1
|
Ha TS, Oh DK, Lee HJ, Chang Y, Jeong IS, Sim YS, Hong SK, Park S, Suh GY, Park SY. Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines. Acute Crit Care 2024; 39:1-23. [PMID: 38476061 PMCID: PMC11002621 DOI: 10.4266/acc.2024.00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Tae Sun Ha
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Kyu Oh
- Department of Pulmonology, Dongkang Medical Center, Ulsan, Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sunghoon Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Department of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Young Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| |
Collapse
|
2
|
Lin DH, Meyers B, Nisar S, Heinz ER. Role of Submandibular Ultrasound in Airway Management of a Patient With Angioedema. Cureus 2022; 14:e22823. [PMID: 35399468 PMCID: PMC8980192 DOI: 10.7759/cureus.22823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/29/2022] Open
Abstract
Angioedema is one of several life-threatening clinical scenarios that lacks clarity on when a patient requires intubation. We present a case of angiotensin-converting enzyme-inhibitor-induced angioedema with peri-oral swelling and normal airway measurements on ultrasound, who was intubated with an abundance of caution and extubated successfully. Current tests for intubation and extubation, such as traditional bedside assessments and the cuff leak test, vary in reliability for angioedema and similar urgent situations. Submandibular ultrasound is a quick, low-cost, non-invasive method for determining quantitative criteria for and assessing when intubation and extubation is indicated, which may lead to improved quality of care and patient safety.
Collapse
|
3
|
Tanaka A, Uchiyama A, Horiguchi Y, Higeno R, Sakaguchi R, Koyama Y, Ebishima H, Yoshida T, Matsumoto A, Sakai K, Hiramatsu D, Iguchi N, Ohta N, Fujino Y. Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study. Sci Rep 2021; 11:19993. [PMID: 34620954 PMCID: PMC8497593 DOI: 10.1038/s41598-021-99501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/24/2021] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yu Horiguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryota Higeno
- Division of Pediatrics, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Ryota Sakaguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hironori Ebishima
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Atsuhiro Matsumoto
- Division of Anesthesiology, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kanaki Sakai
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Hiramatsu
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Noriyuki Ohta
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
4
|
Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:640. [PMID: 33160405 PMCID: PMC7648377 DOI: 10.1186/s13054-020-03358-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Background Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. Methods We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. Results We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49–0.73; I2 = 81.6%) and 0.87 (95% CI 0.82–0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46–0.81; I2 = 48.9%) and 0.88 (95% CI 0.83–0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. Conclusions The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.
Collapse
Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Jeffrey L Jackson
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Jun Kamei
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| |
Collapse
|
5
|
Schnell D, Planquette B, Berger A, Merceron S, Mayaux J, Strasbach L, Legriel S, Valade S, Darmon M, Meziani F. Cuff Leak Test for the Diagnosis of Post-Extubation Stridor: A Multicenter Evaluation Study. J Intensive Care Med 2017; 34:391-396. [PMID: 28343416 DOI: 10.1177/0885066617700095] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND: Cuff leak test was developed to predict the occurrence of post-extubation stridor (PES). This study evaluated the diagnostic performance of this test in unselected critically ill patients. METHODS: Multicenter prospective study including unselected ventilated patients at the time of their first planned extubation. The diagnostic performance of 4 different cuff leak tests was assessed. RESULTS: Post-extubation stridor occurred in 34 (9.4%) of 362 included patients. Compared to patients without PES, patients with PES required more frequently reintubation (6 [17.6%] vs 26 [7.9%], P = .041), prolonged duration of ventilation (6 [3-13] vs 5 [2-9] days, P = .029), and longer intensive care unit (ICU) stay (12 [6-17.5] vs 7.5 [4-13] days, P = .018). However, ICU mortality was similar in both groups (1 [2.9%] vs 23 [7.0%], P = .61). The 4 cuff leak tests display poor diagnostic accuracy: sensitivities ranging from 27% to 46%, specificities from 70% to 88%, positive predictive values from 14% to 19%, and negative predictive values from 92% to 93%. CONCLUSION: Post-extubation stridor occurs in less than 10% of unselected critically ill patients. The several cuff leak tests display limited diagnostic performance for the detection of PES. Given the high rate of false positives, routine cuff leak test may expose to undue prolonged mechanical ventilation.
Collapse
Affiliation(s)
- David Schnell
- 1 Medical ICU, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg Cedex, France.,2 Medical ICU, Hôpital Saint-Louis, AP-HP, Paris, France.,3 UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France.,4 Clinical Research in Intensive Care and Sepsis group, Tours, France
| | | | - Asaël Berger
- 1 Medical ICU, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg Cedex, France
| | - Sybille Merceron
- 2 Medical ICU, Hôpital Saint-Louis, AP-HP, Paris, France.,3 UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France.,5 Centre Hospitalier André Mignot, Polyvalent ICU, Le Chesnay, France
| | - Julien Mayaux
- 6 Pneumology Ward and Medical ICU, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Lucas Strasbach
- 1 Medical ICU, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg Cedex, France
| | - Stéphane Legriel
- 5 Centre Hospitalier André Mignot, Polyvalent ICU, Le Chesnay, France
| | - Sandrine Valade
- 2 Medical ICU, Hôpital Saint-Louis, AP-HP, Paris, France.,3 UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France
| | - Michael Darmon
- 7 Medical-Surgical ICU, Saint-Etienne University Hospital, Saint-Priest-en-Jarez, France.,8 Jacques Lisfranc Medical School, Jean Monnet University, Saint-Etienne, France
| | - Ferhat Meziani
- 1 Medical ICU, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg Cedex, France.,4 Clinical Research in Intensive Care and Sepsis group, Tours, France
| |
Collapse
|
6
|
Girard TD, Alhazzani W, Kress JP, Ouellette DR, Schmidt GA, Truwit JD, Burns SM, Epstein SK, Esteban A, Fan E, Ferrer M, Fraser GL, Gong MN, Hough CL, Mehta S, Nanchal R, Patel S, Pawlik AJ, Schweickert WD, Sessler CN, Strøm T, Wilson KC, Morris PE. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med 2017; 195:120-133. [DOI: 10.1164/rccm.201610-2075st] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
7
|
Lilienstein JT, Davis JW, Bilello JF, Dirks RC. Risk factors associated with post-extubation stridor in the trauma intensive care unit. Am J Surg 2016; 212:379-83. [PMID: 27255781 DOI: 10.1016/j.amjsurg.2016.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 02/18/2016] [Accepted: 02/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Post-extubation stridor is an uncommon complication in medical intensive care units (ICUs) but has not been well studied in trauma patients. We sought to determine the incidence of reintubation due to stridor in trauma patients and describe associated risk factors. METHODS A retrospective review of all intubated trauma patients was performed. Data collected included presence of stridor, demographic data, and details of intubation and extubation. RESULTS Of all trauma patients reintubated, 31% were for stridor. Although female gender, age less than 18, blunt mechanism, and duration of intubation 5 days or more were associated with reintubation for stridor, endotracheal tube diameter was not. Mortality was not increased with reintubation. CONCLUSIONS Trauma ICU patients are reintubated for stridor at a higher rate than medical ICU patients. Age, gender, blunt mechanism, and duration of intubation are risk factors for this complication.
Collapse
Affiliation(s)
- Jordan T Lilienstein
- Department of Surgery, UCSF Fresno, 1st Floor, 2823 Fresno Street, Fresno, CA 93721, USA.
| | - James W Davis
- Department of Surgery, UCSF Fresno, 1st Floor, 2823 Fresno Street, Fresno, CA 93721, USA
| | - John F Bilello
- Department of Surgery, UCSF Fresno, 1st Floor, 2823 Fresno Street, Fresno, CA 93721, USA
| | - Rachel C Dirks
- Department of Surgery, UCSF Fresno, 1st Floor, 2823 Fresno Street, Fresno, CA 93721, USA
| |
Collapse
|
8
|
Wang W, Zhou Y, Tong HS, Su L, Zhao L. Value of the cuff leak test is limited. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:446. [PMID: 26698862 PMCID: PMC4699342 DOI: 10.1186/s13054-015-1152-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Wei Wang
- Department of Critical Care Medicine, Guangzhou General Hospital of Guangzhou Military Command, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Zhuhai Hospital of Jinan University, Zhuhai People's Hospital, 79 Kang-ning road, Zhuhai, 519000, China
| | - Yu Zhou
- Department of Critical Care Medicine, Zhuhai Hospital of Jinan University, Zhuhai People's Hospital, 79 Kang-ning road, Zhuhai, 519000, China
| | - Hua-Sheng Tong
- Department of Critical Care Medicine, Guangzhou General Hospital of Guangzhou Military Command, Southern Medical University, Guangzhou, Guangdong, China
| | - Lei Su
- Department of Critical Care Medicine, Guangzhou General Hospital of Guangzhou Military Command, Southern Medical University, Guangzhou, Guangdong, China
| | - Ling Zhao
- Department of Critical Care Medicine, Zhuhai Hospital of Jinan University, Zhuhai People's Hospital, 79 Kang-ning road, Zhuhai, 519000, China.
| |
Collapse
|
9
|
Patel AB, Ani C, Feeney C. Cuff leak test and laryngeal survey for predicting post-extubation stridor. Indian J Anaesth 2015; 59:96-102. [PMID: 25788742 PMCID: PMC4357893 DOI: 10.4103/0019-5049.151371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. Methods: Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. Results: PES incidence was 4%. CLT demonstrated ‘no leak’ in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. Conclusion: Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.
Collapse
Affiliation(s)
- Anit B Patel
- Department of Internal Medicine, Alameda County Medical Center, Oakland, CA 94602, USA
| | - Chizobam Ani
- Department of Internal Medicine, Alameda County Medical Center, Charles Drew University of Medicine and Science, Lynwood, CA 90262, USA
| | - Colin Feeney
- Department of Internal Medicine, Division of Critical Care, Alameda County Medical Center, Oakland, CA 94602, San Francisco, CA 94143, USA ; Department of Internal Medicine, University of California, San Francisco, CA 94143, USA
| |
Collapse
|
10
|
Schnell D, Darmon M, Meziani F. Faut-il abandonner le test de fuite pour le dépistage de la dyspnée laryngée post-extubation ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
11
|
Graboyes EM, Bradley JP, Kallogjeri D, Cavallone LF, Nussenbaum B. Prognosis and Patterns of Failure for the Extubation of Patients Who Remain Intubated After Head and Neck Surgery. Ann Otol Rhinol Laryngol 2014; 124:179-86. [DOI: 10.1177/0003489414549576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: This study aimed to analyze the rate of failure, patterns of failure, and prognostic factors for patients who remain intubated after head and neck surgery and then undergo delayed extubation. Methods: Retrospective chart review of all otolaryngology patients who remained intubated after head and neck surgery and then underwent delayed extubation between 2006 and 2013. The incidence and patterns of extubation failure were analyzed. Univariable logistic regression analysis was performed to identify risk factors for postextubation failure. Results: Fifteen of the 129 patients (12%) who remained intubated after head and neck surgery and underwent delayed extubation subsequently failed and required either repeat intubation or an emergency surgical airway. The most common reasons for failure were hemorrhage (47%) and upper airway edema (33%). Failure typically occurred within 6 hours of extubation. Twenty-seven percent of the patients who failed extubation (4/15) required an emergency surgical airway. On univariable logistic regression analysis, ligation of a major neck vessel predicted extubation failure (odds ratio = 5.20; 95% confidence interval, 1.48-18.23). Conclusion: Postextubation failure in carefully selected patients undergoing delayed extubation after head and neck surgery is infrequent and most commonly due to postoperative bleeding. Prospective data are required to facilitate safe and quality care for these patients.
Collapse
Affiliation(s)
- Evan M. Graboyes
- Washington University in St Louis School of Medicine, Department of Otolaryngology–Head and Neck Surgery, St Louis, Missouri, USA
| | - Joseph P. Bradley
- Washington University in St Louis School of Medicine, Department of Otolaryngology–Head and Neck Surgery, St Louis, Missouri, USA
| | - Dorina Kallogjeri
- Washington University in St Louis School of Medicine, Department of Otolaryngology–Head and Neck Surgery, St Louis, Missouri, USA
| | - Laura F. Cavallone
- Washington University in St Louis School of Medicine, Department of Anesthesiology, St Louis, Missouri, USA
| | - Brian Nussenbaum
- Washington University in St Louis School of Medicine, Department of Otolaryngology–Head and Neck Surgery, St Louis, Missouri, USA
| |
Collapse
|
12
|
Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67:318-40. [PMID: 22321104 DOI: 10.1111/j.1365-2044.2012.07075.x] [Citation(s) in RCA: 295] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care.
Collapse
|
13
|
Zhou T, Zhang HP, Chen WW, Xiong ZY, Fan T, Fu JJ, Wang L, Wang G. Cuff-leak test for predicting postextubation airway complications: a systematic review. J Evid Based Med 2011; 4:242-54. [PMID: 23672755 DOI: 10.1111/j.1756-5391.2011.01160.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVE Postextubation problems such as laryngeal edema and reintubation are common complications after tracheal intubation. The cuff-leak test has been proposed as a method of identifying those patients at high risk in clinical practice, but its efficacy remains controversial. METHODS We searched electronic databases including PubMed, the Cochrane Controlled Trials Register, Web of Science, Ovid, and Embase. Studies were included if they were concerned with accuracy of the cuff-leak test and the effect of cuff-leak test screening on patient-important outcomes. Two reviewers independently assessed study quality with the QUADAS tool and extracted data. We compiled diagnostic two by two tables and pooled estimates of sensitivity and specificity, but refrained from pooling when there was considerable clinical or statistical heterogeneity. RESULTS Sixteen diagnostic tests with 3172 participants and six clinical trials with 2500 patients were identified. The median diagnostic odds ratios for predicting postextubation laryngeal edema and reintubation were 18.16 (range, 3.54 to 356.00) and 10.80 (2.74 to 1665.00), respectively. The accuracy of the cuff-leak test varied with different methods, duration of intubation, and study population. An indirect comparison found significant differences in post-extubation incidence of laryngeal edema (OR = 2.09, 95% CI, 1.28 to 2.89) but not reintubation (OR = 0.94, 95% CI, 0.32 to 1.57) if using cuff-leak test screening. CONCLUSIONS Our results suggest the cuff-leak test accurately predicts which adult patients are at high risk of postextubation airway complications, but randomized controlled trials are needed to further assess this diagnostic strategy.
Collapse
Affiliation(s)
- Ting Zhou
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, P.R. China
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 2009; 35:1171-9. [DOI: 10.1007/s00134-009-1501-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
|