Factors Associated With Post-Extubation Stridor in Infants Intubated in the Pediatric ICU

BACKGROUND

Post-extubation stridor (PES) is a common problem in the pediatric intensive care unit (PICU) and is associated with extubation failure, longer length of stay, and increased mortality. Infants represent a large proportion of PICU admissions and are at higher risk for PES, making identification and mitigation of factors associated with PES important in this age group.

RESEARCH QUESTION

What factors are associated with PES in infants (age less than 1 year) intubated in the PICU?

STUDY DESIGN & METHODS

The primary outcome was PES as defined by the need for racemic epinephrine within 6 h of extubation. Secondary outcomes were heliox administration and reintubation. Statistical analyses were performed with Fisher's exact test for univariate analyses and multivariate logistic regression.

RESULTS

518 patient charts were retrospectively reviewed. 24.1% of patients developed PES. Duration of mechanical ventilation greater than 48 h was associated with increased risk of PES (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.13-2.71, P = .01), as was nonelective intubation (OR = 2.92, 95% CI 1.91-4.46, P < .01). The presence of a cuff, gastroesophageal reflux disease, prematurity, and known upper airway abnormality had no association with PES. 4.0 endotracheal tubes (ETTs) had an increased association with PES compared to 3.5 ETTs (OR = 1.96, 95% CI 1.18-3.27, P < .01). There was no difference in risk of PES between 3.5 and 3.0 ETTs.

INTERPRETATION

In infants intubated in the PICU, mechanical ventilation greater than 48 h and nonelective intubation were associated with PES. 4.0 ETTs were associated with higher risk of PES compared to 3.5 ETTs. These findings may help providers in ETT selection and to identify infants that may be at increased risk of PES.

The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation

BACKGROUND

Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation.

METHODS

This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer.

DISCUSSION

The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , trial identifier NCT05446272 , registered July 6, 2022.

Effect of intravenous and topical laryngeal lidocaine on sore throat after extubation: a prospective randomized controlled study

OBJECTIVE

The present study aimed to compare the effect of topical laryngeal lidocaine with intravenous lidocaine before endotracheal intubation on the incidence and severity of postoperative sore throat, hoarseness, and cough.

PATIENTS AND METHODS

This prospective randomized controlled study enrolled 144 patients undergoing laparoscopic cholecystectomy with endotracheal intubation. The patients were randomized to three groups and received 2% lidocaine by topical laryngeal spray (group T), intravenous 2% lidocaine (group I), and the equivalent volume of intravenous saline (group C) before intubation. The incidence and severity of sore throat, hoarseness, and cough reaction at 0.5, 1, 6, and 24 h after extubation were collected.

RESULTS

The incidence of sore throat was significantly lower in group T than in groups I and C (6.4% vs. 37.2% and 86.7%, p < 0.001), respectively at 0.5 h after extubation, and it was significantly lower in group I than that in group C (37.2% vs. 86.7%, p < 0.001). Both the incidence of hoarseness and cough were significantly lower in group T than in group I and in group C (14.9% vs. 97.7% and 97.8%, p < 0.001, and 19.1% vs. 72.0% and 93.3%, p < 0.001), respectively. The severity of sore throat, hoarseness and cough in group T was significantly lower than that in group I and that in group C (p < 0.05), and it was significantly lower in group I than in group C (p < 0.05).

CONCLUSIONS

Both topical laryngeal lidocaine and intravenous lidocaine before intubation have positive effects on preventing sore throat. Topical laryngeal route was superior to intravenous route. Chictr.org.cn ID: ChiCTR2100042442.

Pre-Extubation Ultrasound Measurement of In Situ Cuffed Endotracheal Tube Laryngeal Air Column Width Difference: Single-Center Pilot Study of Relationship With Post-Extubation Stridor in Subjects Younger Than 5 Years Old

OBJECTIVES

Post-extubation stridor (PES) is difficult to predict before extubation. We therefore evaluated the potential diagnostic performance of pre-extubation laryngeal air column width difference (LACWD) measurement, as assessed by intensivist-performed point-of-care laryngeal ultrasound, in relation to clinically important PES.

DESIGN

Prospective observational cohort study.

SETTING

Single quaternary care PICU (July 19, 2021, to October 31, 2022).

PATIENTS

Included subjects were younger than 5 years old, intubated with a cuffed endotracheal tube, requiring invasive mechanical ventilation for greater than 24 hours, and nearing extubation. Subjects at high risk for supraglottic airway obstruction were excluded.

INTERVENTIONS

Laryngeal ultrasound with measurement of laryngeal air column width with the endotracheal tube cuff inflated and deflated. Clinically important PES was defined as a high-pitched inspiratory respiratory noise suspected to be from a subglottic focus necessitating received medical intervention or reintubation.

MEASUREMENTS AND MAIN RESULTS

Among 53 enrolled subjects, 18 of 53 (34%) experienced PES and three of 53 (6%) were reintubated because of severe subglottic upper airway obstruction. Median LACWD was significantly lower in the stridor group compared with the nonstridor group (∆ 0.41 mm; 95% CI, 0.37-0.48; p < 0.001). The area under the receiver operating characteristic curve for LACWD as a diagnosis of PES was 0.94 (95% CI, 0.89-1.00; p < 0.001). The LACWD cutoff for PES was less than or equal to 0.47 mm, which yielded a diagnostic sensitivity of 91.4% and specificity of 88.9%. In this population, the pre-to-post-test change in probability of PES for LACWD less than or equal to 0.47 mm is 0.34 to 0.81.

CONCLUSIONS

Pre-extubation LACWD is a novel, noninvasive assessment that can be performed and interpreted by the intensivist at the bedside. There is, however, diagnostic uncertainty in the use of this measurement for identifying those at-risk of PES and larger validation studies are needed.

Artificial intelligence in the NICU to predict extubation success in prematurely born infants

OBJECTIVES

Mechanical ventilation in prematurely born infants, particularly if prolonged, can cause long term complications including bronchopulmonary dysplasia. Timely extubation then is essential, yet predicting its success remains challenging. Artificial intelligence (AI) may provide a potential solution.

CONTENT

A narrative review was undertaken to explore AI's role in predicting extubation success in prematurely born infants. Across the 11 studies analysed, the range of reported area under the receiver operator characteristic curve (AUC) for the selected prediction models was between 0.7 and 0.87. Only two studies implemented an external validation procedure. Comparison to the results of clinical predictors was made in two studies. One group reported a logistic regression model that outperformed clinical predictors on decision tree analysis, while another group reported clinical predictors outperformed their artificial neural network model (AUCs: ANN 0.68 vs. clinical predictors 0.86). Amongst the studies there was an heterogenous selection of variables for inclusion in prediction models, as well as variations in definitions of extubation failure.

SUMMARY

Although there is potential for AI to enhance extubation success, no model's performance has yet surpassed that of clinical predictors.

OUTLOOK

Future studies should incorporate external validation to increase the applicability of the models to clinical settings.

Post-extubation dysphagia in pediatric trauma patients: a single-center case-series study

We aimed to investigate whether ventilator support time influences the occurrence of dysphagia in pediatric trauma patients. This case-series study was conducted in a single pediatric emergency and critical care center from April 2012 to March 2022. Trauma patients aged < 16 years who underwent tracheal intubation were divided into two groups based on the occurrence of dysphagia within 72 h after extubation, and their data were analyzed. Tracheal intubation was performed in 75 pediatric trauma patients, and 53 of them were included in the analysis. A total of 22 patients had post-extubation dysphagia and head trauma. The dysphagia group tended to have more severe head injuries (Abbreviated Injury Scale (AIS) 4 [4-5] vs. 4 [0-4]; p < 0.05), a longer ventilator support time (7 days [4-11] vs. 1 day [1-2.5]; p < 0.05), and a longer length of hospital stay (27 days [18.0-40.3] vs. 11 days [10.0-21.0]; p < 0.05). Severe head trauma and a long duration of tracheal intubation may be risk factors for dysphagia in pediatric trauma patients. Therefore, early recognition of these risk factors could assist in treatment planning for speech-language pathologist intervention and nutritional routes of administration.

Association of post-operative ICU requirements with early extubation in the fontan procedure

OBJECTIVES

This study investigated the association between early extubation (EE) and the degree of postoperative intensive care unit (ICU) support after the Fontan procedure, specifically evaluating the volume of postoperative intravenous fluid (IVF) and vasoactive-inotropic score (VIS).

METHODS

Retrospective analysis of patients who underwent Fontan palliation from 2008 to 2018 at a single center was completed. Patients were initially divided into pre-institutional initiative towards EE (control) and post-initiative (modern) cohorts. Differences between the cohorts were assessed using t-test, Wilcoxon, or chi-Square. Following stratification by early or late extubation, four groups were compared via ANOVA or Kruskal-Wallis Test.

RESULTS

There was a significant difference in the rate of EE between the control and modern cohorts (mean 42.6 versus 75.7%, p = 0.01). The modern cohort demonstrated lower median VIS (5 versus 8, p = 0.002), but higher total mean IVF (101±42 versus 82 ±27 cc/kg, p < 0.001) versus control cohort. Late extubated (LE) patients in the modern cohort had the highest VIS and IVF requirements. This group received 67% more IVF (140 ± 53 versus 84 ± 26 cc/kg, p < 0.001) and had a higher median VIS at 24 hours (10 (IQR, 5-10) versus 4 (IQR, 2-7), p < 0.001) versus all other groups. In comparison, all EE patients had a 5-point lower median VIS when compared to LE patients (3 versus 8, p= 0.001).

CONCLUSIONS

EE following the Fontan procedure is associated with reduced post-operative VIS. LE patients in the modern cohort received more IVF, potentially identifying a high-risk subgroup of Fontan patients deserving of further investigation.

Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a condition associated with high mortality and morbidity. Survivors may require prolonged intubation with mechanical ventilation (MV). The aim of this study was to analyze the predictors of extubation failure and prolonged MV in patients who undergo surgical evacuation.

METHODS

This retrospective study was conducted on adult patients with ICH who underwent MV for at least 48 h and survived > 14 days after surgery. The demographics, clinical characteristics, laboratory tests, and Glasgow Coma Scale score were analyzed.

RESULTS

A total of 134 patients with ICH were included in the study. The average age of the patients was 60.34 ± 15.59 years, and 79.9% (n = 107) were extubated after satisfying the weaning parameters. Extubation failure occurred in 11.2% (n = 12) and prolonged MV in 48.5% (n = 65) patients. Multivariable regression analysis revealed that a white blood cell count > 10,000/mm3 at the time of extubation was an independent predictor of reintubation. Meanwhile, age and initial Glasgow Coma Scale scores were predictors of prolonged MV.

CONCLUSIONS

This study provided the first comprehensive characterization and analysis of the predictors of extubation failure and prolonged MV in patients with ICH after surgery. Knowledge of potential predictors is essential to improve the strategies for early initiation of adequate treatment and prognosis assessment in the early stages of the disease.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation

BACKGROUND

As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h.

OBJECTIVES

The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU.

RESULTS

There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU.

CONCLUSION

The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

Criteria for immediate extubation after pediatric liver transplantation in a single pediatric liver transplant center in Japan

Immediate extubation (IE) following liver transplantation (LT) has become the standard practice, even for pediatric patients. However, no preoperative or postoperative case selection protocols for IE are currently available. We have developed selection criteria for IE following pediatric LT. The aim of this study is to assess the safety and effectiveness of these selection criteria and anesthetic management protocol implemented in our hospital for IE after pediatric LT.

METHOD

This was a retrospective study. The records of all cases undergoing LT in our center from January 2016 to December 2020 were collected. We excluded cases > 18 years old at the time of LT. Enrolled cases were divided into two groups: cases with immediate extubation (IE) or without immediate extubation (NIE). We compared preoperative conditions, intraoperative management, and postoperative courses. Finally, we classified NIE group patients into cases extubated at postoperative day 1 (early; E-NIE) and others (delayed; D-NIE) and compared their underlying diseases and postoperative courses.

RESULTS

In the IE group, there were 81 cases, while the NIE group consisted of 185 cases. All patients in the IE group were successfully extubated without any instances of re-intubation due to respiratory failure. Within the E-NIE group, comprising 130 cases, all patients were ultimately extubated without the need for tracheostomy. However, in the D-NIE group, which encompassed 53 cases, seven patients required tracheostomy.

CONCLUSION

In our center, the implementation of our anesthesia management protocol and the use of pre/postoperative case selection criteria have allowed for the safe practice of IE following pediatric LT. However, it should be noted that patients who cannot be extubated by Postoperative Day 1 (POD1) may be at an increased risk of requiring a tracheostomy. When contemplating IE, it is crucial to take into account the disease-specific physiological aspects and surgical site situations.

Weaning and extubation failure in myasthenic crisis: a multicenter analysis

Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.

Use of a combination of diaphragmatic ultrasound and muscle relaxation monitoring in predicting post-extubation adverse respiratory events among elderly patients in an anesthesia intensive care unit

OBJECTIVE

The purpose of this study was to examine the feasibility of using a combination of diaphragmatic ultrasound and muscle relaxation monitoring in predicting adverse respiratory events after extubation among elderly patients in an anesthetic intensive care unit (AICU).

METHODS

The study participants were 120 elderly patients who were in the AICU after laparoscopic radical resection for colorectal cancer. Based on whether there were critical respiratory events (CREs) after extubation, they were divided into the adverse event group and the non-adverse event group. We used logistic regression to identify factors influencing the occurrence of CREs post-extubation in elderly patients. Using the receiver operating characteristic (ROC) curve, we analyzed the value of each indicator in predicting CREs post-extubation.

RESULTS

We included 109 patients in the final analysis. In the adverse event group (n = 19), the age, proportion of females, and proportion of preoperative respiratory diseases were higher than in the non-adverse event group (n = 90). The muscle relaxation value, quiet breathing diaphragmatic excursion during extubation (DE-QB), deep breathing diaphragmatic excursion during extubation (DE-DB), and deep breathing diaphragmatic thickening fraction during extubation (DTF-DB) of patients in the adverse event group were significantly lower than those in the non-adverse event group (P < 0.05). Using binary logistic regression analysis, we identified muscle relaxation value, DE-DB, and DTF-DB during extubation as significant predictors of CREs post-extubation in elderly patients (P < 0.05). The area under the curve (AUC) of the combination of the muscle relaxation value, DE-DB, and DTF-DB during extubation for predicting CREs after extubation in elderly patients was 0.949, which was higher than that of any single indicator.

CONCLUSION

The combination of diaphragmatic ultrasound and muscle relaxation monitoring was more accurate in predicting CREs post-extubation among elderly patients in the AICU.

The Impact of Head Elevation on Prevalence and Severity of Emergence Cough in Male Patients during Endotracheal Extubation

BACKGROUND Emergence cough during endotracheal extubation can lead to complications. This cough is triggered by the deviation of the endotracheal tube from the airway anatomy, causing pressure on the airway mucosal wall. Head elevation has the potential to align the airway passage with the tube's configuration. In this study, we aimed to investigate the impact of head elevation using a pillow on the prevalence and severity of emergence cough in male patients. MATERIAL AND METHODS A total of 71 male patients undergoing laparoscopic cholecystectomy were randomly assigned to either the head elevation group (n=35) or the control group (n=36). The head elevation group maintained a position with a neck flexion angle of 35º using a pillow, while the control group remained in a neutral position after anesthetic induction. The severity of cough was assessed before, during, and after extubation using a 4-point scale, with grades 2 and 3 indicating cough and grade 3 indicating severe cough. RESULTS The characteristics and intraoperative data of the patients were similar between the two groups. There was no significant difference in the incidence of cough and severe cough between the groups. However, the severity of cough was significantly lower in the head elevation group compared to the control group before extubation (cough scale: 0/5/8/23 vs 1/2/17/15 in the control group vs the head elevation group, P=0.039). The time to extubation, respiratory complications, nausea, pain, and the number of patients receiving fentanyl were comparable between the groups. CONCLUSIONS Head elevation using a pillow effectively reduced the severity of cough before endotracheal extubation during anesthesia emergence in male patients. However, it did not significantly reduce the incidence of cough. These findings highlight the potential benefits of head elevation in minimizing the discomfort associated with emergence cough.

Failed Extubation in Neonates After Cardiac Surgery: A Single-Center, Retrospective Study

OBJECTIVES

To describe factors associated with failed extubation (FE) in neonates following cardiovascular surgery, and the relationship with clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

Twenty-bed pediatric cardiac ICU (PCICU) in an academic tertiary care children's hospital.

PATIENTS

Neonates admitted to the PCICU following cardiac surgery between July 2015 and June 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients who experienced FE were compared with patients who were successfully extubated. Variables associated with FE ( p < 0.05) from univariate analysis were considered for inclusion in multivariable logistic regression. Univariate associations of FE with clinical outcomes were also examined. Of 240 patients, 40 (17%) experienced FE. Univariate analyses revealed associations of FE with upper airway (UA) abnormality (25% vs 8%, p = 0.003) and delayed sternal closure (50% vs 24%, p = 0.001). There were weaker associations of FE with hypoplastic left heart syndrome (25% vs 13%, p = 0.04), postoperative ventilation greater than 7 days (33% vs 15%, p = 0.01), Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5 operations (38% vs 21%, p = 0.02), and respiratory rate during spontaneous breathing trial (median 42 vs 37 breaths/min, p = 0.01). In multivariable analysis, UA abnormalities (adjusted odds ratio [AOR] 3.5; 95% CI, 1.4-9.0), postoperative ventilation greater than 7 days (AOR 2.3; 95% CI, 1.0-5.2), and STAT category 5 operations (AOR 2.4; 95% CI, 1.1-5.2) were independently associated with FE. FE was also associated with unplanned reoperation/reintervention during hospital course (38% vs 22%, p = 0.04), longer hospitalization (median 29 vs 16.5 d, p < 0.0001), and in-hospital mortality (13% vs 3%, p = 0.02).

CONCLUSIONS

FE in neonates occurs relatively commonly following cardiac surgery and is associated with adverse clinical outcomes. Additional data are needed to further optimize periextubation decision-making in patients with multiple clinical factors associated with FE.

Clinical usefulness of reintubation criteria in extremely preterm infants: a cohort study

OBJECTIVE

To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions.

DESIGN

Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018.

SETTING

Multicentre (three neonatal intensive care units).

PATIENTS

Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included.

INTERVENTIONS

After extubation, hourly O2 requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first.

MAIN OUTCOME MEASURES

Thresholds at reintubation were described and grouped into four categories: increased O2, respiratory acidosis, frequent cardiorespiratory events and severe cardiorespiratory events (requiring positive pressure ventilation). An automated algorithm was used to generate multiple combinations of criteria from the four categories and compute their accuracies in capturing reintubated infants (sensitivity) without including non-reintubated infants (specificity).

RESULTS

55 infants were reintubated (median gestational age 25.2 weeks (IQR 24.5-26.1 weeks), birth weight 750 g (IQR 640-880 g)), with highly variable thresholds at reintubation. After extubation, reintubated infants had significantly greater O2 needs, lower pH, higher pCO2 and more frequent and severe cardiorespiratory events compared with non-reintubated infants. After evaluating 123 374 combinations of reintubation criteria, Youden indices ranged from 0 to 0.46, suggesting low accuracy. This was primarily attributable to the poor agreement between clinicians on the number of cardiorespiratory events at which to reintubate.

CONCLUSIONS

Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.

Pediatric unplanned extubation risk score: A predictive model for risk assessment

BACKGROUND

Unplanned extubation is one of the most common preventable adverse events associated with invasive mechanical ventilation.

OBJECTIVE

This research study aimed to develop a predictive model to identify the risk of unplanned extubation in a pediatric intensive care unit (PICU).

METHODS

This single-center, observational study was conducted at the PICU of the Hospital de Clínicas. Patients were included based on the following criteria: aged between 28 days and 14 years, intubated, and using invasive mechanical ventilation.

RESULTS

Over 2 years, 2,153 observations were made using the Pediatric Unplanned Extubation Risk Score predictive model. Unplanned extubation occurred in 73 of 2,153 observations. A total of 286 children participated in the application of the Risk Score. This predictive model was created to categorize the following significant risk factors: 1) inadequate placement and fixation of the endotracheal tube (odds ratio 2.00 [95%CI,1.16-3.36]), 2) Insufficient level of sedation (odds ratio 3.00 [95%CI,1.57-4.37]), 3) age ≤ 12 months (odds ratio 1.27 [95%CI,1.14-1.41]), 4) presence of airway hypersecretion (odds ratio 11.00 [95%CI,2,58-45.26]) inadequate family orientation and/or nurse to patient ratio (odds ratio 5.00 [95%CI,2.64-7.99]), and 6) weaning period from mechanical ventilation (odds ratio 3.00 [95%CI,1.67-4.79]) and 5 risk enhancement factors.

CONCLUSIONS

The scoring system demonstrated effective sensitivity for estimating the risk of UE with the observation of six aspects, which overlap as an isolated risk factor or are associated with a risk enhancement factors.

Systematic review with meta-analysis of relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane

The objective of this systematic review was to estimate the relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. Prolonged times are defined as ≥15 min from end of surgery (or anesthetic discontinuation) to extubation in the operating room. They are associated with reintubations, naloxone and flumazenil administration, longer times from procedure end to operating room exit, greater differences between actual and scheduled operating room times, longer times from operating room exit to next case start, longer durations of the workday, and more operating room personnel idle while waiting for extubation. Published randomized clinical trials of humans were included. Generalized pivotal methods were used to estimate the relative risk of prolonged extubation for each study from reported means and standard deviations of extubation times. The relative risks were combined using DerSimonian-Laird random effects meta-analysis with Knapp-Hartung adjustment. From 67 papers, there were 78 two-drug comparisons, including 5167 patients. Studies were of high quality (23/78) or moderate quality (55/78), the latter due to lack of blinding of observers to group assignment and/or patient attrition because patients were extubated after operating room exit. Desflurane resulted in a 65% relative reduction in the incidence of prolonged extubation compared with sevoflurane (95% confidence interval 49% to 76%, P < .0001) and in a 78% relative reduction compared with isoflurane (58% to 89%, P = .0001). There were no significant associations between studies' relative risks and quality, industry funding, or year of publication (all six meta-regressions P ≥ .35). In conclusion, when emergence from general anesthesia with different drugs are compared with sevoflurane or isoflurane, suitable benchmarks quantifying rapidity of emergence are reductions in the incidence of prolonged extubation achieved by desflurane, approximately 65% and 78%, respectively. These estimates give realistic context for interpretation of results of future studies that compare new anesthetic agents to current anesthetics.

Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

The proportion of early extubation after esophagectomy varies among hospitals; however, the impact on clinical outcomes is unclear. The aim of this retrospective study was to evaluate associations between the proportion of early extubation in hospitals and short-term outcomes after esophagectomy. Because there is no consensus regarding the optimal timing for extubation, the authors considered that hospitals' early extubation proportion reflects the hospital-level extubation strategy.

MATERIALS AND METHODS

Data of patients who underwent oncologic esophagectomy (July 2010-March 2019) were extracted from a Japanese nationwide inpatient database. The proportion of patients who underwent early extubation (extubation on the day of surgery) at each hospital was assessed and grouped by quartiles: very low- (<11%), low- (11-37%), medium- (38-83%), and high-proportion (≥84%) hospitals. The primary outcome was respiratory complications; secondary outcomes included reintubation, anastomotic leakage, other major complications, and hospitalization costs. Multivariable regression analyses were performed, adjusting for patient demographics, cancer treatments, and hospital characteristics. A restricted cubic spline analysis was also performed for the primary outcome.

RESULTS

Among 37 983 eligible patients across 545 hospitals, early extubation was performed in 17 931 (47%) patients. Early extubation proportions ranged from 0-100% across hospitals. Respiratory complications occurred in 10 270 patients (27%). Multivariable regression analyses showed that high- and medium-proportion hospitals were significantly associated with decreased respiratory complications [odds ratio, 0.46 (95% CI, 0.36-0.58) and 0.43 (0.31-0.60), respectively], reintubation, and hospitalization costs when compared with very low-proportion hospitals. The risk of anastomotic leakage and other major complications did not differ among groups. The restricted cubic spline analysis demonstrated a significant inverse dose-dependent association between the early extubation proportion and the risk of respiratory complications.

CONCLUSION

A higher proportion of early extubation in a hospital was associated with a lower occurrence of respiratory complications, highlighting a potential benefit of early extubation after esophagectomy.

Comparison of the Outcomes of Oral Versus Nasal Endotracheal Intubation in Neonates and Infants Undergoing Cardiac Surgery: A Randomized Controlled Study

OBJECTIVE

The choice of oral or nasal endotracheal intubation in children undergoing cardiac surgery is affected by several factors. This study compared the outcomes of oral versus nasal intubation in neonates and infants who underwent open cardiac surgery.

DESIGN

A randomized, controlled, open-labeled study.

SETTING

At a university hospital.

PARTICIPANTS

A total of 220 infants and neonates who underwent cardiac surgery.

INTERVENTIONS

Patients were allocated randomly to oral or nasal intubation.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was postoperative fentanyl consumption (µg/kg/h) by intubated patients. Secondary outcome measures were the increase in heart rate (HR) from baseline during intubation, the time consumed for intubation, accidental intraoperative extubation, the occurrence of epistaxis, time to extubation, the onset of full oral feeding, intensive care unit (ICU) and hospital lengths of stay, and the incidence of postoperative complications (the need for reintubation, stridor, pneumonia, wound infection). The mean (SD) postoperative fentanyl consumption of intubated patients (the primary outcome) was significantly lower (p < 0.001) in the nasal intubation group (0.53 ± 0.48) µg/kg/h compared with the oral intubation group (0.82 ± 0.20) µg/kg/h. The median (IQR) time needed for the intubation (31.5, 27-35 v 16, 14.8-18 seconds) was significantly (p < 0.001) longer, and the mean (SD) increase in HR (beats/min) from baseline during intubation (18 ± 5 v 26 ± 7) was significantly (p < 0.001) lower in the nasal intubation group compared to the oral intubation group. The incidence of inadvertent intraoperative extubation was significantly (p = 0.029) higher in the oral (n = 6, 6.1%) than in the nasal (n = 0, 0%) intubation group. The median (IQR) time to extubation (14, 12.6-17.2 v 20.5, 16.4-25.4 hours) and the ICU length of stay (27, 26-28 v 30, 28-34 hours) were significantly (p < 0.05) shorter in the nasal group compared to the oral group. The median (IQR) time to onset of full oral feeding was significantly (p = 0.031) shorter in the nasal intubation group (3, 1-6 days) compared to the oral intubation group (4, 2-7 days). There were no significant differences between the oral and nasal groups in the duration of hospital stay and the indices for reintubation, postintubation stridor, pneumonia, and surgical wound infection.

CONCLUSIONS

The nasal route for intubation is associated with less postoperative fentanyl consumption, earlier extubation, lower incidence of accidental extubation, and earlier full oral feeding than oral intubation. The nasal route is not associated with an increased risk of postoperative pneumonia or surgical wound infection.

Effects of an open lung extubation strategy compared with a conventional extubation strategy on postoperative pulmonary complications after general anesthesia: a single-centre pilot randomized controlled trial

PURPOSE

Postoperative pulmonary complications (PPCs) are a common cause of morbidity. Postoperative atelectasis is thought to be a significant risk factor in their development. Recent imaging studies suggest that patients' extubation may result in similar postoperative atelectasis regardless of the intraoperative mechanical ventilation strategy used. In this pilot trial, we hypothesized that a study investigating the effects of an open lung extubation strategy compared with a conventional one on PPCs would be feasible.

METHODS

We conducted a pilot, single-centre, double-blinded randomized controlled trial. Adult patients at moderate to high risk of PPCs and scheduled for elective surgery were eligible. Patients were randomized to an open lung extubation strategy (semirecumbent position, fraction of inspired oxygen [FIO2] 50%, pressure support ventilation, unchanged positive end-expiratory pressure) or to a conventional extubation strategy (dorsal decubitus position, FIO2 100%, manual bag ventilation). The primary feasibility outcome was global protocol adherence while the primary exploratory efficacy outcome was PPCs.

RESULTS

We randomized 35 patients to the conventional extubation group and 34 to the open lung extubation group. We observed a global protocol adherence of 96% (95% confidence interval, 88 to 99), which was not different between groups. Eight PPCs occurred (two in the conventional extubation group vs six in the open lung extubation group). Less postoperative supplemental oxygen and better lung aeration were observed in the open lung extubation group.

CONCLUSIONS

In this single-centre pilot trial, we observed excellent feasibility. A multicentre pilot trial comparing the effect of an open lung extubation strategy with that of a conventional extubation strategy on the occurrence of PPCs is feasible.

STUDY REGISTRATION DATE

ClinicalTrials.gov (NCT04993001); registered 6 August 2021.

Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19

OBJECTIVE

We compared outcomes in patients with severe COVID-19 versus non-COVID-19-related acute respiratory distress syndrome (ARDS) managed using a dynamic, goal-driven approach to venovenous extracorporeal membrane oxygenation (ECMO).

METHODS

We performed a retrospective, single-center analysis of our institutional ECMO registry using data from 2017 to 2021. We used Kaplan-Meier plots, Cox proportional hazard models, and propensity score analyses to evaluate the association of COVID-19 status (COVID-19-related ARDS vs non-COVID-19 ARDS) and survival to decannulation, discharge, tracheostomy, and extubation. We also conducted subgroup analyses to compare outcomes with the use of extracorporeal cytoreductive techniques (CytoSorb [CytoSorbents Corp] and plasmapheresis).

RESULTS

The sample comprised 128 patients, 50 with COVID-19 and 78 with non-COVID-19 ARDS. Advancing age was associated with decreased probability of survival to decannulation (P = .04). Compared with the non-COVID-19 ARDS group, patients with COVID-19 had a greater probability of survival to extubation (P < .01) and comparable survival to discharge (P = .14).

CONCLUSIONS

Patients with COVID-19 managed with ECMO had comparable outcomes as patients with non-COVID ARDS. A strategy of early extubation and ambulation might be a safe and effective strategy to improve outcomes and survival, even for patients with severe COVID-19.

Risk factors and outcomes associated with unplanned intraoperative extubation of the pediatric surgical patient: An analysis of the NSQIP-P database

BACKGROUND

Unplanned intraoperative extubation is a rare but potentially catastrophic safety event. Inadvertent extubation in the neonatal and pediatric critical care setting is a recognized quality improvement metric whereas literature for intraoperative extubation is scarce. The aim of this study was to identify risk factors and outcomes associated with unplanned intraoperative extubation.

METHODS

We queried the National Surgical Quality Improvement Program-Pediatric database from 2019 to 2020 for patients <18 years of age. A total of 253 673 patients were included in the analysis. Associations between demographics, clinical variables, and unplanned intraoperative extubation were evaluated with univariable and multivariable logistic regression models. The primary outcome was unplanned intraoperative extubation. Secondary outcomes were postoperative pulmonary complication, unplanned reintubation within 24 h, cardiac arrest on day of surgery, and surgical site infection.

RESULTS

Unplanned intraoperative extubation occurred in 163 (0.06%) patients. Specific procedures experienced unplanned intraoperative extubation at a higher rate such as bilateral cleft lip repair (1.31% of procedure type) and thoracic repair of tracheoesophageal fistula (1.11% of procedure type). Age, operative time (z-score), American Society of Anesthesiologists Classification 3 and 4, neurosurgery, plastic surgery, thoracic surgery, otolaryngology, and structural pulmonary/airway abnormalities were independent risk factors. Unplanned intraoperative extubation was associated with an increased unadjusted risk for postoperative pulmonary complication (p < .005; OR, 6.05; 95% confidence interval [CI]: 1.93-14.44), unplanned reintubation within 24 h (p < .005; OR, 8.41; 95% CI: 2.08-34.03), cardiac arrest on day of surgery (p < .05; OR, 22.67; 95% CI: 0.56-132.35), and surgical site infection (p < .0005; OR, 3.27; 95% CI 1.74-5.67).

CONCLUSIONS

Unplanned intraoperative extubation occurs at a higher frequency in a subset of procedures and patient types. Identifying and targeting at-risk patients with preventative measures may decrease the incidence of unplanned intraoperative extubation and its associated outcomes.

Severe hypoxemia after extubation secondary to myxedema coma: a case report

Myxedema coma is a rare and life-threatening endocrine emergency characterized by abnormalities in multiple organ systems. A 32-year-old woman with prolonged undiagnosed severe hypothyroidism was referred to our hospital owing to lower abdominal pain and menopause for more than 3 months. She underwent exploratory laparotomy and induced abortion under general anesthesia, and developed severe hypoxemia after extubation. She was diagnosed with myxedema coma, and was subsequently discharged with a good prognosis following treatment. This case suggests that myxedema coma should be considered a potential etiology of peri-operative hypoxemia. The findings in this case emphasize the importance of anesthesiologists' comprehensive understanding of myxedema coma. Prompt diagnosis followed by treatment is essential to reduce the mortality rate associated with this condition.

Pre-Extubation Cuffed Tube Leak Test and Subsequent Post-Extubation Laryngeal Edema: Prospective, Single-Center Evaluation of PICU Patients

OBJECTIVES

We performed our standard air leak, leak percentage, and cuff leak percentage tests in pediatric patients intubated with microcuff pediatric tracheal tubes (MPTTs) just before extubation. We examined the association between test findings and the subsequent occurrence of post-extubation laryngeal edema (PLE).

DESIGN

Prospective, single-center, observational study.

SETTING

PICU (June 1, 2020 to May 31, 2021).

PATIENTS

Pediatric patients intubated and scheduled for extubation during the day shift in the PICU.

INTERVENTIONS

Multiple pre-extubation leak tests were performed on each patient immediately before extubation. In our center, the standard leak test is positive if a leak is audible at 30 cm H 2 O applied pressure with the MPTT cuff deflated. Two other tests were calculated in the pressure control-assist control ventilator mode using the following formulas: leak percentage with deflated cuff = (inspiratory tidal volume [V t ]-expiratory V t ) × 100/inspiratory V t ; cuff leak percentage = (expiratory V t with inflated cuff-expiratory V t with deflated cuff) × 100/expiratory V t with inflated cuff.

MEASUREMENTS AND MAIN RESULTS

The diagnostic criteria for PLE was made by at least two healthcare professionals and included upper airway stricture with stridor-requiring nebulized epinephrine. Eighty-five pediatric patients (< 15 yr) who had been intubated for at least 12 hours using the MPTT were included. Positive rates for the standard leak, leak percentage (cutoff 10%), and cuff leak percentage (cutoff 10%) tests were 0.27, 0.20, and 0.64, respectively. The standard leak, leak percentage, and cuff leak tests showed sensitivities of 0.36, 0.27, and 0.55, respectively; and specificities of 0.74, 0.81, and 0.35, respectively. PLE occurred in 11 of 85 patients (13%), and there were no instances of needing reintubation.

CONCLUSIONS

The pre-extubation leak tests in current practice for intubated pediatric patients in the PICU all lack diagnostic accuracy for PLE.

Predictive Score for Early Successful Tracheal Extubation After Liver Transplant: A Case-Control Study

OBJECTIVES

Prolonged tracheal intubation and mechanical ventilation after liver transplant increase postoperative complications. Hence, timely extubation should be considered; however, a standard clinical criteria set or scoring system to select patients has not been established for early extubation after livertransplant.We investigated the factors that affect early extubation to design a predictive scoring system for early extubation.

MATERIALS AND METHODS

This study is a case-control study of adult liver transplant patients. Preoperative, intraoperative, and postoperative clinical data were collected. Early extubation was defined as tracheal extubation immediately or up to 6 hours posttransplant. The variables were compared between the early extubation group and the delayed extubation (>6 hours) group.

RESULTS

Our study enrolled 237 patients; among them, 57 patients (24%) were in the early extubation group, and 180 (76%) were in the delayed extubation group. Multiple logistic regression analysis showed that postoperative base excess level at admission to the intensive care unit, number of units of packed red blood cells transfused during surgery, urine volume, and excess base level 6 hours after surgery were the main predictors of successful early extubation.

CONCLUSIONS

The initial base excess level at the entrance to the intensive care unit(postsurgery) and 6 hours after surgery, packed red blood cell volume transfused during surgery, and urine volume 6 hours after surgery are the main predictors for a successful early tracheal extubation.These factors are considered for the Shiraz Extubation Predictor formula.

Early extubation in extracorporeal life support patients: A propensity score-matched study

BACKGROUND

Extubation strategy in extracorporeal life support patients remains unclear, and literature only reports studies with significant biases.

OBJECTIVES

To explore the prognostic impact of an early ventilator-weaning strategy in assisted patients after controlling for confounding factors.

METHODS

A 10-year retrospective study included 241 patients receiving extracorporeal life support for at least 48 h, corresponding to a total of 977 days spent on assistance. The a priori probability of extubation for each day of assistance was calculated according to daily biological examinations, drug doses, clinical observations, and admission data to pair each day containing an extubation with one on which the patient was not extubated. The primary outcome was survival at day 28. The secondary outcomes were survival at day 7, respiratory infections, and safety criteria.

RESULTS

Two similar cohorts of 61 patients were generated. Survival at day 28 was better in patients extubated under assistance in univariate and multivariate (HR = 0.37 [0.2-0.68], p-value = 0.002) analyses. Patients who underwent failed early extubation did not have a different prognosis from those without early extubation. Successful early extubation was associated with a better outcome than a failed or no attempt at early extubation. Survival at day 7 and the rate of respiratory infections were better in early-extubated patients. Safety data did not differ between the two groups.

CONCLUSIONS

Early extubation during assistance was associated with a superior outcome in our propensity-matched cohort study. The safety data were reassuring. However, due to the lack of prospective randomized studies, the causality remains uncertain.

Effect of high-flow nasal cannula versus non-invasive ventilation after extubation on successful extubation in obese patients: a retrospective analysis of the MIMIC-IV database

BACKGROUND

The pathophysiological characteristics of the respiratory system of obese patients differ from those of non-obese patients. Few studies have evaluated the effects of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) on the prognosis of obese patients. We here compared the effects of these two techniques on the prevention of reintubation after extubation for obese patients.

METHODS

Data were extracted from the Medical Information Mart for Intensive Care database. Patients who underwent HFNC or NIV treatment after extubation were assigned to the HFNC or NIV group, respectively. The reintubation risk within 96 hours postextubation was compared between the two groups using a doubly robust estimation method. Propensity score matching was performed for both groups.

RESULTS

This study included 757 patients (HFNC group: n=282; NIV group: n=475). There was no significant difference in the risk of reintubation within 96 hours after extubation for the HFNC group compared with the NIV group (OR 1.50, p=0.127). Among patients with body mass index ≥40 kg/m2, the HFNC group had a significantly lower risk of reintubation within 96 hours after extubation (OR 0.06, p=0.016). No significant differences were found in reintubation rates within 48 hours (15.6% vs 11.0%, p=0.314) and 72 hours (16.9% vs 13.0%, p=0.424), as well as in hospital mortality (3.2% vs 5.2%, p=0.571) and intensive care unit (ICU) mortality (1.3% vs 5.2%, p=0.108) between the two groups. However, the HFNC group had significantly longer hospital stays (14 days vs 9 days, p=0.005) and ICU (7 days vs 5 days, p=0.001) stays.

CONCLUSIONS

This study suggests that HFNC therapy is not inferior to NIV in preventing reintubation in obese patients and appears to be advantageous in severely obese patients. However, HFNC is associated with significantly longer hospital stays and ICU stays.

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.

Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes

OBJECTIVES

The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU).

DESIGN

Registry data (August 2014 to October 2020).

SETTING

Forty-five Pediatric Cardiac Critical Care Consortium hospitals.

PATIENTS

Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains.

CONCLUSIONS

UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study

OBJECTIVES

Unplanned extubations are an infrequent but life-threatening adverse event in pediatric critical care. Due to the rarity of these events, previous studies have been small, limiting the generalizability of findings and the ability to detect associations. Our objectives were to describe unplanned extubations and explore predictors of unplanned extubation requiring reintubation in PICUs.

DESIGN

Retrospective observational study and multilevel regression model.

SETTING

PICUs participating in Virtual Pediatric Systems (LLC).

PATIENTS

Patients (≤ 18 yr) who had an unplanned extubation in PICU (2012-2020).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We developed and trained a multilevel least absolute shrinkage and selection operator (LASSO) logistic regression model in the 2012-2016 sample that accounted for between-PICU variations as a random effect to predict reintubation after unplanned extubation. The remaining sample (2017-2020) was used to externally validate the model. Predictors included age, weight, sex, primary diagnosis, admission type, and readmission status. Model calibration and discriminatory performance were evaluated using Hosmer-Lemeshow goodness-of-fit (HL-GOF) and area under the receiver operating characteristic curve (AUROC), respectively. Of the 5,703 patients included, 1,661 (29.1%) required reintubation. Variables associated with increased risk of reintubation were age (< 2 yr; odds ratio [OR], 1.5; 95% CI, 1.1-1.9) and diagnosis (respiratory; OR, 1.3; 95% CI, 1.1-1.6). Scheduled admission was associated with decreased risk of reintubation (OR, 0.7; 95% CI, 0.6-0.9). With LASSO (lambda = 0.011), remaining variables were age, weight, diagnosis, and scheduled admission. The predictors resulted in AUROC of 0.59 (95% CI, 0.57-0.61); HL-GOF showed the model was well calibrated (p = 0.88). The model performed similarly in external validation (AUROC, 0.58; 95% CI, 0.56-0.61).

CONCLUSIONS

Predictors associated with increased risk of reintubation included age and respiratory primary diagnosis. Including clinical factors (e.g., oxygen and ventilatory requirements at the time of unplanned extubation) in the model may increase predictive ability.

Prevalence, Risk Factors, and Outcomes of Airway Versus Non-Airway Pediatric Extubation Failure

BACKGROUND

Pediatric extubation failure is associated with morbidity and mortality. The most common cause is upper-airway obstruction. Subglottic edema is common, but upper-airway obstruction can occur from the oral cavity to the trachea. Dichotomous categorization of extubation failure as airway versus non-airway may help identify risk factors as well as strategies that translate to lower extubation failure rates.

METHODS

This was as single-center, retrospective cohort study of invasive mechanical ventilation encounters within a quality improvement database between October 1, 2017-November 30, 2020. Utilizing a 3-physician adjudication process, all extubation failures were categorized as airway versus non-airway. Primary outcome was failure subtype prevalence. Secondary outcome was failure subtype risk factors. Clinical outcomes were explored.

RESULTS

The all-cause extubation failure rate was 10% in a cohort of 844 encounters. Airway and non-airway extubation failure represented 60.7% and 39.3%, respectively. Most airway failures were due to upper-airway obstruction (84.3%)-35.3% were supraglottic, 25.5% subglottic, and 23.5% mixed. Other causes of airway failure were airway patency/secretions (11.8%) and aspiration (3.9%). Non-airway failures were attributed to respiratory failure (75.8%), encephalopathy (15.2%), and other (9%). All-cause extubation failure was associated with dysgenetic/syndromic comorbidity (P = .005), ≥ 3 concurrent comorbid conditions (P = .007), indication for invasive ventilation (P < .001), and longer invasive mechanical ventilation duration (P < .001). Airway extubation failure was significantly associated with the presence of a respiratory comorbidity (P = .01) and Glasgow coma scale < 10 (P = .02). No significant non-airway failure risk factors were identified. Longer pediatric ICU (PICU) stay (P < .001) and PICU mortality (P < .001) were associated with all-cause extubation failure. No significant outcome associations with extubation failure subtype were identified.

CONCLUSIONS

Airway extubation failure prevalence was 1.5 times higher than non-airway failure. Potential risk factors for airway failure were identified. These findings are hypothesis generating for future study focused on key evidence gaps and pragmatic bedside application.

Comparison of Postextubation Complications Between Positive-Pressure and Suctioning Techniques: A Systematic Review

BACKGROUND

Several studies have investigated postextubation complications of the positive-pressure and suctioning techniques; however, these studies yielded inconsistent results. Therefore, in this systematic review, we aimed to assess and compare the risk of complications between these techniques after extubation.

METHODS

This study was registered with the International Prospective Register of Systematic Reviews (CRD42021272068). We searched for randomized controlled trials (RCT) or observational studies that compared positive-pressure and suctioning extubation techniques in medical literature databases. Our search was conducted from the databases' inception to July 7, 2022. The included studies were assessed for quality by using a risk of bias tool.

RESULTS

Six RCTs and 1 non-randomized controlled study were included in this systematic review (N = 1,575 subjects), wherein the positive-pressure and suctioning techniques were applied to 762 and 813 subjects, respectively. Three studies were conducted in operating rooms, and 4 studies were conducted in ICUs. Five studies were conducted among adults, and 2 studies were conducted among children or neonates. All the studies except 1 RCT showed that the positive-pressure technique tended to have a lower but not statistically different risk of complications, including desaturation, airway obstruction, pneumonia, aspiration, atelectasis, and re-intubation, than the suctioning technique. Three of the 6 RCTs were determined to have a high risk of bias and the 1 non-randomized controlled study was determined to have a serious risk of bias.

CONCLUSIONS

The positive-pressure technique tended to have a lower risk of complications than the suctioning technique. Further high-quality studies are warranted.

The risk factors of reintubation in intensive care unit patients on mechanical ventilation: A systematic review and meta-analysis

OBJECTIVE

To assess risk factors of reintubation in intensive care unit patients on mechanical ventilation.

METHODOLOGY

We conducted a systematic review of literature (inception to May 2022) and a meta-analysis. Data are reported as pooled odds ratios for categorical variables and mean differences for continuous variables.

RESULTS

A total of 2459 studies were retrieved of which 38 studies were included in a meta-analysis involving 22,304 patients. Risk factors identified were: older age, higher APACHE II scores, COPD, pneumonia, shock, low SaO₂, low PaO₂, low PaO₂/FiO₂, low hemoglobin, low albumin, high brain natriuretic peptide, low pH, high respiratory rate, low tidal volume, a higher rapid shallow breathing index, a lower vital capacity, a higher number of spontaneous breathing trials, prolonged length of mechanical ventilation, weak cough, a reduced patient's cough peak flow and positive cuff leak test. Subgroup analysis showed that risk factors substantially overlap when reintubation was considered within 48 hours or within 72 hours after extubation.

CONCLUSIONS

We identified 21 factors associated with increased risk for reintubation. These allow to recognize the patient at high risk for reintubation at an early stage. Future studies may combine these factors to develop comprehensive predictive algorithms allowing appropriate vigilance.

The Characteristics and Predicators of Post-extubation Dysphagia in ICU Patients with Endotracheal Intubation

The current status and characteristics of post-extubation dysphagia in intensive care unit (ICU) patients with endotracheal intubation remain unclear, we aimed to evaluate the characteristics and identify the predicators for post-extubation dysphagia, to provide reliable reference to the clinical management and nursing care of dysphagia. Patients who underwent tracheal intubation for mechanical ventilation in the ICU of our hospital from January 1, 2020-May 31, 2021 were selected. The characteristics of patients with and without post-extubation dysphagia were analyzed. Univarinate and binary logistic regression analysis were used to screen the risk factors of dysphagia after extubation, and we established the risk prediction model according to the regression coefficients of each risk factor. 316 ICU patients with endotracheal intubation were included, the incidence of post-extubation dysphagia was 27.85%. Logistic regression analysis showed that age ≥ 65 years (OR 2.368, 95%CI 1.633 ~ 3.946), APACHE II score ≥ 15 (OR 3.727, 95%CI 3.312 ~ 4.202), length of tracheal intubation indwelling ≥ 72 h (OR 2.495, 95%CI 1.824 ~ 3.715), length of gastric tube stay ≥ 72 h (OR 1.923, 95%CI 1.452 ~ 2.882) were the risk factors of post-extubation dysphagia in ICU patients with endotracheal intubation(all p < 0.05). Six score was used as the cuff value of the model with good sensitivity and specificity. The area under the ROC curve and 95% confidence interval was 0.822 (0.746, 0.872). There are many risks of post-extubation dysphagia in ICU patients with endotracheal intubation. For high-risk patients with a score ≥ 6, early nursing care and interventions should be given as soon as possible to reduce the post-extubation dysphagia.

Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews

AIMS

This study was performed to identify and summarize systematic reviews focusing on the prevention of unplanned endotracheal extubation in the intensive care unit.

DESIGN

Overview of systematic reviews.

METHODS

This overview was conducted according to the Preferred Reporting Items for Overviews of Systematic Reviews, including the harms checklist. A literature search of PubMed, the Cochrane Library, CINAH, Embase, Web of Science, SINOMED and PROSPERO was performed from January 1, 2005-June 1, 2021. A systematic review focusing on unplanned extubation was included, resulting in an evidence summary.

RESULTS

Thirteen systematic reviews were included. A summary of evidence on unplanned endotracheal extubation was developed, and the main contents were risk factors, preventive measures and prognosis. The most important nursing measures were restraint, fixation of the tracheal tube, continuous quality improvement, psychological care and use of a root cause analysis for the occurrence of unplanned endotracheal extubation.

CONCLUSIONS

This overview re-evaluated risk factors and preventive measures for unplanned endotracheal extubation in the intensive care unit, resulting in a summary of evidence for preventing unplanned endotracheal extubation and providing direction for future research.

TRIAL REGISTRATION DETAILS

The study was registered on the PROSPERO website.

Immediate extubation following pediatric liver transplantation

BACKGROUND

Immediate extubation (IE) following pediatric liver transplantation is being increasingly performed. The aim of this study was to characterize the rate of IE at our institution and identify recipient factors predictive of IE.

METHODS

All pediatric liver transplants performed at our institution between January 1, 2015 and December 31, 2020 were reviewed. Retransplants and multi-organ transplants were excluded. IE was defined as extubation in the operating room following transplant. Backward stepwise logistic regression at a p-value threshold of .05 was performed to identify variables associated with IE.

RESULTS

IE was achieved in 58 (72%) of the 81 pediatric liver transplants. The IE cohort had significantly shorter ICU length of stay and overall hospital length of stay, though IE was not an independent predictor of posttransplant length of stay. Age <2 years, preoperative mechanical ventilation, and total intraoperative epinephrine and dopamine infusion requirements were significant, independent risk factors against IE. This multivariable model was highly predictive of IE (area under the curve = 0.89).

CONCLUSIONS

We describe the highest rate of IE postpediatric liver transplantation that has been reported to date and identified significant risk factors against successful IE.

Spontaneous-Breathing Trials with Pressure-Support Ventilation or a T-Piece

BACKGROUND

Spontaneous-breathing trials can be performed with the use of either pressure-support ventilation (PSV) or a T-piece. Whether PSV trials may result in a shorter time to tracheal extubation than T-piece trials, without resulting in a higher risk of reintubation, among patients who have a high risk of extubation failure is unknown.

METHODS

In this multicenter, open-label trial, we randomly assigned patients who had a high risk of extubation failure (i.e., were &gt;65 years of age or had an underlying chronic cardiac or respiratory disease) to undergo spontaneous-breathing trials performed with the use of either PSV (with a pressure-support level of 8 cm of water and no positive end-expiratory pressure) or a T-piece. The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial. Secondary outcomes included extubation within 24 hours and extubation within 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.

RESULTS

A total of 969 patients (484 in the PSV group and 485 in the T-piece group) were included in the analysis. At day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% confidence interval [CI], -0.5 to 1; P = 0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5 percentage points; 95% CI, 0.01 to 10.9), and extubation was performed within 7 days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3 percentage points; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3 percentage points; 95% CI, -3.1 to 5.8). Cardiac or respiratory arrest was a reason for reintubation in 9 patients (3 in the PSV group and 6 in the T-piece group).

CONCLUSIONS

Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece. (Supported by the French Ministry of Health; TIP-EX ClinicalTrials.gov number, NCT04227639.).

Rate of Successful Extubation in Mechanically Ventilated Patients with Cirrhosis and Hepatic Coma

BACKGROUND

The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient.

METHODS

Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status.

RESULTS

Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation.

DISCUSSION

Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.

Recruitment s during mechanical ventilation with sequential high-flow nasal oxygen after extubation to prevent postoperative pulmonary complications in patients undergone thoracic surgery: a protocol, prospective randomised controlled trial

INTRODUCTION

The incidence of postoperative pulmonary complications (PPCs) following thoracic surgery is high, which increases the mortality rate, prolongs the length of hospital stay and increases medical costs. Some studies have confirmed that preoperative risk assessment, intraoperative anaesthesia methods and intraoperative mechanical ventilation strategies, including recruitment manoeuvres (RMs), can reduce the incidence of PPCs. Despite these improved strategies, the incidence of PPCs remains high. However, mechanical ventilation strategies have not been studied in the postoperative period.

METHODS AND ANALYSIS

We assume that RM during mechanical ventilation with sequential high-flow nasal oxygen therapy (HFNO) after extubation can maintain the opening of the postoperative alveoli and ultimately reduce the incidence of PPCs after thoracic surgery. We will include thoracic surgery patients and divide them into the RM with sequential HFNO group and the control group. They will be given RMs and sequential HFNO or be given conventional treatment. The sample size is 654 adult patients (327 per group) undergone thoracic surgery and presenting to the intensive care unit.

ETHICS AND DISSEMINATION

This study was approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (REC2019-730). It is expected that this study will lead to a randomised controlled trial. We assume that the findings will provide more evidence about PPCs and improve the management of patients undergone thoracic surgery.

TRIAL REGISTRATION NUMBER

ChiCTR2100046356.

The difficult removal of tracheal tube after general anesthesia: A case report

BACKGROUND

Laryngeal injury is common after endotracheal intubation, presenting with varying degrees of edema, ulceration, granulation, and limited vocal cord movement, usually resulting in lumen narrowing. In these cases, laryngeal edema is a common complication after intubation, usually caused by direct pressure and inflammatory reaction caused by endotracheal intubation on the contact surface.

CASE PRESENTATION

A 71-year-old female was scheduled to undergo open reduction and internal fixation of femoral neck. On admission, she was diagnosed with femoral neck fracture. Tracheal intubation induced by general anesthesia was successful, but the tracheal catheter was difficult to remove after the operation. After 2 days of detumescence in ICU, the extubation was successful under the condition of complete recovery of spontaneous breathing.

CONCLUSIONS

Patients undergoing general anesthesia may have laryngeal or glottic edema due to operation time, operation and other reasons, resulting in difficulty in extubation after general anesthesia. The extubation action shall be gentle. In case of obvious resistance, it shall not be forcibly extubated to prevent serious dyspnea after extubation.

Identification and Prevention of Extubation Failure by Using an Automated Continuous Monitoring Alert Versus Standard Care

BACKGROUND

Postextubation monitoring helps identify patients at risk of developing respiratory failure. This study aimed to evaluate the effect of our standard respiratory therapist (RT) assessment tool versus an automated continuous monitoring alert to initiate postextubation RT-driven care on the re-intubation rate.

METHODS

This was a single-center randomized clinical trial from March 2020 to September 2021 of adult subjects who received mechanical ventilation for > 24 h and underwent planned extubation in the ICU. The subjects were assigned to the standard RT assessment tool or an automated monitoring alert to identify the need for postextubation RT-driven care. The primary outcome was the need for re-intubation due to respiratory failure within 72 h. Secondary outcomes included re-intubation within 7 d, ICU and hospital lengths of stay, hospital mortality, ICU cost, and RT time associated with patient assessment and therapy provision.

RESULTS

Of 234 randomized subjects, 32 were excluded from the primary analysis due to disruption in RT-driven care during the surge of patients with COVID-19, and 1 subject was excluded due to delay in the automated monitoring initiation. Analysis of the primary outcome included 85 subjects assigned to the standard RT assessment group and 116 assigned to the automated monitoring alert group to initiate RT-driven care. There was no significant difference between the study groups in re-intubation rate, median length of stay, mortality, or ICU costs. The RT time associated with patient assessment (P < .001) and therapy provided (P = .031) were significantly lower in the automated continuous monitoring alert group.

CONCLUSIONS

In subjects who received mechanical ventilation for > 24 h, there were no significant outcome or cost differences between our standard RT assessment tool or an automated monitoring alert to initiate postextubation RT-driven care. Using an automated continuous monitoring alert to initiate RT-driven care saved RT time. (ClinicalTrials.gov registration NCT04231890).

Outcomes of Preterm Infants Who Experienced Unplanned Extubation

BACKGROUND

Unplanned extubation (UE) is associated with adverse outcomes. The aim of the study was to compare the clinical outcomes in preterm infants who experienced at least one UE to those who did not experience any UE.

METHODS

The matched cohort study compared ventilated preterm infants < 32 weeks who experienced UE to those who did not experience any UE. The main outcomes were duration of mechanical ventilation after matching, duration of hospital stay, retinopathy of prematurity (ROP) requiring intervention, and bronchopulmonary dysplasia (BPD).

RESULTS

Forty-seven infants were included in each group. The groups were matched for mechanical ventilation duration before UE, birth gestation, and birthweight. The duration of mechanical ventilation after matching (adjusted odds ratio [aOR] 14.8 [11.2-18.4], P = <.001), the total length of stay in the hospital (aOR 16.4 [3.7-29.2], P = .01), and severe ROP (aOR 6.7 [1.7-27.0], P = .007) were significantly higher in infants who experienced UE. After adjusting for mechanical ventilation duration, UE was not associated with ROP or BPD. However, infants who spent longer time on mechanical ventilation had higher odds of developing ROP (aOR 1.1 [1.0-1.2], P = .004) and BPD (aOR 1.5 [1.1-2.1], P = .01). Sensitivity analysis including infants who had UE and managed on noninvasive respiratory support showed significant association between UE and the outcomes of duration of mechanical ventilation, hospital length of stay, ROP, and BPD.

CONCLUSIONS

Infants who experienced UE had higher odds of spending longer time on mechanical ventilation and spent significantly more days in the hospital.

High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation for AECOPD Patients After Extubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To evaluate the clinical efficacy of high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) after extubation.

Research Methods

This systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statements. The primary outcome measures analyzed included: reintubation rate, mortality, complication rate, and ICU length of stay.

Results

Eight studies were included, with a total of 612 subjects, including 297 in the HFNC group and 315 in the NIV group. The effect of HFNC and NIV on the reintubation rate of AECOPD patients after extubation, RR (1.49 [95% CI,0.95 to 2.33], P = 0.082). Subgroup analysis with or without hypercapnia according to the included AECOPD population, with hypercapnia, RR (0.69 [95% CI,0.33 to 1.44], P=0.317), without hypercapnia, RR (2.61 [95% CI,1.41 to 4.83], P=0.002). Mortality, RR (0.92 [95% CI,0.56 to 1.52], P = 0.752). ICU length of stay, MD (−0.44 [95% CI,-1.01 to 0.13], P = 0.132). Complication rate, RR (0.22 [95% CI,0.13 to 0.39], P = 0.000). After subgroup analysis, the reintubation rate of HFNC and NIV has no statistical difference in patients with hypercapnia, but NIV can significantly reduce the reintubation rate in patients without hypercapnia. In the outcome measures of complication rate, HFNC significantly reduced complication rate compared with NIV. In mortality and ICU length of stay, analysis results showed that HFNC and NIV were not statistically different.

Conclusion

According to the available evidence, the application of HFNC can be used as an alternative treatment for NIV after extubation in AECOPD patients with hypercapnia, but in the patients without hypercapnia, HFNC is less effective than NIV.

[Predictors of upper airway obstruction following extubation in critically ill children]

Upper airway obstruction after extubation is a serious complication that can lead to extubation fai lure and other unfavorable outcomes in children.

OBJECTIVE

to describe the incidence and risk fac tors associated with post-extubation upper airway obstruction in critically ill children.

PATIENTS AND METHOD

A prospective descriptive observational study was carried out in a pediatric intensive care unit in Argentina over two years. Patients older than 1 month and younger than 18 years, receiving mechanical ventilatory support (MV) for more than 24 hours through an endotracheal tube (ETT) and with at least one programmed extubation were included.

RESULTS

Of 260 patients, 65 (25%) de veloped post-extubation upper obstruction. Of them, 37 were females (56.9%), with a median age of 14 months and 10 kg weight. The PIM3 score was 2.8 and the most frequent reason for admission was acute lower respiratory infection in 38 (43.1%) patients, among whom 36 (55.4%) had at least one complex chronic condition. Twenty-seven (41.5%) failed extubation and 5 (7.7%) required tracheos tomy. A multiple logistic regression analysis was performed to determine the relationship between different variables with the dependent variable. Independent risk factors explaining post-extubation upper obstruction were age ≤ 24 months and MV support for ≤ 3 days.

CONCLUSION

Post-extubation upper airway obstruction is frequent in the pediatric intensive care unit. We found that infants and mechanical ventilation duration less than or equal to 3 days are independent risk factors for its pre sentation.

[Risk factors of tracheal extubation failure in children with spinal muscular atrophy combined with pneumonia]

Objective: To summarize the risk factors of tracheal extubation failure in children with spinal muscular atrophy (SMA) combined with pneumonia. Methods: In this retrospective study, clinical data of 34 children with SMA combined with pneumonia who were hospitalized in Children's Hospital Affiliated to Capital Institute of Pediatrics from August 2018 to December 2021 were analyzed. According to whether the extubation was successful or not, they were divided into the success group and the failure group. The risk factors that may affect the success of extubation between two groups were derived by comparing the clinical characteristics by Mann-Whitney U test and Chi-square test, followed by multivariate Logistic regression. Results: Among the 34 cases, there were 14 males and 20 females, aged 10.8 (6.0,25.2) months at the time of hospitalization, 31 cases were type 1 SMA and 3 cases were type 2. Eleven children were unable to eat independently before intubation, 22 were treated with airway clearance techniques and 28 had multiple pulmonary infections. There were 21 cases in the success group and 13 cases in the failure group. The failure group had higher maximum partial pressure of arterial carbon dioxide level during intubation and higher rate of consolidation changes in chest images before extubation (81 (49,86) vs. 48 (43,56) mmHg (1 mmHg=0.133 kPa), 6/13 vs. 10%(2/21), Z=-2.55, χ²=5.99, both P<0.05). Multivariate Logistic regression analysis showed that tube feeding before intubation (OR =39.88, 95%CI 3.36-473.29, P=0.003) and not receiving airway clearance therapy (OR =14.55, 95%CI 1.35-156.78, P=0.027) were independent risk factors for extubation failure. Conclusions: The independent risk factors of tracheal extubation failure in children with SMA combined with pneumonia are unable to eat independently before intubation and not receiving airway clearance therapy. Therefore, the conditions to improve the success of extubation consist of having the ability to eat independently before intubation, using airway clearance techniques to improve ventilation and to make the chest images as clear as possible.

Does early extubation after cardiac surgery lead to a reduction in intensive care unit length of stay?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early extubation (EE) after cardiac surgery leads to a reduction in intensive care unit (ICU) length of stay (LOS)? A total of 564 papers were found using the reported search, of which 4 were randomized trials and hence represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. EE was defined as extubation in theatre (n = 2), within 6 h of surgery (n = 1) and within 8 h of surgery (n = 1). EE was associated with significantly reduced ICU LOS in all studies. Despite the Society of Thoracic Surgeons using extubation <6 h after surgery as a measure of quality, this study has demonstrated that no standardized definition for EE currently exists. The body of evidence identified in this work has demonstrated that for appropriately selected patients (avoiding patients with multiple comorbidities, advanced age and undergoing complex non-elective surgery) early tracheal extubation is associated with a reduction in ICU LOS without an increase in the rate of postoperative complications.

Clinical Benefit of Extubation in Patients on Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes.

DESIGN

Retrospective cohort study with propensity score overlap weighting analysis.

SETTING

Three ICUs in a 1,500-bed tertiary university hospital.

PATIENTS

From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias.

MEASUREMENTS AND MAIN RESULTS

Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95-0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21-8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11-26 d] vs 18 d [7-25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51-1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19-1.59]; p = 0.27).As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation-supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0-24 d] vs 0 d [0-18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29-0.71]; p = 0.001).

CONCLUSIONS

Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.