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Miranda BS, Neves VC, Albuquerque YDP, de Souza EF, Koliski A, Cat MNL, Carreiro JE. Fitness checklist model for spontaneous breathing tests in pediatrics. Crit Care Sci 2023; 35:66-72. [PMID: 37712731 PMCID: PMC10275306 DOI: 10.5935/2965-2774.20230312-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/26/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. METHODS This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. RESULTS The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. CONCLUSION The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.
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Affiliation(s)
- Bruno Silva Miranda
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Valéria Cabral Neves
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Yessa do Prado Albuquerque
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Emilly Freitas de Souza
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Adriana Koliski
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - Mônica Nunes Lima Cat
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | - José Eduardo Carreiro
- Complexo do Hospital de Clínicas, Faculdade de Medicina,
Universidade Federal do Paraná - Curitiba (PR), Brazil
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Charernjiratragul K, Saelim K, Ruangnapa K, Sirianansopa K, Prasertsan P, Anuntaseree W. Predictive parameters and model for extubation outcome in pediatric patients. Front Pediatr 2023; 11:1151068. [PMID: 37077338 PMCID: PMC10106763 DOI: 10.3389/fped.2023.1151068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
Background Prolonged mechanical ventilation is associated with significant morbidity in critically ill pediatric patients. In addition, extubation failure and deteriorating respiratory status after extubation contribute to increased morbidity. Well-prepared weaning procedures and accurate identification of at-risk patients using multimodal ventilator parameters are warranted to improve patient outcomes. This study aimed to identify and assess the diagnostic accuracy of single parameters and to develop a model that can help predict extubation outcomes. Materials and methods This prospective observational study was conducted at a university hospital between January 2021 and April 2022. Patients aged 1 month to 15 years who were intubated for more than 12 h and deemed clinically ready for extubation were enrolled. A weaning process with a spontaneous breathing trial (SBT), with or without minimal setting, was employed. The ventilator and patient parameters during the weaning period at 0, 30, and 120 min and right before extubation were recorded and analyzed. Results A total of 188 eligible patients were extubated during the study. Of them, 45 (23.9%) patients required respiratory support escalation within 48 h. Of 45, 13 (6.9%) were reintubated. The predictors of respiratory support escalation consisted of a nonminimal-setting SBT [odds ratio (OR) 2.2 (1.1, 4.6), P = 0.03], >3 ventilator days [OR 2.4 (1.2, 4.9), P = 0.02], occlusion pressure (P0.1) at 30 min ≥0.9 cmH2O [OR 2.3 (1.1, 4.9), P = 0.03], and exhaled tidal volume per kg at 120 min ≤8 ml/kg [OR 2.2 (1.1, 4.6), P = 0.03]; all of these predictors had an area under the curve (AUC) of 0.72. A predictive scoring system to determine the probability of respiratory support escalation was developed using a nomogram. Conclusion The proposed predictive model, which integrated both patient and ventilator parameters, showed a modest performance level (AUC 0.72); however, it could facilitate the process of patient care.
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Al Ghafri M, Al Badi H, Al Hadhrami S. Extubation Failure in Infants with Modified Blalock-Taussig Shunt: The Incidence, Predictors, and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4032-4036. [PMID: 35850754 DOI: 10.1053/j.jvca.2022.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/18/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Infants with congenital heart diseases often require mechanical ventilation and a prolonged intensive care unit (ICU) stay due to complex cardiopulmonary complications. The primary objective of the study was to determine the incidence and predictors of tracheal extubation failure in infants undergoing modified Blalock-Taussig shunt (MBTS). The secondary objective was to evaluate if extubation failure was associated with increased mortality and longer ICU and hospital stays. DESIGN Single-center, retrospective, cohort study. SETTING Tertiary center pediatric cardiac ICU. PARTICIPANTS Infants who underwent MBTS between January 2010 and December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The demographic data and details related to the preoperative, intraoperative, and pretracheal extubation clinical conditions in the ICU were compared between the 2 study arms. Statistically significant predictors were analyzed using multivariate analysis. The p value was based on the Student's -t test for continuous variables and the chi-square test for categorical variables. A total of 146 infants were recruited for the study. Extubation failure occurred in 27 infants (18.5%), resulting in longer ICU and hospital stays. Extubation failure was deemed to be positively associated with preoperative mechanical ventilation duration, the need for escalation of the inotropic score, diaphragmatic paralysis, and systolic blood pressure ≤50th percentile at the time of extubation. CONCLUSIONS The incidence rate of extubation failure after placement of MBTS was 18.5%. Preoperative mechanical ventilation, diaphragmatic paralysis, the need for escalation of the inotropic score, and systolic blood pressure ≤50th percentile could be considered predictors of extubation failure in these infants.
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Affiliation(s)
- Mohammed Al Ghafri
- Department of Cardiac Intensive Care Unit,National Heart Center, Royal Hospital, Muscat, Oman.
| | - Hamid Al Badi
- Department of Pediatrics, Ibri hospital, Muscat, Oman
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Al-Matary A, AlOtaiby S, Alenizi S. Outcomes and factors associated with extubation failure in preterm infants. J Clin Neonatol 2022. [DOI: 10.4103/jcn.jcn_106_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Moura JCDS, Gianfrancesco L, Souza THD, Hortencio TDR, Nogueira RJN. Extubation in the pediatric intensive care unit: predictive methods. An integrative literature review. Rev Bras Ter Intensiva 2021; 33:304-311. [PMID: 34231812 PMCID: PMC8275073 DOI: 10.5935/0103-507x.20210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022] Open
Abstract
For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests.
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Affiliation(s)
| | | | | | - Taís Daiene Russo Hortencio
- Universidade Estadual de Campinas - Campinas (SP), Brasil.,Faculdade de Medicina São Leopoldo Mandic - Campinas (SP), Brasil
| | - Roberto José Negrão Nogueira
- Universidade Estadual de Campinas - Campinas (SP), Brasil.,Faculdade de Medicina São Leopoldo Mandic - Campinas (SP), Brasil
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Abstract
OBJECTIVES Extubation failure is multifactorial, and most tools to assess extubation readiness only evaluate snapshots of patient physiology. Understanding variability in respiratory variables may provide additional information to inform extubation readiness assessments. DESIGN Secondary analysis of prospectively collected physiologic data of children just prior to extubation during a spontaneous breathing trial. Physiologic data were cleaned to provide 40 consecutive breaths and calculate variability terms, coefficient of variation and autocorrelation, in commonly used respiratory variables (i.e., tidal volume, minute ventilation, and respiratory rate). Other clinical variables included diagnostic and demographic data, median values of respiratory variables during spontaneous breathing trials, and the change in airway pressure during an occlusion maneuver to measure respiratory muscle strength (maximal change in airway pressure generated during airway occlusion [PiMax]). Multivariable models evaluated independent associations with reintubation and prolonged use of noninvasive respiratory support after extubation. SETTING Acute care, children's hospital. PATIENTS Children were included from the pediatric and cardiothoracic ICUs who were greater than 37 weeks gestational age up to and including 18 years who were intubated greater than or equal to 12 hours with planned extubation. We excluded children who had a contraindication to an esophageal catheter or respiratory inductance plethysmography bands. INTERVENTIONS Noninterventional study. MEASUREMENTS AND MAIN RESULTS A total of 371 children were included, 32 of them were reintubated. Many variability terms were associated with reintubation, including coefficient of variation and autocorrelation of the respiratory rate. After controlling for confounding variables such as age and neurologic diagnosis, both coefficient of variation of respiratory rate(p < 0.001) and low PiMax (p = 0.002) retained an independent association with reintubation. Children with either low PiMax or high coefficient of variation of respiratory rate had a nearly three-fold higher risk of extubation failure, and when these children developed postextubation upper airway obstruction, reintubation rates were greater than 30%. CONCLUSIONS High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children, with very high rates of extubation failure when these children develop postextubation upper airway obstruction.
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Affiliation(s)
- Kelby E Knox
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Leonardo Nava-Guerra
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael C K Khoo
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Munshi FA, Bukhari ZM, Alshaikh H, Saem Aldahar M, Alsafrani T, Elbehery M. Rapid Shallow Breathing Index as a Predictor of Extubation Outcomes in Pediatric Patients Underwent Cardiac Surgeries at King Faisal Cardiac Center. Cureus 2020; 12:e8754. [PMID: 32714692 PMCID: PMC7377672 DOI: 10.7759/cureus.8754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Weaning patients of ventilation is an important step in the intensive care unit; therefore, assessing the perfect timing to do such critical action is of equal significance to prevent complications. Rapid shallow breathing index (RSBI) has been used as a prediction tool for weaning adult patients, but for pediatric patients it is still an area of unclarity. Accordingly, the aim of this study is to evaluate the RSBI as a predictor of extubation outcome in pediatric patients underwent cardiac surgery at King Faisal Cardiac Center from 2016 until 2019. Methods A retrospective cohort study was conducted at King Faisal Cardiac Center on all extubated children having cardiac surgeries from 2016 to 2019 with excluding the patients who were admitted for causes other than cardiac surgery. Their age was ranged from birth until 14 years. Moreover, the patients were grouped based on the extubation outcomes into: success, success with non-invasive ventilation, or failure which was defined as reintubation within 48 hours after extubation. Regarding the collected data, three readings of RSBI on hourly basis prior to extubation were calculated by dividing respiratory rate (RR) over tidal volume (VT) with a correction based on the body weight. Results A total of 86 patients met the inclusion and exclusion criteria. Thirty (34.9%) patients were successfully extubated, 51 (59.3%) patients had successful extubation with the use of non-invasive ventilation, and only five (5.8%) patients suffered from extubation failure. Two-hour RSBI as a predictor of outcome had a P-value of 0.003, one-hour RSBI had a P-value of 0.01, RSBI at time of extubation had a P-value of 0.02. Mean corpuscular volume (MCV) is higher in extubation failure group with a p-value of 0.01. Conclusion This study suggests that pediatric patients who suffer from extubation failure usually have a higher RSBI measurement compared to the patients who have a successful extubation. The most significant RSBI measurements to predict the extubation outcome were recorded two hours prior to extubation. Our study also found that extubation failure patients could have higher MCV than the success group.
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Affiliation(s)
- Farid A Munshi
- Pediatric Cardiac Critical Care Unit, King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, SAU
| | - Ziad M Bukhari
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Hassan Alshaikh
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Majd Saem Aldahar
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Turki Alsafrani
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Mostafa Elbehery
- Pediatric Cardiac Critical Care Unit, King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, SAU
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Kulkarni R, Kinikar A, Prasad R. Protocol Driven Extubation in Neonates- A Quality Improvement Initiative. Indian Pediatr 2020; 57:183-183. [PMID: 32060253 DOI: 10.1007/s13312-020-1744-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Zhang Z, Xue Y, Li HH, Li YM. [Research advances in validity of predictors for extubation outcome in children receiving invasive mechanical ventilation]. Zhongguo Dang Dai Er Ke Za Zhi 2019; 21:730-734. [PMID: 31315777 PMCID: PMC7389097 DOI: 10.7499/j.issn.1008-8830.2019.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/25/2019] [Indexed: 06/10/2023]
Abstract
The development of invasive mechanical ventilation technology provides effective respiratory support for critically ill children. However, respiratory support is not the end of treatment as the ultimate goal is successful extubation in children. At present, some evaluation indicators before extubation including rapid shallow breathing index, maximal inspiratory pressure, and work of breathing are of high clinical value in predicting adult extubation outcome, but their evidence of evidence-based medicine is not sufficient in the field of pediatric intensive care. This paper reviews the current research on the validity of predictors for extubation outcomes in children. It shows that there is still a lack of indicators with good sensitivity and specificity for assessment before extubation in children. The studies are still in a small-sample size and single-center stage. Therefore, how to optimize evaluation before extubation and improve the success rate of extubation is the direction of joint efforts of doctors in the pediatric intensive care unit and rehabilitation medicine department.
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Affiliation(s)
- Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun 130021, China.
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Yang X, Xu PF, Shan L, Lang LG, DU L, Jia FY. [Advances in respiratory assessment and treatment in children undergoing invasive mechanical ventilation]. Zhongguo Dang Dai Er Ke Za Zhi 2019; 21:94-99. [PMID: 30675871 PMCID: PMC7390170 DOI: 10.7499/j.issn.1008-8830.2019.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/06/2018] [Indexed: 06/09/2023]
Abstract
The widespread use of mechanical ventilation technology has contributed to the successful treatment of many children with respiratory failure. At the same time, forced ventilation and changes in normal respiratory physiology and mechanics may lead to respiratory dysfunction and decreased airway clearance ability. Therefore, how to perform a comprehensive and accurate respiratory function assessment, conduct appropriate respiratory function rehabilitation, perform extubation as soon as possible, and shorten the duration of mechanical ventilation based on the children's own physiological characteristics, is a focus of the research on effective weaning from mechanical ventilation in children with severe conditions. This article reviews the advances in the respiratory function assessment and treatment methods in children undergoing invasive mechanical ventilation.
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Affiliation(s)
- Xue Yang
- Department of Developmental and Behavioral Pediatrics, First Hospital of Jilin University, Changchun 130021, China.
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Khemani RG, Sekayan T, Hotz J, Flink RC, Rafferty GF, Iyer N, Newth CJL. Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength. Crit Care Med 2017; 45:e798-805. [PMID: 28437378 DOI: 10.1097/CCM.0000000000002433] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength. DESIGN Secondary analysis of prospectively collected data. SETTING Tertiary care PICU. PATIENTS Four hundred nine mechanically ventilated children. INTERVENTIONS Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made preextubation during airway occlusion and on continuous positive airway pressure of 5 and pressure support of 10 above positive end-expiratory pressure 5 cm H2O, as well as 5 and 60 minutes postextubation. MEASUREMENTS AND MAIN RESULTS Thirty-four patients (8.3%) were reintubated within 48 hours of extubation. Reintubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax) preextubation, longer length of ventilation, postextubation upper airway obstruction, high respiratory effort postextubation (pressure rate product, pressure time product, tension time index), and high postextubation phase angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). Reintubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (pressure rate product > 500), whereas children with preserved aPiMax had reintubation rates greater than 20% only when postextubation effort was very high (pressure rate product > 1,000). When children developed postextubation upper airway obstruction, reintubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p = 0.02). Multivariable risk factors for reintubation included acute neurologic disease, lower aPiMax, postextubation upper airway obstruction, higher preextubation positive end-expiratory pressure, higher postextubation pressure rate product, and lower height. CONCLUSIONS Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when postextubation effort was high.
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