Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis

Diagnostic accuracy of rapid shallow breathing index based on diaphragm ultrasound predicting successful weaning from mechanical ventilation: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis aimed to evaluate the effectiveness of the rapid shallow breathing index based on diaphragm ultrasound, specifically the diaphragmatic excursion-rapid shallow breathing index (DE-RSBI) and the diaphragmatic thickness fraction- rapid shallow breathing index (DTF-RSBI), in predicting successful weaning from mechanical ventilation.

METHOD

Two researchers independently searched four databases, PubMed, Embase, Cochrane Library and Web of Science, from their inception until 2 November 2024, and conducted literature screening and data extraction. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) was employed to evaluate the methodological quality of the included studies. Data analyses were performed using Stata 15 and Meta-Disc 1.4 software.

RESULTS

Fifteen studies (1,519 patients) were included in the meta-analysis. For the DE-RSBI, the pooled sensitivity was 0.89 (95% CI [0.84-0.93]), the pooled specificity was 0.85 (95% CI [0.79-0.90]), and the area under the curve (AUC) for the summary receiver operator characteristic (SROC) curve was 0.93 (95% CI [0.90-0.95]). For the DTF-RSBI, the pooled sensitivity was 0.85 (95% CI [0.56-0.96]), the pooled specificity was 0.81 (95% CI [0.66-0.90]), and the AUC was 0.88 (95% CI [0.85-0.90]).

CONCLUSION

Both DE-RSBI and DTF-RSBI demonstrate strong diagnostic accuracy in predicting successful weaning from mechanical ventilation. Given the apparent heterogeneity among the studies, we anticipate more large-sample, multi-center, and high-quality clinical studies in the future.

IMPLICATIONS FOR CLINICAL PRACTICE

DE-RSBI and DTF-RSBI are simple, non-invasive and objective evaluation indicators, and both can be utilized to predict a patient's capacity to successfully withdraw from mechanical ventilation. This meta-analysis comprehensively evaluated the value of these two tools in predicting successful extubation, aiming to provide clinicians with a strong decision-making basis to improve the success rate of extubation.

Risk markers for postoperative reintubation of intensive care unit patients: A retrospective multicentre study of the National Intensive Care Registry

OBJECTIVES

To evaluate postoperative reintubation incidence and identify risk markers to expedite the identification of high-risk patients after ICU admission.

METHODS

We performed this retrospective multicentre study that included postoperative adult patients admitted to Japanese ICUs between April 2015 and March 2022 using the Japanese Intensive care PAtient Database (JIPAD). Data regarding the patients treated in included ICUs were accumulated by the JIPAD, which we received for research use. Logistic regression analysis with generalised estimating equations was used to estimate odds ratios (ORs) of 1-standard deviation increments and 95 % confidence intervals (CIs) for the association of each variable available within 24 h after ICU admissions with reintubation.

RESULTS

Among 13,219 admissions during the study period, 828 patients were postoperatively reintubated (incidence = 6.26 %, 95 % CI: 5.86-6.69). Maximum partial pressure of carbon dioxide (PaCO2), bilirubin, and blood urea nitrogen (adjusted OR = 1.138, 95 % CI: 1.055-1.228; adjusted OR = 1.101, 95 % CI: 1.018-1.191; and adjusted OR = 1.105, 95 % CI: 1.016-1.203, respectively) and body mass index (BMI) and minimum white blood cells counts (adjusted OR = 0.867, 95 % CI: 0.797-0.944; and adjusted OR = 0.878, 95 % CI: 0.815-0.946, respectively) were significantly associated with postoperative reintubation.

CONCLUSIONS

Postoperative reintubation incidence in Japanese ICUs was estimated to be 6.26%. BMI, maximum PaCO2, clinical laboratory data reflecting surgical invasiveness, and immunosuppression may be risk markers for postoperative reintubation.

IMPLICATIONS FOR CLINICAL PRACTICE

Our study will help identify high-risk patients for postoperative reintubation early post-ICU admission, enabling early and focused nursing care to prevent reintubation, such as early mobilisation and ambulation.

Standard spontaneous breathing trial parameters may not predict unplanned reintubation for trauma patients

BACKGROUND

The applicability of spontaneous breathing trial (SBT) factors such as negative inspiratory force (NIF) and rapid shallow breathing index (RSBI) as predictors of reintubation in trauma patients (TPs) is unclear. This study aimed to identify predictors of unplanned reintubation (UR) in TPs.

METHODS

A single center, retrospective (1/2017-12/2023) study of TPs ≥18 years-old extubated from endotracheal mechanical ventilation was performed. Patients with UR during admission were compared to patients without UR. A multivariable logistic regression was performed to identify risk factors associated with UR.

RESULTS

39 of 424 ​TPs (9.2 ​%) had UR. UR patients were older (median: 55 vs 39 years-old, p ​= ​0.012) and more often had congestive heart failure (10.3 ​% vs 1.6 ​%, p ​< ​0.001), cirrhosis (7.7 ​% vs 1.9 ​%, p ​= ​0.025), end stage renal disease (7.7 ​% vs 1.6 ​%, p ​= ​0.044), and a higher injury severity scores (ISS) (median: 27 vs 18, p ​< ​0.001). UR patients had increased ventilator days (median: 6 vs 2, p ​< ​0.001) prior to extubation, whereas RSBI and NIF were similar (median: 36 vs 32, p ​= ​0.508) and (median: -24.0 vs -27.0 ​cm ​H2O, p ​= ​0.190). On multivariable analysis, RSBI <50 or <105 and NIF ​< ​-20 were not associated with UR. Age (OR 1.03, CI 1.01-1.05, p ​= ​0.006) and ISS (OR 1.04, CI 1.01-1.08, p ​= ​0.022) were independently associated with increased risk of UR.

CONCLUSIONS

SBT parameters (RSBI and NIF) were not associated with UR. Age and ISS were independently associated with UR. This suggests additional patient-specific factors should help guide extubation decisions for TPs.

Risk factors for failing endotracheal extubation in neurocritical patients: a retrospective cohort study

Objective

To identify risk factors of failing endotracheal extubation among neurocritical care patients with endotracheal intubation for more than 48 h and passing the autonomous breathing test (SBT) and establish a prediction model accordingly.

Methods

This study included the clinical data of patients who received standardized monitoring and treatment in the neurocritical care unit of the First Affiliated Hospital of Anhui Medical University from April 2020 to August 2024. Based on the outcomes of extubation after 5 days, data were divided into the success group and the failure group. Clinical features of two groups were compared and accordingly taken into multivariate logistic regression analysis, eventually generating a scoring model with its receiver operating characteristic curve (ROC). The area under the curves (AUC) of other previous scores was compared by Z-test.

Results

Of 116 recorded cases, 92 (79.3%) were successfully extubated, while 24 (20.7%) required re-intubation within 5 days. Univariate analysis revealed significant differences between two groups in state of consciousness, Glasgow Coma Scale (GCS) total score, GCS motor score (GCS-M), muscle strength, swallowing ability, coughing response, body temperature, oxygenation index, Apache II score, and APS score (all p < 0.05). Multivariate analysis was further carried out, and a scoring model was established accordingly (including GCS-M, coughing ability, and oxygenation index) with a total score of 4 points. The model demonstrated good predictive value, with a cut-off ≥1 distinguishing extubation success with 79.2% sensitivity and 69.6% specificity according to ROC (AUC = 0.79; 95% CI, 0.68-0.90).

Conclusion

This clinical predictive scoring model could provide guidance for extubation decisions in neurocritical care units but requires further external validation.

Clinical outcomes and hemorrhagic or thromboembolic risks in decompressive craniectomy for patients taking antiplatelet or anticoagulant therapy

Decompressive craniectomy (DC) is a critical surgical intervention for elevated intracranial pressure. However, the impact of preoperative antiplatelet or anticoagulant therapy on outcomes and complications remains unclear. A retrospective-prospective study was conducted on 145 patients undergoing DC between November 2021 and May 2023. Patients were categorized into two groups: those with (n = 48) and without (n = 97) preoperative antithrombotic therapy. Demographic data, comorbidities, antithrombotic therapy type and duration, clinical outcomes, and pre-operative risk factors (CHA2DS2-VASc and HAS-BLED scores) were analyzed. While there was a trend towards higher hemorrhagic complications in the antithrombotic therapy group (20.0% vs. 11.3%), this difference was not statistically significant. However, thromboembolic events, primarily stroke (27.7% vs. 9.3%) and acute myocardial infarction (10.6% vs. 0.0%), were significantly more frequent in the antithrombotic therapy group. Multivariate analysis revealed that ischemic stroke as a primary diagnosis, rather than antithrombotic therapy itself, was a significant predictor of thromboembolic complications (adjusted OR 3.49, 95%CI 1.47-8.28, p = 0.005). Pre-operative GCS was associated with improved outcomes (adjusted OR 0.81, 95%CI 0.67-0.97, p = 0.025). While antithrombotic therapy does not appear to increase the risk of hemorrhagic complications after DC, it is associated with a higher risk of thromboembolic events, especially in patients with ischemic stroke. Individualized assessment and tailored management of antithrombotic therapy are crucial to optimize outcomes in DC patients. Further studies are needed to refine strategies for bridging anticoagulation and managing antithrombotic therapy in this population, considering factors such as CHA2DS2-VASc and HAS-BLED scores, as well as patient-specific risk profiles.

Impact of comorbidities on management and outcomes of patients weaning from invasive mechanical ventilation: insights from the WEAN SAFE study

BACKGROUND

The impact of comorbidities on patients weaning from invasive ventilation is incompletely understood. We wished to understand the impact of the number and type of comorbidities on patients' weaning from invasive mechanical ventilation enrolled in the 'WorldwidE AssessmeNt of Separation of pAtients From ventilatory assistancE (WEAN SAFE) study.

METHODS

The study population consisted of patients enrolled in the WEAN SAFE study that commenced the weaning process. We categorized patients by the number of comorbidities (none, 1, 2, or 3 plus), and by specific comorbidity type. The primary outcome was the impact of comorbidities on delayed weaning and failed weaning from invasive MV. Secondary outcomes included the impact of comorbidities on ICU and hospital survival, and decisions to limit life-sustaining interventions.

RESULTS

Of 4523 patients in the study population, 1614 (35.7%) had one comorbidity, 889 (19.7%) had two comorbidities, 432 (9.6%) had three or more comorbidities, while 1562 (34.5%) had no comorbidities. The most frequently occurring comorbid conditions were respiratory (22%) and cardiovascular (11%). Patients with comorbidities were more likely to fail a separation attempt, more likely to receive an extubation attempt, and to require more than 1 extubation attempt. The proportion of patients with failed weaning from invasive MV increased progressively with increasing comorbidities. Neuromuscular comorbidities were associated with increased weaning duration. Weaning failure was increased with respiratory, hepatic, renal, neuromuscular, and immune dysfunction comorbidities. Hospital mortality rates increased progressively from 16% with no comorbidity to 34% with ≥ 3 comorbidities. Each specific comorbidity was independently associated with increased hospital mortality. The presence of comorbidities was associated with decisions to limit life sustaining interventions.

CONCLUSIONS

Most patients weaning from invasive ventilation have comorbidities, which are associated with higher weaning failure risk and worse outcomes. The adverse impact of comorbidities on the weaning outcomes and of the process are not explained by a less aggressive approach to weaning.

Development and validation of machine learning models for predicting extubation failure in patients undergoing cardiac surgery: a retrospective study

Patients with multiple comorbidities and those undergoing complex cardiac surgery may experience extubation failure and reintubation. The aim of this study was to establish an extubation prediction model using explainable machine learning and identify the most important predictors of extubation failure in patients undergoing cardiac surgery. Data from 776 adult patients who underwent cardiac surgery and were intubated for more than 24 h were obtained from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The primary endpoint was extubation failure according to the WIND criteria, with 205 patients experiencing extubation failure. The data was split into a training set (80%) and a test set (20%). The performance of the XGBoost algorithm was the highest (AUC 0.793, Mean Precision 0.700, Brier Score0.150), which was better than that of logistic regression (AUC 0.766, Mean Precision 0.553, Brier Score0.173) and random forest (AUC 0.791, Mean Precision 0.510, Brier Score 0.181). The most crucial predictor of extubation failure is the mean value of the anion gap in the 24 h before extubation. The other main features include ventilator parameters and blood gas indicators. By applying machine learning to large datasets, we developed a new method for predicting extubation failure after cardiac surgery in critically ill patients. Based on the predictive factors analyzed, internal environmental indicators and ventilation characteristics were important predictors of extubation failure. Therefore, these predictive factors should be considered when determining extubation readiness.

Exploring Applications of Artificial Intelligence in Critical Care Nursing: A Systematic Review

Background: Artificial intelligence (AI) has been increasingly employed in healthcare across diverse domains, including medical imaging, personalized diagnostics, therapeutic interventions, and predictive analytics using electronic health records. Its integration is particularly impactful in critical care, where AI has demonstrated the potential to enhance patient outcomes. This systematic review critically evaluates the current applications of AI within the domain of critical care nursing. Methods: This systematic review is registered with PROSPERO (CRD42024545955) and was conducted in accordance with PRISMA guidelines. Comprehensive searches were performed across MEDLINE/PubMed, SCOPUS, CINAHL, and Web of Science. Results: The initial review identified 1364 articles, of which 24 studies met the inclusion criteria. These studies employed diverse AI techniques, including classical models (e.g., logistic regression), machine learning approaches (e.g., support vector machines, random forests), deep learning architectures (e.g., neural networks), and generative AI tools (e.g., ChatGPT). The analyzed health outcomes encompassed postoperative complications, ICU admissions and discharges, triage assessments, pressure injuries, sepsis, delirium, and predictions of adverse events or critical vital signs. Most studies relied on structured data from electronic medical records, such as vital signs and laboratory results, supplemented by unstructured data, including nursing notes and patient histories; two studies also integrated audio data. Conclusion: AI demonstrates significant potential in nursing, facilitating the use of clinical practice data for research and decision-making. The choice of AI techniques varies based on the specific objectives and requirements of the model. However, the heterogeneity of the studies included in this review limits the ability to draw definitive conclusions about the effectiveness of AI applications in critical care nursing. Future research should focus on more robust, interventional studies to assess the impact of AI on nursing-sensitive outcomes. Additionally, exploring a broader range of health outcomes and AI applications in critical care will be crucial for advancing AI integration in nursing practices.

Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study

PURPOSE

A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital.

METHODS

In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia).

RESULTS

We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2 years, standard deviation [SD] 25.2 years) and 8,091 in the normal pressure extubation group (mean age 47.8 years, SD 25.8 years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94).

CONCLUSIONS

These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique.

CLINICAL TRIAL NUMBER

Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

Humidified Noninvasive Ventilation versus High-Flow Therapy to Prevent Reintubation in Patients with Obesity: A Randomized Clinical Trial

Rationale: The optimal strategy to prevent reintubation in patients with obesity remains uncertain. Objectives: We aimed to determine whether noninvasive ventilation (NIV) with active humidification is superior to a high-flow nasal cannula (HFNC) in preventing reintubation in patients with obesity at intermediate risk. Methods: We conducted a randomized controlled trial in two ICUs in Spain (June 2020-June 2021). We included patients ready for planned extubation with a body mass index >30 and three or fewer risk factors for reintubation. Patients with hypercapnia at the end of the spontaneous breathing trial were excluded. Patients were randomized to undergo NIV with active humidification or HFNC for 48 hours after extubation. The primary outcome was the reintubation rate within 7 days after extubation. As a secondary analysis, we performed a post hoc Bayesian analysis using three different priors. Measurements and Main Results: Of 144 patients (median age, 61 [25th-75th percentile range, 61-67] yr; 65 [45%] men), 72 received NIV and 72 received an HFNC. Reintubation was required in 17 (23.6%) patients receiving NIV and in 24 (33.3%) patients receiving HFNC (difference between groups, 9.7; 95% confidence interval, -4.9, 24.4). All of the secondary analysis showed nonsignificant differences. In the exploratory Bayesian analysis, the probability of a reduction in reintubation with NIV was 99% (data-driven prior), 90% (minimally informative prior), or 89% (skeptical prior). Conclusions: Among adult critically ill patients with obesity at intermediate risk for extubation failure, the rate of reintubation was not significantly lower with NIV than with HFNC. Nevertheless, there is a risk for underpowered results. Clinical trial registered with www.clinicaltrials.gov (NCT04125342).

Analysis of Factors and Clinical Outcomes of Planned Tracheal Extubation Failure in Neurosurgical Intensive Care Unit Patients

ABSTRACT

BACKGROUND: Planned tracheal extubation failure is a common occurrence among patients in the neurosurgical intensive care unit (NICU) because of the complex nature of neurocritical injuries, and the failure could result in a poor prognosis. METHODS: We observed and recorded the patients with tracheal intubation in the NICU of a hospital in Shanghai from June 2021 to December 2022 and analyzed data from planned tracheal extubation, categorizing patients by success or failure, and compared outcomes between the two groups while investigating contributing factors. RESULTS: A total of 156 patients were included, 133 (85.3%) of whom were successfully extubated and 23 (14.7%) were not. The results of logistic regression analysis demonstrated that the Glasgow Coma Scale score before extubation (OR, 0.643; 95% CI, 0.444-0.931; P = .020) and the frequency of respiratory secretions suctioning before tracheal extubation (OR, 0.098; 95% CI, 0.027-0.354; P < .001) were independent risk factors for extubation failure. We also found that the extubation failure group experienced a significantly longer ICU stay and incurred higher hospitalization costs. CONCLUSIONS: Poor Glasgow Coma Scale scores and a high frequency of respiratory secretions suctioning before tracheal extubation were the main factors contributing to tracheal extubation failure in NICU patients. To avoid tracheal extubation failure and adverse outcomes, these two factors should be carefully assessed before tracheal extubation.

Assessment of Respiratory Muscles, Lung Parenchyma, and Cardiac Function by Ultrasound for Predicting Weaning Failure in Critically Ill Adults: A Prospective Observational Study

OBJECTIVES

The parasternal intercostal muscle activity, a marker of accessory muscle usage, is found to correlate inversely with the pressure-generating capacity of the diaphragm and level of support of mechanical ventilation. The primary objective of our study was to determine whether the parasternal intercostal muscle thickening fraction (PMTF) measured by ultrasonography can predict weaning. We also evaluated whether addition of lung ultrasound score and echocardiographic assessment can add on to predicting weaning failure.

METHODS

This prospective observational study conducted in a mixed medical-surgical intensive care unit, included 60 adult patients who were eligible for a spontaneous breathing trial (SBT) after being invasively mechanically ventilated for more than 48 hours. Ultrasound of respiratory muscles, lung parenchyma, and echocardiographic assessment were performed before and after 120 minutes of SBT. Parasternal intercostal muscles were imaged with a high frequency linear probe on the right second intercostal space 5 cm lateral to the sternal margin. PMTF was calculated as (maximum-minimum thickness)/minimum thickness.

RESULTS

Among 60 patients, SBT failure was seen in 11 patients and extubation failed in 8 patients. PMTF (%) was significantly higher in the weaning failure group (13.33 [8.33-19.05]) as compared to patients with successful weaning (6.67 [6.06-11.54]). Diaphragmatic thickening fraction (DTF) correlated inversely to PMTF in patients with weaning failure. A pre-SBT PMTF cut-off of ≥7.7% and post-SBT cut-off of ≥15.38% were good predictors of weaning failure and extubation failure, respectively.

CONCLUSIONS

PMTF has good discriminatory power to predict weaning outcomes (area under the receiver operating characteristic curve: 0.74 [0.59-0.88]). Pre-SBT PMTF had similar power as DTF to predict weaning failure.

How to prevent postextubation respiratory failure

PURPOSE OF REVIEW

Postextubation respiratory support treatment approaches, indications, and subgroups of patients with different responses to those therapies are rapidly changing. Planning optimal therapy in terms of choosing devices, timing of application and selecting settings with the goal of minimizing extubation failure is becoming a challenge. This review aims to analyze all the available evidence from a clinical point of view, trying to facilitate decision making at the bedside.

RECENT FINDINGS

There is evidence for high flow nasal cannula support in patients at low risk of extubation failure. Noninvasive ventilation based strategies should be prioritized in patients at very high risk, who are obese or are hypercapnic at the end of a spontaneous breathing trial. Patients not included in the previous groups merit a tailored decision based on more variables.Optimizing the timing of therapy can include facilitation of extubation by transitioning to noninvasive respiratory support or prolonging a planned preventive therapy according to clinical condition.

SUMMARY

Planning postextubatin respiratory support must consider the risk for failing and the presence of some clinical conditions favoring noninvasive ventilation.Extubation can be safely accelerated by modifying screening criteria and spontaneous breathing trial settings, but there is room to increase the role of postextubation noninvasive respiratory support for this indication, always keeping in mind the dangers of delaying a needed intubation.

Transitions in intensive care: Investigating critical slowing down post extubation

Complex biological systems undergo sudden transitions in their state, which are often preceded by a critical slowing down of dynamics. This results in longer recovery times as systems approach transitions, quantified as an increase in measures such as the autocorrelation and variance. In this study, we analysed paediatric patients in intensive care for whom mechanical ventilation was discontinued through removal of the endotracheal tube (extubation). Some patients failed extubation, and required a re-intubation within 48 hours. We investigated whether critical slowing down could be observed post failed extubations, prior to re-intubation. We tested for significant increases (p <.05) between extubation and re-intubation, in the variance and autocorrelation, over the time series data of heart rate, respiratory rate and mean blood pressure. The autocorrelation of the heart rate showed a significantly higher proportion of increases in the group that failed extubation, compared who those who did not. It also showed a significantly higher magnitude of increase for the failed extubation group in a t-test. Moreover, incorporating these magnitudes significantly improved the fit of a logistic regression model when compared to a model that solely used the mean and standard deviation of the vital signs. While immediate clinical utility is limited, the work marks an important first step towards using dynamical systems theory to understand the dynamics of signals measured at the bedside during intensive care.

Clinical risk factors associated with the need for tracheostomy in traumatic cervical and high thoracic spinal cord injury

BACKGROUND

Our objective was to assess the association of completeness and level of spinal cord injury (SCI) with the need for tracheostomy and identify additional risk factors predictive of tracheostomy.

METHODS

This was a retrospective review of patients with SCI between January 2017 and December 2022.

RESULTS

Patients with complete SCI were roughly thirty-three times more likely to have a tracheostomy when compared to incomplete injury (82 ​% vs 12 ​%, p ​< ​0.001, OR ​= ​32.9). The rate of tracheostomy did not differ between spinal cord levels for complete (p ​= ​0.68) or incomplete (p ​= ​0.08) injuries. Penetrating injury, low GCS, high ISS, and polytrauma were associated with tracheostomy need in incomplete SCI.

CONCLUSION

Complete injury was statistically significantly associated with the need for tracheostomy while level of injury failed to reach significance. Patients with incomplete SCI that have certain clinical risk factors should be considered for early tracheostomy.

Postanesthesia Sling Lift Transfer and Upright Extubation of an Adult Secured in a Motorized Wheelchair: A Case Report

This case report describes a 29-year-old patient with cerebral palsy whose mother, for safety reasons, requested that before extubation in the postanesthesia care unit, her son be transferred from the padded stretcher to his personal motorized wheelchair. Using a sling lift, we safely transferred the anesthetized, intubated patient from a supine position to an upright sitting position. Although sling lifts are often used in critical care and rehabilitation environments, use in the perioperative space is rare. In this case report, we demonstrate how a sling lift can enhance safety for patients and perioperative staff.

Best clinical model predicting extubation failure: a diagnostic accuracy post hoc analysis

PURPOSE

Predicting extubation failure remains a clinical challenge. This study aimed to determine diagnostic accuracy of models used at the bed side.

METHODS

Post hoc analysis of 2341 patients at all risk included in five multicenter randomized trials. Diagnostic accuracy of three clinical prediction models was compared: 3-factors model including age > 65y, chronic heart or pulmonary disease; 4-factors model adding prolonged mechanical ventilation; and 11-factors model including age > 65 years, ≥ 2 comorbidities, prolonged mechanical ventilation, acute heart failure as the primary indication for mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, APACHE II score > 12 on extubation day, airway patency problems, inability to deal with respiratory secretions, not simple weaning, obesity, or hypercapnia at the end of the spontaneous breathing trial. Crude and adjusted for spontaneous breathing trial (SBT) models were compared for all-cause reintubation at 7 days using Youden and Kappa indexes.

RESULTS

The 3-factors model had a very low global prediction capability (Youden index 0.08 and Kappa index 0.04); the 4-factors and 11-factors models had low global prediction capability (Youden index 0.12 and 0.16, and Kappa index 0.06 and 0.07, respectively). Aggressive SBT strategies (pressure support ≥ 7 cm H2O with or without positive end-expiratory pressure) were associated with extubation failure risk (p < 0.001). All adjusted models had low diagnostic capability (0.08/0.03, 0.07/0.03, and 0.06/0.02 respectively).

CONCLUSION

Based on these results, the 3-factors model reported a very low diagnostic accuracy, and the 4 or 11-factors models showed similar low accuracy. No improvement was observed after adjusting for other aspects of weaning.

Heart Rate Variability During Weaning from Invasive Mechanical Ventilation: A Systematic Review

Background: The role of Heart Rate Variability (HRV) indices in predicting the outcome of the weaning process remains a subject of debate. The aim of this study is to investigate HRV analysis in critically ill adult patients undergoing weaning from invasive mechanical ventilation (IMV). Methods: The protocol of this systematic review was registered with PROSPERO (CRD42024485800). We searched PubMed and Scopus databases from inception till March 2023 to identify randomized controlled trials and observational studies investigating HRV analysis in critically ill adult patients undergoing weaning from invasive mechanical ventilation. Our primary outcome was to investigate HRV changes occurring during the weaning from IMV. Results: Seven studies (n = 342 patients) were included in this review. All studies reported significant changes in at least one HRV parameter. The indices Low Frequency (LF), High Frequency (HF), and LF/HF ratio seem to be the most promising in predicting the outcome of weaning with reliability. Some HRV indices showed modification in response to different ventilator settings or modalities. Conclusions: Available data report HRV modifications during the process of weaning and suggest a promising role of some HRV indices in predicting weaning outcomes in critically ill patients. Point-of-care HRV monitoring systems might help to early detect patients at risk of weaning failure.

Decibel level of coughing as a predictor of extubation outcome in mechanically ventilated intensive care patients: A prospective, observational study

AIM

This study aims to evaluate the feasibility and clinical utility of measuring cough decibel level as predictive markers for extubation outcomes in mechanically ventilated patients.

DESIGN

A prospective observational study.

SETTING

Three interdisciplinary medical-surgical intensive care units across China.

MAIN OUTCOME MEASURES

The primary outcomes assessed were extubation results in patients. Secondary measures included the cough decibel level, semiquantitative cough intensity scores, and white card test results recorded prior to extubation.

RESULTS

A total of 71 patients were included, 55 patients were in the extubation success group and 16 in the failure group. The mean age was 78(71,83) years, mainly male (73.2 %). Despite the baseline characteristics being mostly consistent across both groups, significant differences were noted in duration of mechanical ventilation, and intensive care units and hospital stay. Remarkably, the cough decibel was substantially lower in the extubation failure group compared to the other group (78.69 ± 8.23 vs 92.28 ± 7.01 dB). The Receiver Operating Characteristic curve analysis revealed that a cough decibel below 85.77 dB is the optimal threshold for predicting extubation failure, exhibiting an 80 % sensitivity and 91.67 % specificity.

CONCLUSION

The study corroborates that the cough decibel level serves as a quantifiable metric in patients undergoing mechanical ventilation. It posits that the likelihood of extubation failure escalates when the cough decibel falls below 85.77 dB.

IMPLICATIONS FOR CLINICAL PRACTICE

Quantification of coughing capacity in decibels may be a good predictor of extubation outcome, thus offering assistance to healthcare professionals in evaluating the readiness of patients for extubation.

End-tidal carbon dioxide during spontaneous breathing trial to predict extubation failure: A prospective observational study

Despite advances in weaning protocols, extubation failure (EF) is associated with poor outcomes. Many predictors of EF have been proposed, including hypercapnia at the end of the spontaneous breathing test (SBT). However, performing arterial blood gases at the end of SBT is not routinely recommended, whereas end-tidal carbon dioxide (EtCO2) can be routinely monitored during SBT. We aimed to evaluate the clinical utility of EtCO2 to predict EF. Patients undergoing planned extubation were eligible. Non-inclusion criteria were tracheostomy and patients extubated after successful T-tube SBT. We recorded clinical data and EtCO2 in 189 patients during a successful one-hour low pressure support SBT. EtCO2 measured before successful SBT was lower in patients with EF compared to those with successful extubation (27 [24-29] vs 30 [27-47] mmHg, p = 0.02), while EtCO2 measured at five minutes and at the end of the SBT was not different between the two groups (26 [22-28] vs. 29 [28-49] mmHg, p = 0.06 and 26 [26-29] vs. 29 [27-49] mmHg, p = 0.09, respectively). Variables identified by multivariable analysis as independently associated with EF were acute respiratory failure as the cause of intubation and ineffective cough. Our study suggests that recording EtCO2 during successful SBT appears to have limited predictive value for EF.

Extubation timing and risk of extubation failure in aneurysmal subarachnoid hemorrhage patients

BACKGROUND

The extubation time is critical during the intensive care unit stay in aneurysmal subarachnoid hemorrhage (aSAH) patients. The current conventional parameters for predicting extubation failure (EF) and extubation time may not be suitable for this population. Here, we aimed to identify factors associated with EF in aSAH patients.

METHODS

From a single-center observational study on aSAH patients with computed tomography angiography from 2019 to 2021, patients who received microsurgery were enrolled and divided into two groups according to whether EF occurred. Multivariable logistic regression was conducted to evaluate disease severity, medical history, and extubation time differences between patients with and without EF.

RESULTS

Of 335 patients included, EF occurred with a rate of 0.14. Delayed cerebral ischemia (67.4% vs. 13.5%) and acute hydrocephalus (6.5% vs. 1.4%) were frequently observed in patients with EF. Also, patients who develop EF presented higher disability (65.9% vs. 17.4%) and mortality (10.9% vs. 0.7%) rates. Multivariable analysis demonstrated that age (OR 1.038; 95% CI 1.004-1.073; P = 0.028), onset to admission time (OR 0.731; 95% CI 0.566-0.943; p = 0.016), WFNS grade > 3 (OR 4.309; 95% CI 1.639-11.330; p = 0.003), and extubation time < 24 h (OR 0.097; 95% CI 0.024-0.396; p = 0.001) were significantly associated with EF occurrence.

CONCLUSIONS

These data provide further evidence that older aSAH patients with onset to admission time < 2 days and WFNS grade > 3 have a high risk of developing EF, which is amplified by the ultra-early extubation. Moreover, in patients with two or more risk factors, a prolonged intubation recommendation requires consideration to avoid the EF.

Prospective multi-center evaluation of the incidence of unplanned extubation and its outcomes in French intensive care units. The Safe-ICU study

BACKGROUND

We aimed to determine the epidemiology and outcomes of unplanned extubation (UE), both accidental and self-extubation, in ICU.

METHODS

A multicentre prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, and planned and unplanned extubation were recorded in each center over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes were compared based on the UE mechanism (accidental or self-extubation). Self-extubation outcomes were compared with planned extubation using a propensity-matched population. Finally, risk factors for extubation failure (re-intubation before day 7) were determined following self-extubation.

RESULTS

During the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 605 UE, 88% were self-extubation and 12% were accidental-extubations. The latter had a worse prognosis than self-extubation (34% vs. 8% ICU-mortality, p < 0.001). Self-extubation did not increase mortality compared with planned extubation (8% vs. 11%, p = 0.075). Regardless of the type of extubation, planned or unplanned, extubation failure was independently associated with a poor outcome. Cancer, higher respiratory rate, lower PaO2/FiO2 at the time of extubation, weaning process not-ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation.

CONCLUSION

Unplanned extubation, mostly represented by self-extubation, is common in ICU and accounts for 9% of all endotracheal extubations. While accidental extubations are a serious and infrequent adverse event, self-extubation does not increase mortality compared to planned extubation.

Prolonged weaning from mechanical ventilation: who, what, when and how?

Weaning from invasive mechanical ventilation is an important part of the management of respiratory failure patients. Patients can be classified into those who wean on the first attempt (simple weaning), those who require up to three attempts (difficult weaning) and those who require more than three attempts (prolonged weaning). The process of weaning includes adequately treating the underlying cause of respiratory failure, assessing the readiness to wean, evaluating the response to a reduction in ventilatory support, and eventually liberation from mechanical ventilation and extubation or decannulation. Post-extubation respiratory failure is a contributor to poorer outcomes. Identifying and addressing modifiable risk factors for post-extubation respiratory failure is important; noninvasive ventilation and high-flow nasal cannulae may be useful bridging aids after extubation. Factors to consider in the pathophysiology of prolonged mechanical ventilation include increased respiratory muscle load, reduced respiratory muscle capacity and reduced respiratory drive. Management of these patients involves a multidisciplinary team, to first identify the cause of failed weaning attempts, and subsequently optimise the patient's physiology to improve the likelihood of being successfully weaned from invasive mechanical ventilation.

Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients

INTRODUCTION

Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes.

MATERIALS AND METHODS

This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value.

RESULTS

Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure.

CONCLUSIONS

In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.

Features related to temporary tracheotomy in patients undergoing Transoral Robotic Surgery (TORS) for supraglottic squamous cell cancer of the larynx: A systematic review

OBJECTIVE

The aim of this systematic review is to assess a relation between demographical, clinical and tumoral features and the need for a prophylactic tracheotomy during TORS procedure in patients affected by supraglottic laryngeal cancer.

METHODS

PRISMA 2020 guidelines were applied in this systematic literature review. A computerized search was performed using the Embase/Pubmed, Scopus and Cochrane database, for articles published from 2007 to December 2023. A statistical univariate analysis including selected papers with low or intermediate risk of bias was performed.

RESULTS

Through a study selection process 8 full texts were eligible for statistical univariate analysis. The most relevant factor related to a prophylactic tracheotomy was a contextual bilateral cervical nodes dissection, which increased the need for a tracheotomy of about 3 times. Other factors contribute with a minor impact, such as a patients age >60 years at the time of the diagnosis, a cervical lymph node metastasis and a false vocal fold involvement. Each ones increase by 20-70 % the need for a tracheotomy. However, this rate is decreased by about 60 % by the epiglottis involvement.

CONCLUSIONS

The prophylactic tracheotomy is considered a temporary protection strategy to achieve a valid recovery after TORS procedure. However, there are no guidelines regarding its routinely use. Only 25 % of patients undergone tracheotomy during TORS to treat supraglottic laryngeal cancer. These preliminary results may add more significant evidence regarding the use of tracheotomy during the TORS procedure, in order possibly to help the surgeon decide preoperatively whether to perform it or not.

The premise, promise, and perils of artificial intelligence in critical care cardiology

Artificial intelligence (AI) is an emerging technology with numerous healthcare applications. AI could prove particularly useful in the cardiac intensive care unit (CICU) where its capacity to analyze large datasets in real-time would assist clinicians in making more informed decisions. This systematic review aimed to explore current research on AI as it pertains to the CICU. A PRISMA search strategy was carried out to identify the pertinent literature on topics including vascular access, heart failure care, circulatory support, cardiogenic shock, ultrasound, and mechanical ventilation. Thirty-eight studies were included. Although AI is still in its early stages of development, this review illustrates its potential to yield numerous benefits in the CICU.

Evaluating high-flow oxygen therapy after mechanical thrombectomy under general anesthesia in acute ischemic stroke: A retrospective single-center study

BACKGROUND

The use of mechanical thrombectomy for acute intracranial vascular occlusion under general anesthesia with endotracheal intubation is well-established as a safe and effective method. However, the process of extubation post-surgery presents challenges for certain patients. This retrospective study assesses the safety and efficacy of combining mechanical ventilation with high-flow oxygen inhalation as an interim strategy, while also examining its impact on long-term clinical outcomes.

METHODS

This research enrolled 119 patients with acute intracranial large vessel occlusion who underwent mechanical thrombectomy under general anesthesia with tracheal intubation between January 2020 and November 2023. Participants were categorized into two groups: Group 1 (n=55), which received high-flow oxygen (HFO) post-extubation, and Group 2 (n=64), which was treated with routine oxygen supplementation (RO). The study compared reintubation and tracheotomy rates between these groups to determine safety and effectiveness. Additionally, it analyzed long-term clinical outcomes by comparing NIHSS and mRS scores before treatment and at 90-day follow-up.

RESULTS

The reintubation rate post-extubation was significantly lower in the HFO group (12.7 %, n=7) compared to the RO group (31.2 %, n=20, p=0.016). The incidence of tracheotomy within 7 days was also reduced in the HFO group compared to the RO group (7.3 %, n=4 vs 20.3 %, n=13, p=0.043). Moreover, a greater proportion of patients in the HFO group achieved mRS scores of 0-2 at 90 days post-stroke than those in the RO group (60 %, n=33 vs 40.6 %, n=26, p=0.035). The median NIHSS score at 90 days was more favorable in the HFO group than in the RO group (6, IQR [1-18] vs 8, IQR [1-20], p=0.005).

CONCLUSION

The study suggests that high-flow oxygen therapy after mechanical thrombectomy under general anesthesia with tracheal intubation may lessen the need for reintubation and tracheotomy, potentially leading to improved long-term prognosis.

Impact of Inspiratory Muscle Training and Positive Expiratory Pressure on Lung Function and Extubation Success of ICU Patients: a Randomized Controlled Trial

Introduction

Preparing patients for extubation from mechanical ventilation (MV) necessitates focused respiratory muscle strengthening. This study aimed to evaluate the effect of threshold inspiratory muscle training (IMT) and positive expiratory pressure (PEP) exercises on outcomes of patients who underwent MV in intensive care unit (ICU).

Methods

This randomized controlled trial was conducted in 2023 at the ICUs of Imam Reza Hospital, Mashhad, Iran. Participants were allocated to either intervention or control group (each comprising 35 patients) through block randomization. The intervention group received standard daily chest physiotherapy as well as targeted inspiratory and expiratory muscle strengthening exercises using the threshold IMT/PEP device, administered twice daily over one week. The control group received standard daily chest physiotherapy alone. Finally, the outcomes (lung compliance, duration of intubation, extubation success rate, and diaphragmatic metrics) of the two groups were compared.

Results

70 patients with the mean age of 56.10 ± 14.15 (range: 28.00-85.00) years were randomly divided into two groups (50% male). Significant improvements were observed in the intervention group regarding pulmonary compliance values (35.62 ± 4.43 vs. 30.85 ± 6.93; p= 0.001), peak expiratory flow (PEF) (55.20 ± 10.23 vs. 47.80 ± 11.26; p = 0.002), and maximum inspiratory pressure (MIP) (33.40 ± 4.25 vs. 30.08 ± 6.08; p = 0.01) compared to the control group. Diaphragm inspiratory thickness (0.29 ± 0.03 vs. 0.26 ± 0.04; p = 0.001), diaphragm expiratory thickness (0.22 ± 0.03 vs. 0.20 ± 0.04; p = 0.006) and motion (1.61 ± .29 vs. 1.48 ± .21; p = 0.04) also exhibited significant differences between the two groups. Extubation success rate was higher in the intervention group (68.60% vs. 40%; p = 0.01). The duration of mechanical ventilation was 15.14±7.07 days in the intervention group and 17.34±7.87 days in the control group (p = 0.20). The mean extubation time was 7.00 ± 1.88 days for the intervention group and 9.00 ± 2.00 days for the control (p < 0.001).

Conclusion

Threshold IMT/PEP device exercises effectively enhance respiratory muscle strength, diaphragm thickness, and reduce ventilator dependency. These findings support their potential for inclusion in rehabilitation programs for ICU patients.

Independent Risk Factors of Failed Extubation among Adult Critically Ill Patients: A Prospective Observational Study from Saudi Arabia

Background

Mechanical ventilation provides essential support for critically ill patients in several diagnoses; however, extubation failure can affect patient outcomes. From Saudi Arabia, no study has assessed the factors associated with extubation failure in adults.

Methods

This prospective observational study was conducted in the intensive care unit of a tertiary care hospital in Riyadh, Saudi Arabia. Adult patients who had been mechanically ventilated via the endotracheal tube for a minimum of 24 hours and then extubated according to the weaning protocol were included. Failed extubation was defined as reintubation within 48 hours of extubation.

Results

A total of 505 patients were included, of which 72 patients had failed extubation (14.3%, 95% CI: 11.4%-17.7%). Compared with the failed extubation group, the successfully extubated group had significantly shorter duration of mechanical ventilation (mean difference: -2.6 days, 95% CI: -4.3 to -1; P = 0.001), a slower respiratory rate at the time of extubation (mean difference: -2.3 breath/min, 95% CI: -3.8 to -1; P = 0.0005), higher pH (mean difference: 0.02, 95% CI: 0.001-0.04; P = 0.03), and more patients with strong cough (percent difference: 17.7%, 95% CI: 4.8%-30.5%; P = 0.02). Independent risk factors of failed extubation were age (aOR = 1.02; 95% CI: 1.002-1.03; P = 0.03), respiratory rate (aOR = 1.06, 95% CI: 1.01-1.1; P = 0.008), duration of mechanical ventilation (aOR = 1.08, 95% CI: 1.03 - 1.1; P < 0.001), and pH (aOR = 0.02, 95% CI: 0.0006-0.5; P = 0.02).

Conclusion

Older age, longer duration of mechanical ventilation, faster respiratory rate, and lower pH were found to be independent risk factors that significantly increased the odds of extubation failure among adults.

Use of high-flow nasal cannula versus other noninvasive ventilation techniques or conventional oxygen therapy for respiratory support following pediatric cardiac surgery: A systematic review and meta-analysis

INTRODUCTION

Noninvasive respiratory support may be provided to decrease the risk of postextubation failure following surgery. Despite these efforts, approximately 3%-27% of infants and children still experience respiratory failure after tracheal extubation following cardiac surgery. This systematic review evaluates studies comparing the efficacy of high-flow nasal cannula to conventional oxygen therapy such as nasal cannula and other noninvasive ventilation techniques in preventing postextubation failure in this patient population.

METHODS

A systematic and comprehensive search was conducted in major databases including MEDLINE, EMBASE, Web of Science, and Central. The search encompassed articles focusing on the prophylactic use of high-flow nasal cannula following tracheal extubation in pediatric patients undergoing cardiac surgery for congenital heart disease. The inclusion criteria for this review consisted of randomized clinical trials as well as observational, cohort, and case-control studies.

RESULTS

A total of 1295 studies were screened and 12 studies met the inclusion criteria. These 12 studies included a total of 1565 children, classified into three groups: seven studies compared high-flow nasal cannula to noninvasive ventilation techniques, four studies compared high-flow nasal cannula to conventional oxygen therapy, and one observational single-arm study explored the use of high-flow nasal cannula with no control group. There was no significant difference in the incidence of tracheal reintubation between high-flow nasal cannula and conventional oxygen therapy (risk ratio [RR] = 0.67, 95% confidence interval [CI]: 0.24-1.90, p = .46). However, there was a lower incidence of tracheal reintubation in patients who were extubated to high-flow nasal cannula versus those extubated to noninvasive ventilation techniques (RR = 0.45, 95% CI: 0.32-0.63, p < .01). The high-flow nasal cannula group also demonstrated a lower mortality rate compared to the noninvasive ventilation techniques group (RR = 0.31, 95% CI: 0.16-0.61, p < .01) as well as a shorter postoperative length of stay (mean difference = -8.76 days, 95% CI: -13.08 to -4.45, p < .01) and shorter intensive care length of stay (mean difference = -4.63 days, 95% CI: -9.16 to -0.11, p = .04).

CONCLUSION

High-flow nasal cannula is more effective in reducing the rate of postextubation failure compared to other forms of noninvasive ventilation techniques following surgery for congenital heart disease in pediatric-aged patients. high-flow nasal cannula is also associated with lower mortality rates and shorter length of stay. However, when comparing high-flow nasal cannula to conventional oxygen therapy, the findings were inconclusive primarily due to a limited number of scientific studies available on this specific comparison. Future study is needed to further define the benefit of high-flow nasal cannula compared to conventional oxygen therapy and various types of noninvasive ventilation techniques.

Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study

Objectives

This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes.

Methods

We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients' clinical status and extubation readiness criteria.

Results

In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38-36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2-48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001).

Conclusion

A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.

The diaphragmatic electrical activity during spontaneous breathing trial in patients with mechanical ventilation: physiological description and potential clinical utility

BACKGROUNDS

Increased respiratory drive has been demonstrated to correlate with weaning failure, which could be quantified by electrical activity of the diaphragm (EAdi). We described the physiological process of EAdi-based parameters during the spontaneous breathing trial (SBT) and evaluated the change of EAdi-based parameters as potential predictors of weaning failure.

METHODS

We conducted a prospective study in 35 mechanically ventilated patients who underwent a 2-hour SBT. EAdi and ventilatory parameters were continuously measured during the SBT. Diaphragm ultrasound was performed before the SBT and at the 30 min of the SBT. Three EAdi-based parameters were calculated: neuro-ventilatory efficiency, neuro-excursion efficiency and neuro-discharge per min.

RESULTS

Of the thirty 35 patients studied, 25 patients were defined as SBT success, including 22 patients weaning successfully and 3 patients reintubated. Before the SBT, neuro-excursion efficiency differed significantly between two groups and had the highest predictive value for SBT failure (AUROC 0.875, p < 0.01). Early increases in EAdi were observed in SBT, which are more prominent in SBT failure group. One minute, changes in EAdi and neuro-discharge per min also predicted weaning outcome (AUROCs 0.944 and 0.918, respectively).

CONCLUSIONS

EAdi-based parameters, especially neuro-excursion efficiency and changes in neuro-discharge per min, may detect impending weaning failure earlier than conventional indices. EAdi monitoring provides physiological insights and a more tailored approach to facilitate successful weaning. Further research should validate these findings and explore the utility of combined EAdi and diaphragm ultrasound assessment in weaning ICU patients from mechanical ventilation.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov on 20 September 2022 (Identifier: NCT05632822).

The Value of Ischemic Cardiac Biomarkers to Predict Spontaneous Breathing Trial or Extubation Failure: A Systematic Review

Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20-215] versus 30 ng/L [IQR, 10-86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT.

Using Artificial Intelligence to Predict Mechanical Ventilation Weaning Success in Patients with Respiratory Failure, Including Those with Acute Respiratory Distress Syndrome

The management of mechanical ventilation (MV) remains a challenge in intensive care units (ICUs). The digitalization of healthcare and the implementation of artificial intelligence (AI) and machine learning (ML) has significantly influenced medical decision-making capabilities, potentially enhancing patient outcomes. Acute respiratory distress syndrome, an overwhelming inflammatory lung disease, is common in ICUs. Most patients require MV. Prolonged MV is associated with an increased length of stay, morbidity, and mortality. Shortening the MV duration has both clinical and economic benefits and emphasizes the need for better MV weaning management. AI and ML models can assist the physician in weaning patients from MV by providing predictive tools based on big data. Many ML models have been developed in recent years, dealing with this unmet need. Such models provide an important prediction regarding the success of the individual patient's MV weaning. Some AI models have shown a notable impact on clinical outcomes. However, there are challenges in integrating AI models into clinical practice due to the unfamiliar nature of AI for many physicians and the complexity of some AI models. Our review explores the evolution of weaning methods up to and including AI and ML as weaning aids.

Development of a clinical prediction tool for extubation failure in pediatric cardiac intensive care unit

Introduction/objective

Extubation failure in pediatric patients with congenital or acquired heart diseases increases morbidity and mortality. This study aimed to develop a clinical risk score for predicting extubation failure to guide proper clinical decision-making and management.

Methods

We conducted a retrospective study. This clinical prediction score was developed using data from the Pediatric Cardiac Intensive Care Unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Thailand, from July 2016 to May 2022. Extubation failure was defined as the requirement for re-intubation within 48 h after extubation. Multivariable logistic regression was used for modeling. The score was evaluated in terms of discrimination and calibration.

Results

A total of 352 extubation events from 270 patients were documented. Among these, 40 events (11.36%) were extubation failure. Factors associated with extubation failure included history of pneumonia (OR: 4.14, 95% CI: 1.83-9.37, p = 0.001), history of re-intubation (OR: 5.99, 95% CI: 2.12-16.98, p = 0.001), and high saturation in physiologic cyanosis (OR: 5.94, 95% CI: 1.87-18.84, p = 0.003). These three factors were utilized to develop the risk score. The score showed acceptable discrimination with an area under the curve (AUC) of 0.77 (95% CI: 0.69-0.86), and good calibration.

Conclusion

The derived Pediatric CMU Extubation Failure Prediction Score (Ped-CMU ExFPS) could satisfactorily predict extubation failure in pediatric cardiac patients. Employing this score could promote proper personalized care. We suggest conducting further external validation studies before considering implementation in practice.

Predicting Successful Weaning from Mechanical Ventilation by Reduction in Positive End-expiratory Pressure Level Using Machine Learning

Weaning patients from mechanical ventilation (MV) is a critical and resource intensive process in the Intensive Care Unit (ICU) that impacts patient outcomes and healthcare expenses. Weaning methods vary widely among providers. Prolonged MV is associated with adverse events and higher healthcare expenses. Predicting weaning readiness is a non-trivial process in which the positive end-expiratory pressure (PEEP), a crucial component of MV, has potential to be indicative but has not yet been used as the target. We aimed to predict successful weaning from mechanical ventilation by targeting changes in the PEEP-level using a supervised machine learning model. This retrospective study included 12,153 mechanically ventilated patients from Medical Information Mart for Intensive Care (MIMIC-IV) and eICU collaborative research database (eICU-CRD). Two machine learning models (Extreme Gradient Boosting and Logistic Regression) were developed using a continuous PEEP reduction as target. The data is splitted into 80% as training set and 20% as test set. The model's predictive performance was reported using 95% confidence interval (CI), based on evaluation metrics such as area under the receiver operating characteristic (AUROC), area under the precision-recall curve (AUPRC), F1-Score, Recall, positive predictive value (PPV), and negative predictive value (NPV). The model's descriptive performance was reported as the variable ranking using SHAP (SHapley Additive exPlanations) algorithm. The best model achieved an AUROC of 0.84 (95% CI 0.83-0.85) and an AUPRC of 0.69 (95% CI 0.67-0.70) in predicting successful weaning based on the PEEP reduction. The model demonstrated a Recall of 0.85 (95% CI 0.84-0.86), F1-score of 0.86 (95% CI 0.85-0.87), PPV of 0.87 (95% CI 0.86-0.88), and NPV of 0.64 (95% CI 0.63-0.66). Most of the variables that SHAP algorithm ranked to be important correspond with clinical intuition, such as duration of MV, oxygen saturation (SaO2), PEEP, and Glasgow Coma Score (GCS) components. This study demonstrates the potential application of machine learning in predicting successful weaning from MV based on continuous PEEP reduction. The model's high PPV and moderate NPV suggest that it could be a useful tool to assist clinicians in making decisions regarding ventilator management.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Effectiveness of high flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) in preventing tracheal reintubation in patients with high risk of extubation failure in intensive care unit - A randomised comparative trial

Background and Aims

The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure.

Methods

This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done.

Results

Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients.

Conclusion

BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure.

Rapid shallow breathing index predicting extubation outcomes: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to assess the predictive value of the rapid shallow breathing index for extubation outcomes.

METHODOLOGY

We conducted a systematic review of literature (inception to March 2023) and a meta-analysis. Statistical analysis was performed using Meta-Disc 1.4 software, RevMan 5.4 software and Stata 14.0 software to evaluate the predictive value of RSBI for extubation outcomes.

RESULTS

A total of 1,987 studies were retrieved, and after applying the inclusion criteria, 79 studies were included in the final analysis, involving 13,170 patients undergoing mechanical ventilation. The random-effects model was employed for statistical analysis. The summary receiver operating characteristic curves (SROC) area under the curve (AUC) was 0.8144. The pooled sensitivity was 0.60 (95% CI: 0.59, 0.61), the pooled specificity was 0.68 (95% CI: 0.66, 0.70).

CONCLUSIONS

The Rapid Shallow Breathing Index demonstrated moderate accuracy, poor pooled sensitivity and specificity in predicting successful extubation, however the study does not present adequate data to support or reject the use of this tool as a single parameter that predicts extubation outcome. Future studies should explore the combination of The Rapid Shallow Breathing Index with other indicators and clinical experience to improve the success rate of extubation and reduce the risk of extubation failure.

IMPLICATIONS FOR CLINICAL PRACTICE

Premature and delayed extubation in mechanically ventilated patients can have a negative impact on prognosis and prolong hospital stay. The Rapid Shallow Breathing Index is a simple, cost-effective, and easily monitored objective evaluation index, which can be used to predict the outcome of extubation, especially in primary hospitals. Our study comprehensively evaluated the value of this tool in predicting extubation outcomes, which can help clinicians combine subjective experience with objective indicators to improve the accuracy of extubation time decisions.

Sex difference in the risk of extubation failure in ICUs

BACKGROUND

Little attention has been paid to potential differences in prognosis between mechanically ventilated males and females in intensive care units (ICUs). We hypothesized that a sex gap in the risk of extubation failure in ICUs may exist.

METHODS

Post hoc analysis of a large-scale clinical trial including patients at high risk of extubation failure in ICUs, with the aim of assessing the risk of extubation failure according to sex. The primary outcome was reintubation within the 7 days following extubation.

RESULTS

Out of 641 patients, 425 (66%) were males and 216 (34%) were females. Males were more likely to be admitted for cardiac arrest and to have underlying ischemic heart disease whereas females were more likely to be admitted for coma and to have obesity. Whereas the rate of reintubation at 48 h was significantly higher in males than in females (11.0% vs. 6.0%; difference, + 5.0 [95% CI, 0.2 to 9.2]; P = 0.038), the rate of reintubation at day 7 did not significantly differ between males and females (16.7% vs. 11.1%; difference, + 5.6% [95%CI, - 0.3 to 10.8], P = 0.059). Using multivariable logistic regression analysis, male sex was independently associated with reintubation within the 7 days following extubation (adjusted OR 1.70 [95% CI, 1.01 to 2.89]; P = 0.048), even after adjustment on reason for admission, body-mass index, severity score, respiratory rate before extubation, and noninvasive ventilation after extubation.

CONCLUSION

In this post hoc analysis of a clinical trial including a homogeneous subset of patients at high risk of extubation failure, sex was independently associated with reintubation. The role of sex on outcomes should be systematically examined in future studies of critically ill patients.

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury

Objective

Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy.

Methods

The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups.

Results

All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101.

Conclusion

GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

Effectiveness of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series

Introduction

Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited. Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.

Material and Methods

We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.

Results

Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8-14.3 days) and 23 days (interquartile range: 15.5-41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11-18.5 days) and 30 days (interquartile range: 16-45.5 days), respectively, in the reintubation group.

Conclusions

The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.

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 .

Modifiable risk factors for ventilator associated diaphragmatic dysfunction: a multicenter observational study

BACKGROUND

Diaphragmatic dysfunction is known to be associated with difficulties weaning from invasive mechanical ventilation and is related to worse patient outcomes yet our understanding of how to prevent diaphragmatic dysfunction remains incomplete. We examined potentially modifiable risk factors for diaphragmatic dysfunction and attempted to estimate benefits attributable to altering these modifiable risk factors.

METHODS

This prospective multicenter observational study was undertaken in the general ICUs of two tertiary care teaching hospitals. Critically ill adults expected to receive invasive mechanical ventilation for at least 48 h were enrolled. Diaphragm function was assessed by ultrasound each study day, with dysfunction defined as thickening fraction less than 20%.

RESULTS

From January to December 2019, 856 patients were screened and 126 patients were enrolled. Overall, 40.5% (51/126) of patients experienced diaphragmatic dysfunction during invasive mechanical ventilation. Patients with diaphragmatic dysfunction were more likely to develop ventilator associated pneumonia (risk difference [RD] + 12.9%, 95% Confidence Interval [CI] 1.4 to 24.4%, P = 0.028), were more likely to experience extubation failure (RD + 8.5%, 95% CI 0.4 to 16.6%, P = 0.039) and required a longer duration of invasive mechanical ventilation (RD + 1.3 days, 95% CI 0.1 to 2.5 days, P = 0.035). They also required a longer hospital stay (RD + 1.2 days, 95% CI 0.04 to 2.4 days, P = 0.041) and were more likely to die before hospital discharge (RD + 18.1%, 95% CI 3.7 to 32.5%, P = 0.014). Multivariable analysis considered the impact of age, sex, pre-existing nutritional status, caloric intake, amino acid intake, acute disease severity, modes of mechanical ventilation, measures of respiratory status, sedation, pain control and baseline diaphragm thickness. Only SOFA score (P = 0.008) and early amino acid intake (P = 0.001) remained significant independent risk factors for the onset of diaphragmatic dysfunction. Causal path modeling suggested early amino acid intake may significantly reduce diaphragmatic dysfunction (RRR 29%, 95% CI 10% to 48%, P = 0.003) and may also reduce mortality (RRR 49%, 95% CI 25% to 73%, P < 0.0001).

CONCLUSIONS

Amino acid intake during the first 24 h of ICU stay may represent an important, modifiable risk factor for diaphragmatic dysfunction and may have a direct causal effect on mortality. We recommend additional research on this topic.

Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses

BACKGROUND

No assessment tool for predicting ventilator withdrawal success is currently available in Japan. Thus, an accessible and valid assessment tool to address this issue is needed. The Burns Wean Assessment Program (BWAP) has been validated as a reliable predictor of ventilator withdrawal outcomes. However, nurses must be familiar with this tool to ensure its efficient utilization in clinical settings.

PURPOSE

This study was designed to examine the effect of a 26-item Japanese version of BWAP (J-BWAP) e-learning materials on ventilator withdrawal in a sample of intensive care unit nurses in Japan.

METHODS

The BWAP was translated into Japanese, checked, and verified as the J-BWAP. Nonrandomized intensive care unit nurses from six hospitals were assigned to three groups, including Intervention Group 1 (e-learning in one session), Intervention Group 2 (e-learning over three sessions during 1 week), and the control group. The participants underwent pretests and posttests using web-based, simulated patients. The primary outcome measure was the difference in online pretest and posttest total scores among the two intervention groups and the control group. The feasibility of the J-BWAP and its e-learning materials was evaluated using four frameworks: acceptability, demand, implementation, and adaptation.

RESULTS

Of the 48 participants in the study, 32 completed the posttest and were included in the analysis (dropout rate: 33.3%). The difference between pretest and posttest scores was significantly higher in the intervention groups than the control group (2 vs. -1, p = .0191) and in Intervention Group 2 than the control group (2.0 vs. -0.5, p = .049). The feasibility frameworks for the J-BWAP and its e-learning materials were mostly positive.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The development of the J-BWAP and training nurses using e-learning were shown to be feasible in this study. The J-BWAP contents are appropriate for predicting the outcome of mechanical ventilation withdrawal. The J-BWAP has the potential to become a common tool among Japanese medical professionals after the contents are further simplified for daily application in clinical practice. Subsequent studies should verify the reliability and validity of this tool and test the real-world utility of the J-BWAP using randomized controlled trials in Japanese clinical settings.

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.