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

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.

[Role of respiratory therapists in weaning patients from invasive mechanical ventilation: a description of their responsibilities from a certified weaning centre]

Respiratory therapists have been trained by the German Respiratory Society (DGP) since 2005. Respiratory therapeutic interventions related to weaning patients from invasive mechanical ventilation are a major focus. Respiratory therapists have been an integral part of the therapeutic team at the Thorax Clinic Heidelberg for more than 10 years. This article describes their tasks and responsibilities in the context of weaning from invasive mechanical ventilation. The acute treatment phase of invasively ventilated patients in the acute intensive care unit and the prolonged weaning phase in the pneumological intensive care unit are presented in chronological order. The therapeutic focus of each phase is presented and described.

Establishment of a prediction model for extubation failure risk in ICU patients using bedside ultrasound technology

BACKGROUND

Mechanical ventilation (MV) is crucial for managing critically ill patients; however, extubation failure, associated with adverse outcomes, continues to pose a significant challenge.

OBJECTIVE

The purpose of this prospective observational study was to develop and validate a predictive numerical model utilizing bedside ultrasound to forecast extubation outcomes in ICU patients.

METHODS

We enrolled 300 patients undergoing MV, from whom clinical variables, biomarkers, and ultrasound parameters were collected. Patients were randomly assigned to two groups at a 6:4 ratio: the derivation cohort (n = 180) and the validation cohort (n = 120). A nomogram prediction model was developed using significant predictors identified through multivariate analysis and its performance was assessed and validated by evaluating its discrimination, calibration, and clinical utility.

RESULTS

A total of 300 patients (mean age 72 years; 57.3 % male) were included, with an extubation failure rate of 26.7 %. The model, including diaphragm thickening fraction (OR: 0.890, P = 0.009), modified lung ultrasound score (OR: 1.371, P < 0.001), peak relaxation velocity (OR: 1.515, P = 0.015), and APACHE II (OR: 1.181, P = 0.006), demonstrated substantial discriminative capability, as indicated by an area under the receiver operating characteristic curve (AUC) of 0.886 (95 % CI: 0.830-0.942) for the derivation cohort and 0.846 (95 % CI: 0.827-0.945) for the validation cohort. Hosmer-Lemeshow tests yielded P-values of 0.224 and 0.212 for the derivation and validation cohorts.

CONCLUSIONS

We have established a risk prediction model for extubation failure in mechanically ventilated ICU patients. This risk model base on bedside ultrasound parameters provides valuable insights for identifying high-risk patients and preventing extubation failure.

Predictors of weaning failure in ventilated intensive care patients: a systematic evidence map

BACKGROUND

Ventilator weaning is of great importance for intensive care patients in order to avoid complications caused by prolonged ventilation. However, not all patients succeed in weaning immediately. Their spontaneous breathing may be insufficient, resulting in extubation failure and the subsequent need for reintubation. To identify patients at high risk for weaning failure, a variety of potential predictors has already been examined in individual studies and meta-analyses over the last decades. However, an overview of all the predictors investigated is missing.

AIM

To provide an overview of empirically investigated predictors for weaning failure.

METHODS

A systematic evidence map was developed. To this end, we conducted a systematic search in the Medline, Cochrane, and CINAHL databases in December 2023 and added a citation search and a manual search in June 2024. Studies on predictors for weaning failure in adults ventilated in the intensive care unit were included. Studies on children, outpatients, non-invasive ventilation, or explanatory factors of weaning failure were excluded. Two reviewers performed the screening and data extraction independently. Data synthesis followed an inductive approach in which the predictors were thematically analyzed, sorted, and clustered.

RESULTS

Of the 1388 records obtained, 140 studies were included in the analysis. The 112 prospective and 28 retrospective studies investigated a total of 145 predictors. These were assigned to the four central clusters 'Imaging procedures' (n = 22), 'Physiological parameters' (n = 61), 'Scores and indices' (n = 53), and 'Machine learning models' (n = 9). The most frequently investigated predictors are the rapid shallow breathing index, the diaphragm thickening fraction, the respiratory rate, the P/F ratio, and the diaphragm excursion.

CONCLUSION

Predictors for weaning failure are widely researched. To date, 145 predictors have been investigated with varying intensity in 140 studies that are in line with the current weaning definition. It is no longer just individual predictors that are investigated, but more comprehensive assessments, indices and machine learning models in the last decade. Future research should be conducted in line with international weaning definitions and further investigate poorly researched predictors. Registration, Protocol: https://doi.org/10.17605/OSF.IO/2KDYU.

Association Between Spontaneous Breathing Trial Methods and Reintubation in Adult Critically Ill Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation.

RESEARCH QUESTION

Are different methods of conducting SBTs in critically ill patients associated with different risk of reintubation compared with T-tube?

STUDY DESIGN AND METHODS

We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to January 26, 2024. The surface under the cumulative ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach.

RESULTS

A total of 22 randomized controlled trials were included, for a total of 6,196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and pressure support ventilation without positive end-expiratory pressure, with 2,135 and 2,101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared with T-tube was high-flow oxygen (HFO) (risk ratio, 0.23; 95% credibility interval, 0.09-0.51; moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%; SUCRA, 96.42), followed by CPAP (11.8%; SUCRA, 76.75).

INTERPRETATION

In this study, HFO SBT was associated with a lower risk of reintubation compared with other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBTs and potential clinical heterogeneity related to cointerventions. Further trials should be performed to confirm the results on larger cohorts of patients and to assess specific subgroups.

TRIAL REGISTRATION

PROSPERO; No.: CRD42023449264; URL: https://www.crd.york.ac.uk/prospero/.

Noninvasive ventilation on reintubation in patients with obesity and hypoxemic respiratory failure following abdominal surgery: a post hoc analysis of a randomized clinical trial

PURPOSE

Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity.

METHODS

We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival.

RESULTS

Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2).

CONCLUSIONS

Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.