve (AUC) of 0.84 (95% CI 0.78, 0.90). This score ranged from 0 to 29 and was classified into three subcategories for clinical practicability, in which the positive predictive values were 6.01 (95% CI 2.63, 11.50) for low risk, 18.64 (95% CI 9.69, 30.91) for moderate risk, and 71.05 (95% CI 54.09, 84.58) for high risk.

Conclusion

The independent predictors for postanesthetic reintubation according to this simplified risk-based scoring system designed to aid anesthesiologists before extubation were found to be advanced age, higher American Society of Anesthesiologists physical status, obesity, and head and neck surgery.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study

BACKGROUND

Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes.

METHODS

This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation.

RESULTS

Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h).

CONCLUSIONS

Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.

Lung aeration estimated by chest electrical impedance tomography and lung ultrasound during extubation

BACKGROUND

This study hypothesized that patients with extubation failure exhibit a loss of lung aeration and heterogeneity in air distribution, which could be monitored by chest EIT and lung ultrasound. Patients at risk of extubation failure were included after a successful spontaneous breathing trial. Lung ultrasound [with calculation of lung ultrasound score (LUS)] and chest EIT [with calculation of the global inhomogeneity index, frontback center of ventilation (CoV), regional ventilation delay (RVD) and surface available for ventilation] were performed before extubation during pressure support ventilation (H0) and two hours after extubation during spontaneous breathing (H2). EIT was then repeated 6 h (H6) after extubation. EIT derived indices and LUS were compared between patients successfully extubated and patients with extubation failure.

RESULTS

40 patients were included, of whom 12 (30%) failed extubation. Before extubation, when compared with patients with successful extubation, patients who failed extubation had a higher LUS (19 vs 10, p = 0.003) and a smaller surface available for ventilation (352 vs 406 pixels, p = 0.042). After extubation, GI index and LUS were higher in the extubation failure group, whereas the surface available for ventilation was lower. The RVD and the CoV were not different between groups.

CONCLUSION

Before extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss of lung aeration persisted and was associated with regional lung ventilation heterogeneity. Trial registration Clinical trials, NCT04180410, Registered 27 November 2019-prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04180410 .

Predictors of Noninvasive Ventilation Failure in the Post-Extubation Period: A Systematic Review and Meta-Analysis

OBJECTIVES

To identify factors associated with failure of noninvasive ventilation (NIV) in the post-extubation period.

DATA SOURCES

We searched Embase Classic +, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to February 28, 2022.

STUDY SELECTION

We included English language studies that provided predictors of post-extubation NIV failure necessitating reintubation.

DATA EXTRACTION

Two authors conducted data abstraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarized estimates of effect using odds ratios (ORs) mean difference (MD), respectively. We used the Quality in Prognosis Studies tool to assess risk of bias and the Grading of Recommendations, Assessment, Development and Evaluations to assess certainty.

DATA SYNTHESIS

We included 25 studies ( n = 2,327). Illness-related factors associated with increased odds of post-extubation NIV failure were higher critical illness severity (OR, 3.56; 95% CI, 1.96-6.45; high certainty) and a diagnosis of pneumonia (OR, 6.16; 95% CI, 2.59-14.66; moderate certainty). Clinical and biochemical factors associated with moderate certainty of increased risk of NIV failure post-extubation include higher respiratory rate (MD, 1.54; 95% CI, 0.61-2.47), higher heart rate (MD, 4.46; 95% CI, 1.67-7.25), lower Pa o2 :F io2 (MD, -30.78; 95% CI, -50.02 to -11.54) 1-hour after NIV initiation, and higher rapid shallow breathing index (MD, 15.21; 95% CI, 12.04-18.38) prior to NIV start. Elevated body mass index was the only patient-related factor that may be associated with a protective effect (OR, 0.21; 95% CI, 0.09-0.52; moderate certainty) on post-extubation NIV failure.

CONCLUSIONS

We identified several prognostic factors before and 1 hour after NIV initiation associated with increased risk of NIV failure in the post-extubation period. Well-designed prospective studies are required to confirm the prognostic importance of these factors to help further guide clinical decision-making.

Effect of high-flow nasal cannula versus non-invasive ventilation in preventing re-intubation in high-risk chronic obstructive pulmonary disease patients: A randomised controlled trial

Background

Currently, a high-flow nasal cannula (HFNC) has been shown to improve extubation outcomes. However, there is a lack of evidence on the utilisation of HFNC in high-risk chronic obstructive pulmonary disease (COPD) patients. This study aimed to compare the effectiveness of HFNC versus non-invasive ventilation (NIV) in preventing re-intubation following planned extubation in high-risk COPD patients.

Patients and Methods

In this prospective, randomised, controlled trial, 230 mechanically ventilated COPD patients at high risk for re-intubation who fulfilled the criteria for planned extubation were enrolled. Post-extubation blood gases and vital signs at 1, 24, and 48 hours were recorded. The primary outcome was the re-intubation rate within 72 hours. Secondary outcomes included post-extubation respiratory failure, respiratory infection, intensive care unit and hospital length of stay, and mortality rate at 60 days.

Results

230 patients after planned extubation were randomly allocated to receive either HFNC (n = 120) or NIV (n = 110). Re-intubation within 72 hours was significantly lower in the high-flow group: 8 patients (6.6%) versus 23 patients (20.9%) in the NIV group {absolute difference, 14.3% [95% confidence interval (CI), 10.9-16.3]; P = 0.001}. The frequency of post-extubation respiratory failure was less in patients assigned to HFNC than in those allocated NIV (25% vs. 35.4%) [absolute difference, 10.4% (95% CI, 2.4-14.3); P = 0.001]. There was no significant difference between the two groups regarding reasons for respiratory failure after extubation. It was observed that the 60-day mortality rate was lower in patients who received HFNC than in those assigned to NIV (5% vs. 13.6%) [absolute difference, 8.6 (95% CI, 4.3 to 9.10); P = 0.001].

Conclusion

The use of HFNC after extubation appears to be superior to NIV in reducing the risk of re-intubation within 72 hours and 60-day mortality in high-risk COPD patients.

Developing a machine-learning model for real-time prediction of successful extubation in mechanically ventilated patients using time-series ventilator-derived parameters

Background

Successful weaning from mechanical ventilation is important for patients admitted to intensive care units. However, models for predicting real-time weaning outcomes remain inadequate. Therefore, this study aimed to develop a machine-learning model for predicting successful extubation only using time-series ventilator-derived parameters with good accuracy.

Methods

Patients with mechanical ventilation admitted to the Yuanlin Christian Hospital in Taiwan between August 2015 and November 2020 were retrospectively included. A dataset with ventilator-derived parameters was obtained before extubation. Recursive feature elimination was applied to select the most important features. Machine-learning models of logistic regression, random forest (RF), and support vector machine were adopted to predict extubation outcomes. In addition, the synthetic minority oversampling technique (SMOTE) was employed to address the data imbalance problem. The area under the receiver operating characteristic (AUC), F1 score, and accuracy, along with the 10-fold cross-validation, were used to evaluate prediction performance.

Results

In this study, 233 patients were included, of whom 28 (12.0%) failed extubation. The six ventilatory variables per 180 s dataset had optimal feature importance. RF exhibited better performance than the others, with an AUC value of 0.976 (95% confidence interval [CI], 0.975-0.976), accuracy of 94.0% (95% CI, 93.8-94.3%), and an F1 score of 95.8% (95% CI, 95.7-96.0%). The difference in performance between the RF and the original and SMOTE datasets was small.

Conclusion

The RF model demonstrated a good performance in predicting successful extubation in mechanically ventilated patients. This algorithm made a precise real-time extubation outcome prediction for patients at different time points.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Impact of neurological problems on mechanical ventilation and intensive care unit outcomes in pulmonary intensive care unit patients: a retrospective analysis of a single-center cohort

Neurological problems (NPs) are frequently connected with different critical illnesses in intensive care unit (ICU) patients, and they may influence ICU outcomes. This study aims to examine the effects of NPs on ICU outcomes, especially in pulmonary ICU patients. This is a retrospective observational study comprising adult pulmonary critical care patients who were hospitalized between 2015 and 2019. The frequency of NPs at admission, their impact on mechanical ventilation (MV), ICU outcomes, the rate of NP development during the ICU stay, and risk factors for them were investigated. A total of 361 patients were included in the study, and 130 of them (36%) had NPs (group 1). The noninvasive ventilation requirement rate in patients with NPs was less than in those without NPs (group 2), and the requirement of MV was significantly more frequent in this group (37% and 19%, p<0.05). The duration of MV (19±27 and 8±6 days, p=0.003) and sepsis rate (31% and 18%, p=0.005) were also higher in group 1. NPs developing after ICU admission increased the MV requirement 3 times as an independent risk factor. Risk factors for ICU-acquired NPs were the existence of sepsis during admission [odds ratio (OR): 2.01, confidence interval (CI) 95%: 1.02-4, p=0.045] and longer MV durations before ICU admission (OR: 1.05, CI 95%: 1.004-41.103, p=0.033). NPs were not independent risk factors for mortality (OR: 0.67, CI 95%: 0.37-1.240, p=0.207). NPs did not increase mortality but more frequently caused MV requirement, more extubation failure, and a longer ICU stay in this study population. Additionally, our data suggest that having sepsis during admission and a longer length of MV prior to admission may increase the neurological complication rate.

Diagnostic value of an increase in central venous pressure during SBT for prediction of weaning failure in mechanically ventilated patients: A cross-sectional study

Background

Timely and successful extubation is an essential step forward in clinical practice to minimize complications of mechanical ventilation and unsuccessful weaning processes. Thus, research into predictive factors of weaning outcome to optimize spontaneous breathing trial (SBT) precision before extubation is critical in intensive care practices. In this study, we aimed to investigate the predictive factors of the weaning outcome before and during SBT in mechanically ventilated patients.

Methods

In this cross-sectional study, 159 mechanically ventilated patients who were eligible for SBT were enrolled. Of these patients, 140 had successful extubation, whereas the remainder failed. Each patient's PaCO₂ and PaO₂ levels, respiratory rate (RR), SpO₂, mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) values at the start of SBT, 3 min later, and at the end of SBT were measured. These values, along with the patients' clinical characteristics, were then investigated to determine if there was any correlation between these variables and the weaning outcome.

Results

Our analysis revealed that increase in CVP, independent of hemoglobin (Hb) concentration, PaO₂, SpO₂, duration of mechanical ventilation (MV), length of intensive care unit (ICU) stay, and SBT process, as well as underlying disease, was positively correlated with extubation/weaning failure. While age, gender, vital signs (MAP, RR, and HR), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation (APACHE) scores had no significant correlation with patients' extubation outcomes.

Conclusion

According to our findings, integrating CVP assessment into SBT besides routine indices measurement and monitoring can be considered for the prediction of weaning outcome in critically ill mechanically ventilated patients.

Prognostic Factors Associated With Extubation Failure in Acutely Brain-Injured Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Extubation failure in brain-injured patients is associated with increased morbidity. Our objective was to systematically review prognostic factors associated with extubation failure in acutely brain-injured adult patients receiving invasive ventilation in an ICU.

DATA SOURCES

MEDLINE, Embase, and Cochrane Central were searched from inception to January 31, 2022.

STUDY SELECTION

Two reviewers independently screened citations and selected English-language cohort studies and randomized trials examining the association of prognostic factors with extubation failure. Studies were considered if they included greater than or equal to 80% adult patients with acute brain injury admitted to the ICU and mechanically ventilated for greater than or equal to 24 hours.

DATA EXTRACTION

Two reviewers extracted data on population, prognostic factors, extubation outcomes, and risk of bias (using the quality in prognostic factors tool).

DATA SYNTHESIS

In the primary analysis, adjusted odds ratios (aOR) for each prognostic factor were pooled using random-effects models. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The search identified 7,626 citations, of which 21 studies met selection criteria. Moderate-certainty evidence suggested increased risk of extubation failure with older age (aOR, 3.0 for upper vs lower tertile; 95% CI, 1.78-5.07) and longer duration of mechanical ventilation (aOR, 3.47 for upper vs lower tertile; 95% CI, 1.68-7.19). Presence of cough (aOR, 0.40; 95% CI, 0.28-0.57) and intact swallow (aOR, 0.34; 95% CI, 0.21-0.54) probably decreased risk of extubation failure (moderate certainty). Associations of other factors with extubation failure were informed by low or very low certainty evidence.

CONCLUSIONS

Patient age, duration of mechanical ventilation, and airway reflexes were associated with extubation failure in brain-injured patients with moderate certainty. Future studies are needed to determine the optimal application of these variables in clinical practice.

Postoperative prophylactic intermittent noninvasive ventilation versus usual postoperative care for patients at high risk of pulmonary complications: a multicentre randomised trial

BACKGROUND

Pulmonary complications are an important cause of morbidity and mortality after surgery. We evaluated the clinical effectiveness of noninvasive ventilation (NIV) in preventing postoperative acute respiratory failure.

METHODS

This is an open, multicentre randomised trial that included patients at high risk of postoperative pulmonary complications after elective or semi-urgent surgery with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score ≥45. Patients were randomly assigned to intermittent prophylactic face-mask NIV for 6-8 h day^-1 or usual postoperative care. The primary outcome was in-hospital acute respiratory failure within 7 days after surgery. Patients who underwent surgery and postoperative extubation were included in the modified intended-to-treat analysis. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals.

RESULTS

Between November 2017 and October 2019, 266 patients were randomised and 253 included in the main analysis. Of these, 203 (80.2%) were male with a mean age of 68 (11) yr and an ARISCAT score of 53 (6); 237 subjects (93.7%) underwent cardiac or thoracic surgery. There were 125 patients allocated to prophylactic NIV and 128 to usual care. Unplanned treatment termination occurred in 58 subjects in the NIV group, which was linked to NIV discomfort for 36 subjects. There was no difference in the incidence of the primary outcome of postoperative acute respiratory failure between treatment groups (NIV: 30 of 125 subjects [24.0%] vs usual care: 35 of 128 subjects [27.3%]; OR 0.97 [0.90-1.04]; P=0.54).

CONCLUSIONS

Prophylactic NIV was difficult to implement after high-risk surgery because of low patient compliance. Prophylactic NIV did not prevent acute respiratory failure.

CLINICAL TRIAL REGISTRATION

NCT03629431 and EudraCT 2017-001011-36.

Underweight predicts extubation failure after planned extubation in intensive care units

BACKGROUND

Body weight is associated with different physiological changes and the association between weight and mortality in critical care setting had been discussed before. In this study, we investigated the linkage between underweight and post-extubation failure in mechanical ventilated patients in critical setting.

METHODS

This is a retrospective cohort study including patients who were admitted to medical or surgical intensive care units (ICU) between June 2016 and July 2018 and had received endotracheal intubation for more than 72 hours. Those who passed spontaneous breathing trial and underwent a planned extubation were enrolled. Extubation failure was defined as those who required reintubation within the first 72 hours for any reasons. The probability of extubation failure was calculated. Demographic and clinical characteristics were recorded. Multivariate logistic regression models were then used to determine the potential risk factors associated with extubation failure.

RESULTS

Overall, 268 patients met the inclusion criteria and were enrolled in our study for analysis. The median age of included patients was 67 years (interquartile range, 55-80 years) with 65.3% being male; 63.1% of the patients were included from medical ICU. The proportion of extubation failure in our cohort was 7.1% (19/268; 95% confidence interval [CI], 4.3-10.9%). Overall, underweight patients had the highest risk of extubation failure (8/50), as compared with normoweight (9/135) and overweight patients (2/83). In the multivariate analysis, being underweight (adjust OR [aOR], 3.80, compared to normoweight; 95% CI, 1.23-11.7) and lower maximal inspiratory airway pressure (aOR per one cmH2O decrease, 1.05; 95% CI 1.00-1.09) remained significantly associated with extubation failure.

CONCLUSION

In our study, being underweight and lower maximal inspiratory airway pressure was associated with post-extubation respiratory failure after a planned extubation.

Frequency of Positive Cuff Leak Test Before Extubation in Robotic Surgeries Done in Steep Trendelenburg Position

Anaesthesia for robotic surgeries done in steep trendelenburg position are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24 h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.

Use of Maximum Tongue Pressure Values to Examine the Presence of Dysphagia after Extubation and Prevent Aspiration Pneumonia in Elderly Emergency Patients

Background: Tongue pressure values in patients with dysphagia are reported to be significantly lower than those in healthy controls. The aim of this study was to measure the maximum tongue pressure (MTP) values after extubation in order to assess the presence of post-extubation dysphagia for the safe initiation of oral intake in elderly patients. Methods: Data from 90 patients who were extubated after mechanical ventilation under tracheal intubation were collected retrospectively. The patients were divided into two groups as follows: normal group (those who did not develop aspiration pneumonia after extubation; median age 62 years) and aspiration group (those who developed aspiration during the evaluation period; median age 75 years). The MTP values were measured at 6 h, 24 h, 3 days, and 7 days after extubation. Results: The values were significantly increased 24 h after extubation in the normal group (p < 0.05). Alternatively, no increase was observed even after 1 week of extubation in the aspiration group, and the values were significantly lower than those in the normal group. The cutoff values at 6 and 24 h after extubation, which were measured using the receiver operator characteristic (ROC) curve, were 17.8 and 23.2 kpa, respectively; furthermore, the results of these assessments were strongly related to the development of aspiration 6 h after extubation (χ2-value: 6.125; p = 0.0133). Conclusions: The presence of post-extubation dysphagia in patients who are intubated for ≥24 h can be predicted based on age and the MTP values at 6 h after extubation.

Efficacy of preventive use of oxygen therapy after planned extubation in high-risk patients with extubation failure: A network meta-analysis of randomized controlled trials

Background

Extubation failure is common in critically ill patients, especially those with high-risk factors, and is associated with poor prognosis. Prophylactic use of oxygen therapy after extubation has been gradually introduced. However, the best respiratory support method is still unclear.

Purpose

This study aimed to evaluate the efficacy of four post-extubation respiratory support approaches in reducing reintubation and respiratory failure in patients at high-risk of extubation failure.

Methods

A comprehensive search was performed in Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science from inception to June 2022. Randomized controlled trials (RCTs) comparing post-extubation preventive use of respiratory management strategies, including conventional oxygen therapy (COT), non-invasive ventilation (NIV), and high-flow nasal catheter (HFNC) in high-risk patients with extubation failure were reviewed. Primary outcomes were reintubation rate and respiratory failure. Secondary outcomes included intensive care unit (ICU) mortality, ICU stay and length of hospital stay (LOS).

Results

Seventeen RCTs comprising 2813 participants were enrolled. Compared with COT, the three respiratory support methods (NIV, HFNC, NIV + HFNC) were all effective in preventing reintubation [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.32–0.67; OR 0.26, 95% CI 0.14–0.48; OR 0.62, 95% CI 0.39–0.97, respectively] and respiratory failure (OR 0.23, 95% CI 0.10–0.52; OR 0.15, 95% CI 0.04–0.60; OR 0.26, 95% CI 0.10–0.72, respectively). NIV and NIV + HFNC also reduced ICU mortality (OR 0.40, 95% CI 0.22–0.74; OR 0.32, 95% CI 0.12–0.85). NIV + HFNC ranked best in terms of reintubation rate, respiratory failure and ICU mortality based on the surface under the cumulative ranking curve (SUCRA) (99.3, 87.1, 88.2, respectively). Although there was no significant difference in shortening ICU stay and LOS among the four methods, HFNC ranked first based on the SUCRA.

Conclusion

Preventive use of NIV + HFNC after scheduled extubation is probably the most effective respiratory support method for preventing reintubation, respiratory failure and ICU death in high-risk patients with extubation failure. HFNC alone seems to be the best method to shorten ICU stay and LOS.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022340623].

Weaning Outcomes in Patients with Brain Injury

BACKGROUND

Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons.

METHODS

We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28.

RESULTS

Among the 20,929 patients enrolled, we included 12,618 (60%) who started the weaning from MV, of whom 1722 (14%) were patients with acute brain injury. In the acutely brain-injured cohort, 538 patients (31%) did not undergo planned extubation, defined as the need for a tracheostomy without an attempt of extubation, accidental extubation, and death. Among the 1184 planned extubated patients with acute brain injury, 202 required reintubation (17%). Patients with acute brain injury had a higher odds for unplanned extubation (odds ratio [OR] 1.35, confidence interval for 95% [CI 95%] 1.19-1.54; p < 0.001), a higher odds of failure after the first attempt of weaning (spontaneous breathing trial or gradual reduction of ventilatory support; OR 1.14 [CI 95% 1.01-1.30; p = 0.03]), and a higher odds for reintubation (OR 1.41 [CI 95% 1.20-1.66; p < 0.001]) than patients without brain injury. Patients with hemorrhagic stroke had the highest odds for unplanned extubation (OR 1.47 [CI 95% 1.22-1.77; p < 0.001]), of failed extubation after the first attempt of weaning (OR 1.28 [CI 95% 1.06-1.55; p = 0.009]), and for reintubation (OR 1.49 [CI 95% 1.17-1.88; p < 0.001]). In relation to weaning evolution over time in patients with acute brain injury, the risk for unplanned extubation showed a downward trend; the risk for reintubation was not associated to time; and there was a significant increase in the percentage of patients who underwent extubation after the first attempt of weaning from MV.

CONCLUSIONS

Patients with acute brain injury, compared with patients without brain injury, present higher odds of undergoing unplanned extubated after weaning was started, lower odds of being extubated after the first attempt, and a higher risk of reintubation.

Effect of Prolonged Mechanical Ventilation on Cough Function and TRPV1 Expression

Cough is a pivotal airway protective reflex, yet the effects of prolonged mechanical ventilation (PMV) on cough function are unknown. This study compared the cough function in subjects with PMV (≥ 21 days, n = 29) and those with short-term mechanical ventilation (SMV, ≤ 7 days, n = 27). Cough reflex sensitivity was measured by capsaicin provocation concentrations after extubation. The cough strength of respiratory muscles was assessed by involuntary cough peak expiratory flow (iCPEF). The mRNA expression of transient receptor potential vanilloid 1 (TRPV1), a cough sensor activated by capsaicin, in tracheal tissues was determined. We found that cough reflex sensitivity and iCPEF were significantly lower in the PMV group than in the SMV group. The tracheal expression of TRPV1 was similar in both groups, suggesting that changes in TRPV1 expression may not be a contributing factor. Our finding regarding the cough dysfunction after PMV highlights the need to implement effective airway clearance management and rehabilitation in this population.

Novel Use of Catheter Mount as an Alternative to T-piece

Catheter mounts with swivel connectors are used to attach the endotracheal tube to the ventilator circuit, dampening jerks and drags and increasing patient comfort. We suggest a unique application of catheter mount as T-piece for weaning, eliminating the need for a single inventory purchase and repurposing a previously used item for a new use, lowering the financial burden on patients. In our ICU, catheter mounts are being used as an alternative to T-piece for 30-minute weaning trials following successful SBT trials to evaluate patients’ response to Zero PEEP (ZEEP) and therefore the probable occurrence of alveolar derecruitment to decrease extubation failure.

Mechanical power normalized to lung-thorax compliance indicates weaning readiness in prolonged ventilated patients

Since critical respiratory muscle workload is a significant determinant of weaning failure, applied mechanical power (MP) during artificial ventilation may serve for readiness testing before proceeding on a spontaneous breathing trial (SBT). Secondary analysis of a prospective, observational study in 130 prolonged ventilated, tracheotomized patients. Calculated MP’s predictive SBT outcome performance was determined using the area under receiver operating characteristic curve (AUROC), measures derived from k-fold cross-validation (likelihood ratios, Matthew's correlation coefficient [MCC]), and a multivariable binary logistic regression model. Thirty (23.1%) patients failed the SBT, with absolute MP presenting poor discriminatory ability (MCC 0.26; AUROC 0.68, 95%CI [0.59‒0.75], p = 0.002), considerably improved when normalized to lung-thorax compliance (LTC_dyn-MP, MCC 0.37; AUROC 0.76, 95%CI [0.68‒0.83], p < 0.001) and mechanical ventilation P_aCO₂ (so-called power index of the respiratory system [PI_rs]: MCC 0.42; AUROC 0.81 [0.73‒0.87], p < 0.001). In the logistic regression analysis, PI_rs (OR 1.48 per 1000 cmH₂O²/min, 95%CI [1.24‒1.76], p < 0.001) and its components LTC_dyn-MP (1.25 per 1000 cmH₂O²/min, [1.06‒1.46], p < 0.001) and mechanical ventilation P_aCO₂ (1.17 [1.06‒1.28], p < 0.001) were independently related to SBT failure. MP normalized to respiratory system compliance may help identify prolonged mechanically ventilated patients ready for spontaneous breathing.

Diaphragm ultrasound to predict weaning outcome: systematic review and meta-analysis

Proper timing for discontinuation of mechanical ventilation is of great importance, especially in patients with previous weaning failures. Different indices obtained by ultra-sonographic evaluation of the diaphragm muscle have improved determination of weaning success. The aim of the present systematic review was to evaluate and compare the accuracy of the diagnostic indices obtained by ultrasonographic examination, including diaphragm thickening fraction (DTF), diaphragmatic excursion (DE) and the rapid shallow breathing index (RSBI). A systematic literature search (Web of Science, MEDLINE, Embase and Google Scholar) was performed to identify original articles assessing diaphragm muscle features including excursion and thickening fraction. A total of 2738 citations were retrieved initially; available data of 19 cohort studies (1114 patients overall) were included in the meta-analysis, subdivided into groups based on the ultrasonographic examination type. Our results showed the superiority of the diagnostic accuracy of the DTF in comparison to the DE and the RSBI. Data on the combination of the different indices are limited. Diaphragmatic ultrasound is a cheap and feasible tool for diaphragm function evaluation. Moreover, DTF in the assessment of weaning outcome provides more promising outcomes, which should be evaluated more meti-culously in future randomised trials.

Continuous noninvasive ventilatory support outcomes for patients with neuromuscular disease: a multicenter data collaboration

BACKGROUND

Typically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV.

METHODS

Centers with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA).

RESULTS

There were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies.

CONCLUSIONS

ALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.

Weaning from mechanical ventilation in neurocritical care

In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.

Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study

The cuff leak test (CLT) has been widely accepted as a simple and noninvasive method for predicting post-extubation stridor (PES). However, its accuracy and clinical impact remain uncertain. We aimed to evaluate the reliability of CLT and to assess the impact of pre-extubation variables on the incidence of PES. A prospective observational study was performed on adult critically ill patients who required mechanical ventilation for more than 24 h. Patients were extubated after the successful spontaneous breathing trial, and CLT was conducted before extubation. Of the 191 patients studied, 26 (13.6%) were deemed positive through CLT. PES developed in 19 patients (9.9%) and resulted in a higher reintubation rate (8.1% vs. 52.6%, p < 0.001) and longer intensive care unit stay (8 [4.5-14] vs. 12 [8-30.5] days, p = 0.01) than patients without PES. The incidence of PES and post-extubation outcomes were similar in patients with both positive and negative CLT results. Compared with patients without PES, patients with PES had longer durations of endotracheal intubation and required endotracheal suctioning more frequently during the 24-h period prior to extubation. After adjusting for confounding factors, frequent endotracheal suctioning more than 15 times per day was associated with an adjusted odds ratio of 2.97 (95% confidence interval, 1.01-8.77) for PES. In conclusion, frequent endotracheal suctioning before extubation was a significant PES predictor in critically ill patients. Further investigations of its impact on the incidence of PES and patient outcomes are warranted.

Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children

OBJECTIVES

Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction.

DESIGN

Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children's Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation.

SETTING

Single center, tertiary, 391-bed children's hospital.

PATIENTS

From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50-9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67-11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36-8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46-8.34) remained independently associated with the diagnosis of new airway anomalies.

CONCLUSIONS

Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.

Noninvasive ventilation versus conventional oxygen therapy after extubation failure in high-risk patients in an intensive care unit: a pragmatic clinical trial

Objetivo

Determinar la efectividad de la ventilación no invasiva frente a oxigenoterapia convencional en pacientes con insuficiencia respiratoria aguda tras fracaso de la extubación.

Métodos

Ensayo clínico pragmático realizado una unidad de cuidados intensivos de marzo de 2009 a septiembre de 2016. Se incluyeron pacientes sometidos a ventilación mecánica > 24 horas, y que desarrollaron insuficiencia respiratoria aguda tras extubación programada, siendo asignados a ventilación no invasiva u oxigenoterapia convencional. El objetivo primario fue reducir la tasa de reintubación. Los objetivos secundarios fueron: mejora de los parámetros respiratorios, reducción de las complicaciones, de la duración de la ventilación mecánica, de la estancia en unidad de cuidados intensivos y hospitalaria, así como de la mortalidad en unidad de cuidados intensivos, hospitalaria y a los 90 días. También se analizaron los factores relacionados con la reintubación.

Resultados

De un total de 2.574 pacientes, se analizaron 77 (38 en el grupo de ventilación no invasiva y 39 en el grupo de oxigenoterapia convencional). La ventilación no invasiva redujo la frecuencia respiratoria y cardíaca más rápidamente que la oxigenoterapia convencional. La reintubación fue menor en el grupo de ventilación no invasiva [12 (32%) versus 22(56%) en grupo oxigenoterapia convencional, RR 0,58 (IC95% 0,34 - 0,97), p = 0,039], el resto de los parámetros no mostró diferencias significativas. En el análisis multivariante, la ventilación no invasiva prevenía la reintubación [OR 0,17 (IC95% 0,05 - 0,56), p = 0,004], mientras que el fracaso hepático previo a la extubación y la incapacidad para mantener vía aérea permeable predisponían a la reintubación.

Conclusión

El empleo de la ventilación no invasiva en pacientes que fracasa la extubación podría ser beneficiosa frente a la oxigenoterapia convencional.

The cuff leak test in critically ill patients: An international survey of intensivists

BACKGROUND

The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT.

METHODS

A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses.

RESULTS

1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology.

CONCLUSION

Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training.

Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial

OBJECTIVES

To identify whether factors associated with withholding extubation in the ICU also predict the risk of extubation failure.

DESIGN

Retrospective cohort study.

SETTING

Eight medical-surgical ICUs in Toronto.

PATIENTS

Adult patients receiving invasive mechanical ventilation, with a first successful spontaneous breathing trial within 28 days of initial ICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary end point had three mutually exclusive levels, including: 1) withholding extubation after a successful spontaneous breathing trial, 2) extubation failure within 48 hours, and 3) successful extubation. Among 9,910 patients, 38% of patients were not extubated within 24 hours of their first successful spontaneous breathing trial. A total of 12.9% of patients who were promptly extubated failed within the next 48 hours. Several discrepancies were evident in the association of factors with risk of withholding extubation and extubation failure. Specifically, both age and female sex were associated with withholding extubation (odds ratio, 1.07; 95% CI, 1.03-1.11; and odds ratio, 1.13; 95% CI, 1.02-1.26, respectively) but not a higher risk of failed extubation (odds ratio, 0.99; 95% CI, 0.93-1.05; and odds ratio, 0.93; 95% CI, 0.77-1.11, respectively). Conversely, both acute cardiovascular conditions and intubation for hypoxemic respiratory failure were associated with a higher risk of failed extubation (odds ratio, 1.32; 95% CI, 1.06-1.66; and odds ratio, 1.46; 95% CI, 1.16-1.82, respectively) but not a higher odds of a withheld extubation attempt (odds ratio, 0.79; 95% CI, 0.68-0.91; and odds ratio, 1.07; 95% CI, 0.93-1.23, respectively).

CONCLUSIONS

Several factors showed discordance between the decision to withhold extubation and the risk of extubation failure. This discordance may lead to longer duration of mechanical ventilation or higher reintubation rates. Improving the decision-making behind extubation may help to reduce both exposure to invasive mechanical ventilation and extubation failure.

Prevalence of Reintubation Within 24 Hours of Extubation in Bronchiolitis: Retrospective Cohort Study Using the Virtual Pediatric Systems Database

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation are used to support children following liberation from invasive mechanical ventilation. Evidence comparing extubation failure rates between patients randomized to high-flow nasal cannula and noninvasive positive pressure ventilation is available for adult and neonatal patients; however, similar pediatric trials are lacking. In this study, we employed a quality controlled, multicenter PICU database to test the hypothesis that high-flow nasal cannula is associated with higher prevalence of reintubation within 24 hours among patients with bronchiolitis.

DESIGN

Secondary analysis of a prior study utilizing the Virtual Pediatric Systems database.

SETTING

One-hundred twenty-four participating PICUs.

PATIENTS

Children less than 24 months old with a primary diagnosis of bronchiolitis who were admitted to one of 124 PICUs between January 2009 and September 2015 and received invasive mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 759 patients, median age was 2.4 months (1.3-5.4 mo), 41.2% were female, 39.7% had greater than or equal to 1 comorbid condition, and 43.7% were Caucasian. Median PICU length of stay was 8.7 days (interquartile range, 5.8-13.7 d) and survival to PICU discharge was 100%. Median duration of intubation was 5.5 days (3.4-9.0 d) prior to initial extubation. High-flow nasal cannula was used following extubation in most (656 [86.5%]) analyzed subjects. The overall prevalence of reintubation within 24 hours was 5.9% (45 children). Extubation to noninvasive positive pressure ventilation was associated with greater prevalence of reintubation than extubation to high-flow nasal cannula (11.7% vs 5.0%; p = 0.016) and, in an a posteriori model that included Pediatric Index of Mortality 2 score and comorbidities, was associated with increased odds of reintubation (odds ratio, 2.43; 1.11-5.34; p = 0.027).

CONCLUSIONS

In this secondary analysis of a multicenter database of children with bronchiolitis, extubation to high-flow nasal cannula was associated with a lower prevalence of reintubation within 24 hours compared with noninvasive positive pressure ventilation in both unmatched and propensity-matched analysis. Prospective trials are needed to determine if post-extubation support modality can mitigate the risk of extubation failure.

Dyspnea and respiratory muscles ultrasound to predict extubation failure

This study investigated dyspnea intensity and respiratory muscles ultrasound early after extubation to predict extubation failure.It was conducted prospectively in two intensive care units in France and Canada. Patients intubated for at least 48 h were studied within 2 h after an extubation following a successful spontaneous breathing trial. Dyspnea was evaluated by the Dyspnea-Visual Analog Scale from 0 to 10 cm (VAS) and the Intensive Care - Respiratory Distress Observational Scale (range 0-10). The ultrasound thickening fraction of the parasternal intercostal and the diaphragm were measured; limb muscle strength was evaluated using the Medical Research Council score (MRC) (range 0-60).Extubation failure occurred in 21 of the 122 enrolled patients (17%). Dyspnea-VAS and Intensive Care - Respiratory Distress Observational scale were higher in patients with extubation failure versus success: 7 (5-9) cm versus 3 (1-5) cm respectively (p<0.001) and 4.4 (2.5-6.5) versus 2.4 (2.1-2.8) respectively (p<0.001). The ratio of intercostal muscle to diaphragm thickening fraction was significantly higher and MRC was lower in patients with failure (0.9 [0.4-3.0] versus 0.3 [0.2-0.5], p<0.001, and 45 [36-50] versus 52 [44-60], p=0.012). The thickening fraction of the intercostal and its ratio to diaphragm thickening showed the highest area under the receiver operating characteristic curves for an early prediction of extubation failure (0.81). Areas under the receiver operating characteristic curves of Dyspnea-VAS and Intensive Care - Respiratory Distress Observational scale reached 0.78 and 0.74 respectively.Respiratory muscle ultrasound and dyspnea measured within 2 h after extubation predict subsequent extubation failure.

Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients

BACKGROUND

Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation.

METHODS

In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT.

RESULTS

In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups.

CONCLUSIONS

In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (No. NCT02863237).

Machine learning for the prediction of successful extubation among patients with mechanical ventilation in the intensive care unit: A retrospective observational study

BACKGROUND

Ventilator weaning protocols are commonly implemented for patients receiving mechanical ventilation. However, the rate of extubation failure remains high despite the protocols. This study investigated the usefulness and accuracy of ventilator weaning through machine learning to predict successful extubation.

METHODS

We retrospectively evaluated the data of patients who underwent intubation for respiratory failure and received mechanical ventilation in the intensive care unit (ICU). Data on 57 factors including patient demographics, vital signs, laboratory data, and data from ventilator were extracted. Extubation failure was defined as re-intubation within 72 hours of extubation. For supervised learning, the data were labeled requirement of intubation or not. We used three learning algorithms (Random Forest, XGBoost, and LightGBM) to predict successful extubation. We also analyzed important features and evaluated the area under curve (AUC) and prediction metrics.

RESULTS

Overall, 13 of the 117 included patients required re-intubation. LightGBM had the highest AUC (0.950), followed by XGBoost (0.946) and Random Forest (0.930). The accuracy, precision, and recall performance were 0.897, 0.910, and 0.909, for Random Forest; 0.910, 0.912, and 0.931 for XGBoost; and 0.927, 0.915, and 0.960 for LightGBM, respectively. The most important feature was the duration of mechanical ventilation followed by the fraction of inspired oxygen, positive end-expiratory pressure, maximum and mean airway pressures, and Glasgow Coma Scale.

CONCLUSIONS

Machine learning could predict successful extubation among patients on mechanical ventilation in the ICU. LightGBM has the highest overall performance. The duration of mechanical ventilation was the most important feature in all models.

Risk factors associated with symptoms of post-extubation upper airway obstruction in the emergency setting

Objective

Post-extubation stridor and hoarseness are important clinical manifestations that indicate laryngeal edema due to intubation. In previous studies the incidence of post-extubation stridor and hoarseness ranged from 1.5% to 26.3% in postoperative patients and patients in the intensive care unit. Female sex and prolonged intubation are reportedly risk factors for post-extubation stridor. However, the risk factors for post-extubation stridor and the appropriate endotracheal tube size in emergency settings remain unknown. This study was performed to identify the risk factors for post-extubation laryngeal edema after emergency intubation.

Methods

A prospective observational study was conducted in a tertiary emergency medical center/trauma center. The primary outcome was post-extubation stridor and hoarseness.

Results

During the study period, 482 emergency intubations and 227 extubations were performed in adult patients. In total, 29% of the patients presented symptoms of stridor and/or hoarseness. Female sex (odds ratio, 2.65; 95% confidence interval, 1.21–5.81) and the duration of intubation (odds ratio, 1.18; 95% confidence interval, 1.05–1.32) were associated with stridor and/or hoarseness.

Conclusions

Patients who undergo emergency intubation have a higher risk of post-extubation upper airway obstruction symptoms than postoperative patients and patients in the intensive care unit, and female sex is associated with these symptoms.

Respiratory Modalities in Preventing Reintubation in a Pediatric Intensive Care Unit

Post-extubation respiratory failure requiring reintubation in a Pediatric Intensive Care Unit (PICU) results in significant morbidity. Data in the pediatric population comparing various therapeutic respiratory modalities for avoiding reintubation is lacking. Our objective was to compare therapeutic respiratory modalities following extubation from mechanical ventilation. About 491 children admitted to a single-center PICU requiring mechanical ventilation from January 2010 through December 2017 were retrospectively reviewed. Therapeutic respiratory support assisted in avoiding reintubation in the majority of patients initially extubated to room air or nasal cannula with high-flow nasal cannula (80%) or noninvasive positive pressure ventilation (100%). Patients requiring therapeutic respiratory support had longer PICU LOS (10.92 vs 6.91 days, P-value = .0357) and hospital LOS (16.43 vs 10.20 days, P-value = .0250). Therapeutic respiratory support following extubation can assist in avoiding reintubation. Those who required therapeutic respiratory support experienced a significantly longer PICU and hospital LOS. Further prospective clinical trials are warranted.

Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study

OBJECTIVE

To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury.

STUDY DESIGN

A single center observational cohort study.

SETTING

Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre).

POPULATION

During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV.

INCLUSION/EXCLUSION CRITERIA

Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation.

MEASUREMENTS AND RESULTS

Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated.

CONCLUSIONS

AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.