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Liu J, Li F, Qi X, Zhuang X, Cui Z. Positive- vs. negative-pressure extubation technique: a scoping review. Front Med (Lausanne) 2023; 10:1169879. [PMID: 37250624 PMCID: PMC10213366 DOI: 10.3389/fmed.2023.1169879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives This review aimed to summarize the recent literature on positive-pressure extubation. Design A scoping review was conducted under the framework of the Joanna Briggs Institute. Data sources Web of Science, PubMed, Ovid, Cumulative Index to Nursing & Allied Health, EBSCO, Cochrane Library, Wan Fang Data, China National Knowledge Infrastructure, and China Biology Medicine databases were searched for studies on adults and children. Study selection All articles describing the use of positive-pressure extubation were considered eligible for inclusion. The exclusion criteria were articles not available in English or Chinese, and those without full text available. Data extraction and synthesis The database searches identified 8,381 articles, 15 of which could be included in this review, with an aggregated patient number of 1,544. Vital signs, including mean arterial pressure, heart rate, R-R interval, and SpO2 before and after extubation; blood gas analysis indexes, including pH, oxygen saturation, PaO2, and PaCO2 before and after extubation; and incidence of respiratory complications, including bronchospasm, laryngeal edema, aspiration atelectasis, hypoxemia, and hypercapnia, were reported in the included studies. Results The majority of these studies reported that the positive-pressure extubation technique can maintain stable vital signs and blood gas analysis indices as well as prevent complications during the peri-extubation period. Conclusions The positive-pressure extubation technique has a safety performance similar to that of the traditional negative-pressure extubation technique and may lead to better clinical outcomes, including stable vital signs, arterial blood gas analysis, and a lower incidence of respiratory complications.
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Farhadi R, Nakhshab M, Hojjati A, Khademloo M. Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial. Ann Med Surg (Lond) 2022; 76:103573. [PMID: 35495371 PMCID: PMC9052286 DOI: 10.1016/j.amsu.2022.103573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background Post-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA. Materials and methods We enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups. Results The prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation. Conclusion The use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates. Post extubation atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates. This study compares two different extubation methods for the prevention of PEA in neonates. The prevalence of PEA in the extubation with positive pressure method was significantly lower than the negative pressure. Extubation by a positive pressure method is recommended in neonates.
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Affiliation(s)
- Roya Farhadi
- Pediatrics Department, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
- Corresponding author. Division of Neonatology, Department of Pediatrics, Boo Ali Sina Hospital, Pasdaran Boulevard, Sari, Iran.
| | - Maryam Nakhshab
- Pediatrics Department, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Atefeh Hojjati
- Pediatrics Department, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Khademloo
- Department of Community Medicine, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Wang TP, Li HH, Lin HL. Positive Airway Pressure at Extubation Minimizes Subglottic Secretion Leak In Vitro. J Clin Med 2022; 11:jcm11020307. [PMID: 35054001 PMCID: PMC8778407 DOI: 10.3390/jcm11020307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 11/21/2022] Open
Abstract
Accumulated secretion above the endotracheal tube cuff can be aspirated during extubation after deflation. The possible techniques for minimizing pulmonary aspiration from subglottic secretion during extubation have not been well explored. This study aimed to determine the effect of different extubation techniques on secretion leakage. An endotracheal tube was placed in a tube mimicking an airway. We measured the leak volume of water or artificial sputum of different viscosities with three extubation techniques—negative pressure with suctioning; positive pressure with a resuscitator; and continuous positive airway pressure set at 5, 10, and 20 cm H2O. Extubation with continuous positive airway pressure resulted in lower secretion leakage than that with negative pressure with suctioning and positive pressure with a resuscitator. Increasing the continuous positive airway pressure level decreased secretion leakage volume during extubation. We further determined a correlation of leak volume with sputum viscosity. Continuous positive airway pressure at 5 cm H2O produced lower volume secretion leakage than the other two techniques, even with higher secretion viscosity. Based on these results, using continuous positive airway pressure with a previous ventilator continuous positive airway pressure/positive end-expiratory pressure setting for extubation is recommended.
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Affiliation(s)
- Tzu-Pei Wang
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 61363, Taiwan
- Correspondence: ; Tel.: +886-3-2118800 (ext. 5228)
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Gacouin A, Lesouhaitier M, Reizine F, Painvin B, Maamar A, Camus C, Le Tulzo Y, Tadié JM. 1-hour t-piece spontaneous breathing trial vs 1-hour zero pressure support spontaneous breathing trial and reintubation at day 7: A non-inferiority approach. J Crit Care 2021; 67:95-99. [PMID: 34741964 DOI: 10.1016/j.jcrc.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/28/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Physiological data suggest that T-piece and zero pressure support (PS0) ventilation both accurately reflect spontaneous breathing conditions after extubation. These two types of spontaneous breathing trials (SBTs) are used in our Intensive Care Unit to evaluate patients for extubation readiness and success but have rarely been compared in clinical studies. MATERIALS AND METHODS We performed a prospective observational study to confirm the hypothesis that 1-hour T-piece SBT and 1-h PS0 zero PEEP (ZEEP) SBT are associated with similar rates of reintubation at day 7 after extubation. A non-inferiority approach was used for sample size calculation. RESULTS The cohort consisted of 529 subjects invasively ventilated for more than 24 h and extubated after successful 1-hour T-piece SBT (n = 303, 57%) or 1-h PS0 ZEEP SBT (n = 226, 43%). The reintubation rate at day 7 was 14.6% with PS0 ZEEP and 17.5% with T-piece (difference - 2.6% [95% confidence interval, -8.3% to 4.3%]; p = 0.40). The reasons for reintubation did not differ significantly when compared between patients with 1-h PS0 ZEEP SBT and patients with 1-hour T-piece SBT. CONCLUSION Our results suggest that successful 1-hour T-piece and 1-h PSO ZEEP SBTs are associated with similar reintubation rates at day 7.
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Affiliation(s)
- Arnaud Gacouin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France; Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033 Rennes, France.
| | - Mathieu Lesouhaitier
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Florian Reizine
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Benoit Painvin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Adel Maamar
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Christophe Camus
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Yves Le Tulzo
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France; Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033 Rennes, France
| | - Jean Marc Tadié
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France; Université Rennes1, Faculté de Médecine, Biosit, F-35043 Rennes, France; Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033 Rennes, France
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Iracily DP, Rusmawatiningtyas D, Makrufardi F, Kumara IF, Nurnaningsih, Moeljono E. Post-herniorrhaphy extubation technique in pediatric patient with congenital diaphragmatic hernia and VACTERL association: A case report. Ann Med Surg (Lond) 2021; 69:102801. [PMID: 34540207 PMCID: PMC8437770 DOI: 10.1016/j.amsu.2021.102801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction and importance: Congenital diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm causing protrusion of abdominal organs into the thoracic cavity. Comprehensive management, definitive surgical procedures and postoperative care are able to significantly reduce morbidity and mortality in post-herniorrhaphy patients. Here, we reported a case of post herniorrhaphy pediatric patient with a challenge in extubation. Case presentation A 4-month-old girl with a chief complaint of respiratory distress from was admitted to our Pediatric Intensive Care Unit. The diagnosis of diaphragmatic hernia was confirmed through small bowel follow-through radiological examination. Definitive treatment of laparotomy and herniorrhaphy were then done. The special technique for extubation was applied. Currently, the patient survives without any sequelae awaiting stoma closure. Clinical discussion Extubation is the removal of an endotracheal tube when it is no longer needed. In mechanically ventilated patients, extubation can be performed in two ways, either using the tracheal suction catheter (TSC) or positive pressure breath (PPB) techniques. Studies show that the PBB extubation technique has better patient outcomes compared to the TSC technique. However, the TSC technique is more commonly done by medical professionals. We used the PPB technique because there were recurrent atelectases in the left lung. Conclusion This case report illustrates extubation technique in a post-herniorrhaphy patient with congenital diaphragmatic hernia and VACTERL association. Moreover, several options of extubation techniques can be used for extubation procedure in pediatric patient with CDH. Most children with congenital diaphragmatic hernia comes with respiratory problems. Comprehensive management, definitive surgical procedures and postoperative care. Good outcome of comprehensive management and appropriate extubation technique.
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Affiliation(s)
- Diajeng Putri Iracily
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Desy Rusmawatiningtyas
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Firdian Makrufardi
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Intan Fatah Kumara
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Nurnaningsih
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Edy Moeljono
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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Battaglini D, Robba C, Caiffa S, Ball L, Brunetti I, Loconte M, Giacobbe DR, Vena A, Patroniti N, Bassetti M, Torres A, Rocco PR, Pelosi P. Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19. Respir Physiol Neurobiol 2020; 282:103529. [PMID: 32818606 PMCID: PMC7430249 DOI: 10.1016/j.resp.2020.103529] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 02/08/2023]
Abstract
In late 2019, an outbreak of a novel human coronavirus causing respiratory disease was identified in Wuhan, China. The virus spread rapidly worldwide, reaching pandemic status. Chest computed tomography scans of patients with coronavirus disease-2019 (COVID-19) have revealed different stages of respiratory involvement, with extremely variable lung presentations, which require individualized ventilatory strategies in those who become critically ill. Chest physiotherapy has proven to be effective for improving long-term respiratory physical function among ICU survivors. The ARIR recently reported the role of chest physiotherapy in the acute phase of COVID-19, pointing out limitation of some procedures due to the limited experience with this disease in the ICU setting. Evidence on the efficacy of chest physiotherapy in COVID-19 is still lacking. In this line, the current review discusses the important role of chest physiotherapy in critically ill mechanically ventilated patients with COVID-19, around the weaning process, and how it can be safely applied with careful organization, including the training of healthcare staff and the appropriate use of personal protective equipment to minimize the risk of viral exposure.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Medicine, University of Barcelona (UB), Barcelona, Spain.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Salvatore Caiffa
- Intensive Care Respiratory Physiotherapy, Rehabilitation and Functional Education, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Maurizio Loconte
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Nicolò Patroniti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Antoni Torres
- Department of Medicine, University of Barcelona (UB), Barcelona, Spain; Division of Animal Experimentation, Department of Pulmonology, Hospital Clinic, Barcelona, Spain; Centro de investigacion en red de enfermedades respiratorias (CIBERES), Madrid, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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Andreu MF, Bezzi MG, Dotta ME. Incidence of immediate postextubation complications in critically Ill adult patients. Heart Lung 2020; 49:774-778. [PMID: 32979642 DOI: 10.1016/j.hrtlng.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postextubation complication rates vary among studies. It is necessary to standardize a method to identify postextubation complications and determine their potential association with extubation failure and reintubation in critically ill adult patients. OBJECTIVES To describe immediate (up to 60 min) endotracheal postextubation complications in critically ill adult patients and determine whether these complications are associated with extubation failure. METHODS Secondary analysis of a Randomized Clinical Trial that included 240 critically ill adult patients, who were eligible for extubation. Overall complications include at least one major complication (upper airway obstruction, desaturation, vomiting, post-obstructive pulmonary edema) and/or minor complications (bronchospasm, severe cough, hypertension, tachycardia, tachypnea, poor respiratory mechanics). RESULTS Incidence of overall, major and minor complications was 71.2%, 30.9% and 62.7%, respectively. Forty (16.9%) patients failed extubation, and thirty (12.7%) were reintubated. Of 168 patients who developed a postextubation complication, 137 (81.5%) were successfully extubated. Only major complications were significantly associated with reintubation after extubation failure (p<0.001). CONCLUSION We have observed high incidence rates of overall, major and minor complications. The development of major complications was statistically significantly associated with extubation failure and reintubation. It is still unknown whether the identification and treatment of immediate postextubation complications have positive effects on patients' clinical course or whether the complications are a mere effect of the extubation procedure.
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Affiliation(s)
- Mauro Federico Andreu
- Hospital Donación Francisco Santojanni, Autonomous City of Buenos Aires, Argentina; Universidad Nacional de la Matanza, San Justo, Province of Buenos Aires, Argentina.
| | | | - María Eugenia Dotta
- Hospital Donación Francisco Santojanni, Autonomous City of Buenos Aires, Argentina
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