Investigating the risk of reintubation by cough force assessment using cough peak expiratory flow: a single-center observational pilot study

BACKGROUND

No objective indicator exists for evaluating cough strength during extubation of tracheally intubated patients. This study aimed to determine whether cough peak expiratory flow (CPEF) can predict the risk of reintubation due to decreased cough strength.

METHODS

This was a retrospective cohort study of patients who were admitted to our Emergency Intensive Care Unit between September 1, 2020 and August 31, 2021 and were under artificial ventilation management for ≥ 24 h. The patients were divided into two groups: successful extubation and reintubation groups, and the relationship between CPEF immediately before extubation and reintubation was investigated.

RESULTS

Seventy-six patients were analyzed. In the univariate analysis, CPEF was significantly different between the successful extubation (90.7 ± 25.9 L/min) and reintubation (57.2 ± 6.4 L/min) groups (p < 0.001). In the multivariate analysis with age and duration of artificial ventilation as covariates, CPEF was significantly lower in the reintubation group (p < 0.01). The cutoff value of CPEF for reintubation according to the receiver operating characteristic curve was 60 L/min (area under the curve, 0.897; sensitivity, 78.5%; specificity, 90.9%; p < 0.01).

CONCLUSION

CPEF in tracheally intubated patients may be a useful indicator for predicting the risk of reintubation associated with decreased cough strength. The cutoff CPEF value for reintubation due to decreased cough strength was 60 L/min.

External validation of a predictive model for reintubation after cardiac surgery: A retrospective, observational study

STUDY OBJECTIVE

Explore validation of a model to predict patients' risk of failing extubation, to help providers make informed, data-driven decisions regarding the optimal timing of extubation.

DESIGN

We performed temporal, geographic, and domain validations of a model for the risk of reintubation after cardiac surgery by assessing its performance on data sets from three academic medical centers, with temporal validation using data from the institution where the model was developed.

SETTING

Three academic medical centers in the United States.

PATIENTS

Adult patients arriving in the cardiac intensive care unit with an endotracheal tube in place after cardiac surgery.

INTERVENTIONS

Receiver operating characteristic (ROC) curves and concordance statistics were used as measures of discriminative ability, and calibration curves and Brier scores were used to assess the model's predictive ability.

MEASUREMENTS

Temporal validation was performed in 1642 patients with a reintubation rate of 4.8%, with the model demonstrating strong discrimination (optimism-corrected c-statistic 0.77) and low predictive error (Brier score 0.044) but poor model precision and recall (Optimal F1 score 0.29). Combined domain and geographic validation were performed in 2041 patients with a reintubation rate of 1.5%. The model displayed solid discriminative ability (optimism-corrected c-statistic = 0.73) and low predictive error (Brier score = 0.0149) but low precision and recall (Optimal F1 score = 0.13). Geographic validation was performed in 2489 patients with a reintubation rate of 1.6%, with the model displaying good discrimination (optimism-corrected c-statistic = 0.71) and predictive error (Brier score = 0.0152) but poor precision and recall (Optimal F1 score = 0.13).

MAIN RESULTS

The reintubation model displayed strong discriminative ability and low predictive error within each validation cohort.

CONCLUSIONS

Future work is needed to explore how to optimize models before local implementation.

Physiological effects of high-flow nasal cannula oxygen therapy after extubation: a randomized crossover study

BACKGROUND

Prophylactic high-flow nasal cannula (HFNC) oxygen therapy can decrease the risk of extubation failure. It is frequently used in the postextubation phase alone or in combination with noninvasive ventilation. However, its physiological effects in this setting have not been thoroughly investigated. The aim of this study was to determine comprehensively the effects of HFNC applied after extubation on respiratory effort, diaphragm activity, gas exchange, ventilation distribution, and cardiovascular biomarkers.

METHODS

This was a prospective randomized crossover physiological study in critically ill patients comparing 1 h of HFNC versus 1 h of standard oxygen after extubation. The main inclusion criteria were mechanical ventilation for at least 48 h due to acute respiratory failure, and extubation after a successful spontaneous breathing trial (SBT). We measured respiratory effort through esophageal/transdiaphragmatic pressures, and diaphragm electrical activity (ΔEAdi). Lung volumes and ventilation distribution were estimated by electrical impedance tomography. Arterial and central venous blood gases were analyzed, as well as cardiac stress biomarkers.

RESULTS

We enrolled 22 patients (age 59 ± 17 years; 9 women) who had been intubated for 8 ± 6 days before extubation. Respiratory effort was significantly lower with HFNC than with standard oxygen therapy, as evidenced by esophageal pressure swings (5.3 [4.2-7.1] vs. 7.2 [5.6-10.3] cmH2O; p < 0.001), pressure-time product (85 [67-140] vs. 156 [114-238] cmH2O*s/min; p < 0.001) and ΔEAdi (10 [7-13] vs. 14 [9-16] µV; p = 0.022). In addition, HFNC induced increases in end-expiratory lung volume and PaO2/FiO2 ratio, decreases in respiratory rate and ventilatory ratio, while no changes were observed in systemic hemodynamics, Troponin T, or in amino-terminal pro-B-type natriuretic peptide.

CONCLUSIONS

Prophylactic application of HFNC after extubation provides substantial respiratory support and unloads respiratory muscles. Trial registration January 15, 2021. NCT04711759.

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

BACKGROUND

Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes.

METHODS

This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation.

RESULTS

Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h).

CONCLUSIONS

Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.

Unplanned Extubation in the Pediatric Intensive Care Unit

Unplanned extubations (UEs) are common, potentially avoidable complications of endotracheal intubation among pediatric patients. UE can be associated with adverse patient outcomes including increased length of stay, hospitalization cost, and cardiorespiratory decompensation. Inconsistency in the definition of UE has led to underreporting. Staff must be able to recognize and intervene appropriately when an UE occurs. Risk factors have been identified and quality improvement initiatives aimed at reducing UE have shown to be effective in reducing the incidence. The lack of consistent definition may lead to underreporting and may not lead to effective quality improvement initiatives.

Impact of delay extubation on the reintubation rate in patients after cervical spine surgery: a retrospective cohort study

BACKGROUND

The incidence of cervical airway obstruction after cervical spine surgery (CSS) ranges from 1.2 to 14%, and some require reintubation. If not addressed promptly, the consequences can be fatal. This study investigated delayed extubation's effect on patients' reintubation rate after cervical spine surgery.

METHODS

We performed a retrospective case-control analysis of cervical spine surgery from our ICU from January 2021 to October 2022. Demographic and preoperative characteristics, intraoperative data, and postoperative clinical outcomes were collected for all 94 patients. Univariable analysis and multivariable logistic regression were used to analyze postoperative unsuccessful extubation risk factors following cervical spine surgery.

RESULTS

The patients in the early extubation (n = 73) and delayed extubation (n = 21) groups had similar demographic characteristics. No significant differences were found in the reintubation rate (0 vs. 6.8%, p = 0.584). However, the delayed extubation group had significantly more patients with 4 and more cervical fusion segments (42.9 vs. 15.1%, p = 0.013),more patients with an operative time greater than 4 h (33.3 vs. 6.8%, p = 0.004)and all patients involved C2-4 (78 vs. 100%, p = 0.019).Also, patients in the delayed extubation group had a longer duration of ICU stay (152.9 ± 197.1 h vs. 27.2 ± 45.4 h, p < 0.001) and longer duration of hospital stay (15.2 ± 6.9 days vs. 11.6 ± 4.1 days, p = 0.003). Univariate and multivariate analysis identified the presences of cervical spondylotic myelopathy (CSM) (OR 0.02, 95% CI 0-0.39, p = 0.009) and respiratory diseases (OR: 23.2, 95% CI 2.35-229.51, p = 0.007) as unfavorable prognostic factor for reintubation.

CONCLUSIONS

Our analysis of patients with cervical spondylosis who received CSS indicated that delayed extubation was associated with the presence of respiratory diseases and CSM, longer operative time, more cervical fusion segments, and longer duration of ICU and hospital stays.

A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks

INTRODUCTION

How to avoid reintubations in prematurity remains a hard nut. This study aimed to develop and validate a nomogram for predicting extubation failure in preterm infants who received different modes of noninvasive ventilation as post-extubation support.

METHODS

This was a secondary analysis of pre-existing data from a large multicenter RCT combined with a multicenter retrospective investigation in three tertiary referral NICUs in China. The training cohort consisted of extubated infants from the RCT and the validation cohort included neonates admitted to the three NICUs in the last 5 years. The nomogram was developed through univariate and multivariate logistic regression analyses of peri-extubation clinical variables.

RESULTS

A total of 432 and 183 preterm infants (25 weeks ≤ gestational age [GA] <29 weeks) were, respectively, included in the training cohort and the validation cohort. Lower birth weight, lower Apgar 5-min score, lower postmenstrual age at extubation, lower PO2 and higher PCO2 before extubation, and continuous positive airway pressure rather than nasal intermittent positive pressure ventilation or noninvasive high-frequency oscillatory ventilation after extubation were associated with higher risks of extubation failure (p < 0.05), on which the nomogram was established. In both the training cohort and the validation cohort, the nomogram demonstrated good predictive accuracy (area under the receiver operating characteristic curve = 0.744 and 0.826); the Hosmer-Lemeshow test (p = 0.192 and 0.401) and the calibration curve (R2 = 0.195 and 0.307) proved a good fitness and conformity; and the decision curve analysis showed significant net benefit at the best threshold (p = 0.201).

CONCLUSION

This nomogram could serve as a good decision-support tool when predicting extubation failure in preterm infants with GA less than 29 weeks.

A machine learning approach to predicting early and late postoperative reintubation

Accurate estimation of surgical risks is important for informing the process of shared decision making and informed consent. Postoperative reintubation (POR) is a severe complication that is associated with postoperative morbidity. Previous studies have divided POR into early POR (within 72 h of surgery) and late POR (within 30 days of surgery). Using data provided by American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), machine learning classification models (logistic regression, random forest classification, and gradient boosting classification) were utilized to develop scoring systems for the prediction of combined, early, and late POR. The risk factors included in each scoring system were narrowed down from a set of 37 pre and perioperative factors. The scoring systems developed from the logistic regression models demonstrated strong performance in terms of both accuracy and discrimination across the different POR outcomes (Average Brier score, 0.172; Average c-statistic, 0.852). These results were only marginally worse than prediction using the full set of risk variables (Average Brier score, 0.145; Average c-statistic, 0.870). While more work needs to be done to identify clinically relevant differences between the early and late POR outcomes, the scoring systems provided here can be used by surgeons and patients to improve the quality of care overall.

Reintubation in COVID-19 patients: a multicenter observational study in Japan (J-RECOVER study)

BACKGROUND

Reintubation is not an uncommon occurrence following extubation and discontinuation of mechanical ventilation. In COVID-19 patients, the proportion of reintubation may be higher than that of non-COVID-19 patients. Furthermore, COVID-19 patients may have a higher risk for developing laryngotracheal stenosis, along with a higher proportion of reintubation than in non-COVID-19 patients. Our understanding of the proportion of reintubation in COVID-19 patients is limited in Japan. Additionally, the reasons for reintubation have not been adequately examined in previous studies outside of Japan. Thus, the present study aimed to describe the proportion and causes of reintubation among COVID-19 patients in Japan.

METHODS

This was a multicenter observational study that included 64 participating centers across Japan. This study included mechanically ventilated COVID-19 patients who were discharged between April 1, 2020 and September 30, 2020. The outcomes examined were the proportion and causes of reintubation.

RESULTS

A total of 373 patients were eligible for inclusion in the current analysis. The median age of patients was 64 years and 80.4% were male. Reintubation was required for 35 patients (9.4%) and the most common causes for reintubation were respiratory failure (71.4%; n = 25) and laryngotracheal stenosis (8.6%; n = 3).

CONCLUSIONS

The proportion of reintubation among COVID-19 patients in Japan was relatively low. Respiratory failure was the most common cause for reintubation. Reintubation due to laryngotracheal stenosis accounted for only a small fraction of all reintubated COVID-19 patients in Japan.

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.

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

BACKGROUND

A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation.

METHODS

This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality.

RESULTS

Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, - 6.1-13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, - 3.4-25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04-0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded.

CONCLUSIONS

Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.

Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial

PURPOSE

High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure).

METHODS

Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation.

RESULTS

Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference -15.5%; 95% confidence interval (CI) -28.3 to -1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5-21.1]). No additional differences in the other secondary outcomes were observed.

CONCLUSIONS

Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation.

Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.

Risk factors associated with reintubations in children undergoing foreign body removal using flexible bronchoscopy: a single-center retrospective cross-sectional study

Background

Reintubation is a severe complication during foreign body (FB) removal that uses flexible bronchoscopy.

Objective

To investigate the incidence and risk factors for reintubations in children undergoing FB extraction by flexible bronchoscopy in a single center.

Design

A retrospective cross-sectional study.

Setting

All children with foreign body aspiration at Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University from January 2015 to December 2020.

Patients

Children with FB removal using a flexible bronchoscopy were enrolled in the trial according to the inclusion criteria.

Measurements

Both multivariable and logistic regression analyses were used to analyze the association between characteristic data and reintubations. The results were presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

In total, 244 patients met with the inclusion criteria and were included in the analysis. Among those participants, 28 children (11.5%) underwent reintubations after FB removal by flexible bronchoscopy. Independent factors associated with reintubations were identified as operative time ≥ 60 min [OR: 3.68, 95% CI (1.64–8.82)] and ASA ≥ III [OR: 5.7, 95% CI (1.23–26.4)].

Conclusions

Children undergoing FB removal by a flexible bronchoscopy may encounter with a high incidence of postoperative reintubations. Both long operative duration and a severe physical status cause a growing risk of reintubations.

Cardiac dysfunction is not associated with increased reintubation rate in patients treated with post-extubation high-flow nasal cannula

Background

Cardiac dysfunction patients have long been considered at high risk of reintubation. However, it is based on past studies in which only conventional oxygen therapy was applied after extubation. We investigated association between cardiac dysfunction and reintubation rate in situation where high-flow nasal cannula (HFNC) was widely used during post-extubation period.

Methods

We conducted a retrospective observational cohort study of patients treated with HFNC after planned extubation in medical intensive care unit of single tertiary center. Patients were divided into normal function group (ejection fraction [EF] ≥45%) and cardiac dysfunction group (EF <45%). The primary outcome was reintubation rate within 72 hours following extubation.

Results

Of 270 patients, 35 (13%) had cardiac dysfunction. Baseline characteristics were similar in both groups. There were no differences in the changes in vital signs between the two groups during the first 12 hours after extubation except diastolic blood pressure. The reintubation rates were 20% and 17% for cardiac dysfunction group and normal function group, respectively (p=0.637). In a multivariate Cox regression analysis, cardiac dysfunction was not associated with an increased risk of reintubation within 72 hours following extubation (hazard ratio, 1.56; p=0.292).

Conclusion

Cardiac dysfunction was not associated with increased reintubation rate within 72 hours when HFNC is immediately applied after planned extubation.

Extubation strategies after esophageal atresia repair

BACKGROUND/PURPOSE

Early extubation following repair of esophageal atresia (EA) is desirable unless the anastomosis is under tension, in which case paralysis and post-operative ventilation may reduce the risk of anastomotic leakage. However, complications from emergency reintubations do occur with either strategy. We aim to examine the risk/benefit balance of early and delayed extubation following EA repair.

METHODS

A seven-year retrospective review of all babies that underwent EA repair was performed. Babies extubated within 24 h of surgery were classified as early extubation (EE). Babies intubated beyond the first 24 h were classified as delayed extubation (DE). The EE group was subdivided into babies extubated in operating room (EIOR), and babies who returned to the neonatal intensive care unit (NICU) intubated but extubated within 24 h (EW24).

RESULTS

Forty-six babies were analyzed, and overall 15 (32.6%) required 24 reintubation episodes. Eight (28.6%) babies in the EE group required reintubation. The EIOR group (n = 12) had significantly increased risk of requiring reintubation (OR:7, 95%CI:1.08 to 45.16:p = 0.04) compared to the EW24 group (n = 16). Seven (38.9%) babies in the DE group required reintubation. The complication rate from reintubation after EA repair was 17%.

CONCLUSIONS

Extubation on the NICU within 24 h of surgery carried the lowest risk of reintubation. For babies with a tight anastomosis, elective postoperative ventilation appeared to confer a protective benefit without incurring a high risk of complications from reintubation.

Postoperative Respiratory Failure After Elective Abdominal Surgery: A Case-Control Study

INTRODUCTION

Postoperative respiratory failure (PRF) contributes significantly to morbidity and mortality. We sought to identify patient characteristics and perioperative risk factors associated with PRF in patients undergoing elective abdominal surgery to improve patient outcomes.

METHODS

We retrospectively reviewed patients undergoing elective abdominal surgery from 2011 to 2016 at our institution. An experimental group consisting of adult patients with the Patient Safety Indicator 11 diagnosis of PRF was compared with a time-matched control group.

RESULTS

Each group consisted of 233 patients. Comorbidities associated with PRF included ascites, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II, hypertension, and hypoalbuminemia (P < 0.05). American Society of Anesthesiologists score IV (20.2% versus 3.95%; P < 0.001), operative time (4.13 versus 2.55 h; P < 0.001), laparotomy with open operation (77.7% versus 45.5%; P < 0.001), and net intraoperative fluid balance (3635 versus 2410 mL; P < 0.001) were higher in patients with PRF. On multivariate analysis, age, American Society of Anesthesiologists score, chronic obstructive pulmonary disease, diabetes mellitus type II, laparotomy, and net intraoperative fluid balance maintained significance (P < 0.05).

CONCLUSIONS

We identified contributing pre- and intra-operative risk factors for PRF undergoing elective abdominal surgery. These findings may help identify those at increased risk for respiratory failure and mitigate complications.

Frequent tracheal suctioning is associated with extubation failure in patients with successful spontaneous breathing trial: a single-center retrospective cohort study

BACKGROUND

Extubation failure, i.e., reintubation in ventilated patients, is a well-known risk factor for mortality and prolonged stay in the intensive care unit (ICU). Although sputum volume is a risk factor, the frequency of tracheal suctioning has not been validated as a predictor of reintubation. We conducted this study to examine whether frequent tracheal suctioning is a risk factor for reintubation.

PATIENTS AND METHODS

We included adult patients who were intubated for > 72 h in the ICU and extubated after completion of spontaneous breathing trial (SBT). We compared the characteristics and weaning-related variables, including the frequency of tracheal suctioning between patients who required reintubation within 24 h after extubation and those who did not, and examined the factors responsible for reintubation.

RESULTS

Of the 400 patients enrolled, reintubation was required in 51 (12.8%). The most common cause of reintubation was difficulty in sputum excretion (66.7%). There were significant differences in sex, proportion of patients with chronic kidney disease, pneumonia, ICU admission type, the length of mechanical ventilation, and ICU stay between patients requiring reintubation and those who did not. Multivariate analysis showed frequent tracheal suction (> once every 2 h) and the length of mechanical ventilation were independent factors for predicting reintubation.

CONCLUSION

We should examine the frequency of tracheal suctioning > once every 2 h in addition to the length of mechanical ventilation before deciding to extubate after completion of SBT in patients intubated for > 72 h in the ICU.

A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial

BACKGROUND

High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients.

METHODS

We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation.

RESULTS

Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59).

CONCLUSIONS

Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.

Reintubation rates after extubation to different non-invasive ventilation modes in preterm infants

INTRODUCTION

Respiratory Distress Syndrome (RDS) is a common cause of neonatal morbidity and mortality in premature newborns. In this study, we aim to compare the reintubation rate in preterm babies with RDS who were extubated to Nasal Continuous Positive Airway Pressure (NCPAP) versus those extubated to Nasal Intermittent Positive Pressure Ventilation (NIPPV).

METHODS

This is a retrospective study conducted in the Neonatal Intensive Care Unit (NICU) of Women's Wellness and Research Center (WWRC), Doha, Qatar. The medical files (n = 220) of ventilated preterm infants with gestational age ranging between 28 weeks 0 days and 36 weeks + 6 days gestation and extubated to non-invasive respiratory support (whether NCPAP, NIPPV, or Nasal Cannula) during the period from January 2016 to December 2017 were reviewed.

RESULTS

From the study group of 220 babies, n = 97 (44%) babies were extubated to CPAP, n = 77 (35%) were extubated to NIPPV, and n = 46 (21%) babies were extubated to Nasal Cannula (NC). Out of the n = 220 babies, 18 (8.2%) were reintubated within 1 week after extubation. 14 of the 18 (77.8%) were reintubated within 48 h of extubation. Eleven babies needed reintubation after being extubated to NCPAP (11.2%) and seven were reintubated after extubation to NIPPV (9.2%), none of those who were extubated to NC required reintubation (P = 0.203). The reintubation rate was not affected by extubation to any form of non-invasive ventilation (P = 0.625). The mode of ventilation before extubation does not affect the reintubation rate (P = 0.877). The presence of PDA and NEC was strongly associated with reintubation which increased by two and four-folds respectively in those morbidities. There is an increased risk of reintubation with babies suffering from NEC and BPD and this was associated with an increased risk of hospital stay with a P-value ranging (from 0.02-0.003). Using multivariate logistic regression, NEC the NEC (OR = 5.52, 95% CI 1.26, 24.11, P = 0.023) and the vaginal delivery (OR = 0.23, 95% CI 0.07, 0.78, P = 0.018) remained significantly associated with reintubation.

CONCLUSION

Reintubation rates were less with NIPPV when compared with NCPAP, however, this difference was not statistically significant. This study highlights the need for further research studies with a larger number of neonates in different gestational ages birth weight categories. Ascertaining this information will provide valuable data for the factors that contribute to re-intubation rates and influence the decision-making and management of RDS patients in the future.

A Machine Learning decision-making tool for extubation in Intensive Care Unit patients

BACKGROUND AND OBJECTIVE

To increase the success rate of invasive mechanical ventilation weaning in critically ill patients using Machine Learning models capable of accurately predicting the outcome of programmed extubations.

METHODS

The study population was adult patients admitted to the Intensive Care Unit. Target events were programmed extubations, both successful and failed. The working dataset is assembled by combining heterogeneous data including time series from Clinical Information Systems, patient demographics, medical records and respiratory event logs. Three classification learners have been compared: Logistic Discriminant Analysis, Gradient Boosting Method and Support Vector Machines. Standard methodologies have been used for preprocessing, hyperparameter tuning and resampling.

RESULTS

The Support Vector Machine classifier is found to correctly predict the outcome of an extubation with a 94.6% accuracy. Contrary to current decision-making criteria for extubation based on Spontaneous Breathing Trials, the classifier predictors only require monitor data, medical entry records and patient demographics.

CONCLUSIONS

Machine Learning-based tools have been found to accurately predict the extubation outcome in critical patients with invasive mechanical ventilation. The use of this important predictive capability to assess the extubation decision could potentially reduce the rate of extubation failure, currently at 9%. With about 40% of critically ill patients eventually receiving invasive mechanical ventilation during their stay and given the serious potential complications associated to reintubation, the excellent predictive ability of the model presented here suggests that Machine Learning techniques could significantly improve the clinical outcomes of critical patients.

Incidence of immediate postextubation complications in critically Ill adult patients

BACKGROUND

Postextubation complication rates vary among studies. It is necessary to standardize a method to identify postextubation complications and determine their potential association with extubation failure and reintubation in critically ill adult patients.

OBJECTIVES

To describe immediate (up to 60 min) endotracheal postextubation complications in critically ill adult patients and determine whether these complications are associated with extubation failure.

METHODS

Secondary analysis of a Randomized Clinical Trial that included 240 critically ill adult patients, who were eligible for extubation. Overall complications include at least one major complication (upper airway obstruction, desaturation, vomiting, post-obstructive pulmonary edema) and/or minor complications (bronchospasm, severe cough, hypertension, tachycardia, tachypnea, poor respiratory mechanics).

RESULTS

Incidence of overall, major and minor complications was 71.2%, 30.9% and 62.7%, respectively. Forty (16.9%) patients failed extubation, and thirty (12.7%) were reintubated. Of 168 patients who developed a postextubation complication, 137 (81.5%) were successfully extubated. Only major complications were significantly associated with reintubation after extubation failure (p<0.001).

CONCLUSION

We have observed high incidence rates of overall, major and minor complications. The development of major complications was statistically significantly associated with extubation failure and reintubation. It is still unknown whether the identification and treatment of immediate postextubation complications have positive effects on patients' clinical course or whether the complications are a mere effect of the extubation procedure.

Effect of high-flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation for preventing reintubation: a Bayesian network meta-analysis and systematic review

Background

Adequate respiratory support can improve clinical outcomes in patients who are ready for weaning from a ventilator. We aimed to investigate the efficacy of respiratory methods in adults undergoing planned extubation using a Bayesian network meta-analysis.

Methods

We searched PubMed, Embase, and ClinicalTrials.gov for unpublished and ongoing trials up to November 2019 for randomized controlled trials (RCTs) published in English that compared conventional oxygen therapy (COT), a high-flow nasal cannula (HFNC), and noninvasive ventilation (NIV) for post-extubation respiratory support. Screening of citations, study selection, data extraction, and assessment of risk were performed independently by two authors. The primary outcome was the reintubation rate.

Results

Twenty-two studies (4,218 patients) were included in our meta-analysis. Extubated patients supported with NIV had a significantly lower incidence of reintubation than those supported with COT [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.42, 0.89]. However, there was no significant difference in the reintubation rate between the HFNC and NIV, and HFNC and COT groups (OR: 1.05, 95% CI: 0.60, 1.81; OR: 0.60, 95% CI: 0.33, 1.02, respectively). HFNC and NIV reduced the incidence of hospital-acquired pneumonia (HAP) (OR: 0.50, 95% CI: 0.25, 0.93; OR: 0.55, 95% CI: 0.27, 0.87, respectively) and post-extubation acute respiratory failure (ARF) (OR: 0.35, 95% CI: 0.14, 0.89; OR: 0.31, 95% CI: 0.14, 0.63, respectively) compared with COT. There was no significant difference in a decreased incidence of HAP (OR: 1.1, 95% CI: 0.56, 1.8) or post-extubation ARF (OR: 0.87, 95% CI: 0.33, 2.1) between NIV and HFNC. There were also no significant differences in improvements in other clinical outcomes, including intensive care unit (ICU) and hospital mortality and the length of stay (LOS) between NIV and HFNC.

Conclusions

NIV reduces the reintubation rate in adult patients undergoing planned extubation compared with COT and HFNC.

Interest of hand grip strength to predict outcome in mechanically ventilated patients

BACKGROUND

Weaning from mechanical ventilation is a crucial process for critically ill patients. Hand grip strength (HGS) is an assessment tool for respiratory muscle function to assist guidance of extubation.

OBJECTIVE

To evaluate HGS as a predictor for in-hospital clinical outcomes in mechanically ventilated patients.

METHODS

A prospective study was conducted. Patients requiring mechanical ventilation with tracheal intubation in medical wards and intensive care units were recruited. HGS, reintubation, number of ventilator-free days and mortality were recorded.

RESULTS

A total of 34 patients (52.9% men) were included. When compared to the non re-intubation group, the re-intubation group had significantly lower HGS at 10 min and 30 min after starting spontaneous breathing trial (7.6 ± 4.8 kg Vs 13.4 ± 6.5 kg, P = 0.045, and 8 ± 5.1 kg Vs 13.2 ± 5.7 kg, P = 0.047). Moreover, at 1 h and 48 h of post extubation, the re-intubation group had lower HGS than the non re-intubation group. HGS at 1 h of post extubation was positively correlated with ventilator-free day at 28 days (r = 0.34, P = 0.05). HGS did not differ between survival group and death group in hospital over time.

CONCLUSIONS

Hand grip strength may be a predictive tool for extubation failure in mechanically ventilated patients. Low strength corresponded to significantly increased re-intubation rate. Furthermore, this measurement could not predict in-hospital mortality.

Failure to extubate and delayed reintubation in elective lumbar fusion: An analysis of 57,677 cases

OBJECTIVES

There is a scarcity of literature exploring the consequences of Failure To Extubate (FTE) and Delayed Reintubation (DRI) in spine surgery. While it is reasonable to believe that patients who FTE or undergo DRI after Posterior Lumbar Fusion (PLF) and Transforaminal Lumbar Interbody Fusion (TLIF) are at risk for graver outcomes, there is minimal data to explicitly support that. The goal of this study was to investigate the morbidity and mortality associated with FTE and DRI after lumbar spine surgery in a large pool of patients.

PATIENTS AND METHODS

We conducted a retrospective multicenter study of patients that underwent elective posterior lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. We excluded patients with disseminated cancer, metastatic disease to the neural axis, patient with spinal epidural abscess, and patients with ventilator dependency prior to the operation.

RESULTS

57,677 patients from 2006 to 2016 were identified; 55 patients (0.1 %) had FTE and 262 patients (0.46 %) had DRI. The incidence of pneumonia was 27.2-fold greater in the FTE group and septic shock was 63.5-fold greater. All complications listed below are significance to p < 0.001. Deep vein thrombosis, pulmonary embolism, myocardial infarction and cardiac arrest were respectively, 10.4-, 12.2-, 22.8-, and 45.5- fold greater in the FTE group. Overall complication rate differed significantly between the two groups and were 9.8-fold greater in the FTE group. FTE was associated with increased, length of stay and all complications except DVT and pulmonary embolism. FTE was profoundly associated with severe complications (OR 13.0, 95 % CI 7.2-23.5) and mortality (OR = 21.5, CI = 7.5-61.0). The DRI group had a significantly higher morbidity (OR = 71.0, CI = 44.1-114.4), including overall complication (OR = 21.2, CI = 16.0-28.0) and severe complications (OR = 34.4, CI = 26.1-45.3). The DRI group had significantly higher rates of pneumonia (OR = 37.0), DVT (OR = 9.6) and pulmonary embolism (OR = 7.0), septic shock (OR = 60.5), myocardial infarction (OR = 32.1,) and cardiac arrest (OR = 236.4).

CONCLUSION

FTE and DRI were highly predictive of morbidity and mortality. Overall, investigations of the effects of FTE and DRI following spine procedures are lacking. This large multi-center national database review is one of the first to provide insight into the consequences of FTE and DRI in lumbar fusion cases. Future investigation into the consequences and predictors of FTE and DRI in spine surgery are required.

A comprehensive protocol for ventilator weaning and extubation: a prospective observational study

Background

Ventilator weaning protocols have been shown to reduce the duration of mechanical ventilation (MV), intensive care unit length of stay, and resource use. However, weaning protocols have not significantly affected mortality or reintubation rates. The extubation process is a critical component of respiratory care in patients who receive MV. Post-extubation respiratory failure (PERF) is a common event associated with significant morbidity and mortality. We hypothesized that a comprehensive protocol for ventilator weaning and extubation would be effective for preventing PERF and reintubation and reducing mortality in critically ill patients.

Methods

A ventilator weaning and extubation protocol was developed. The protocol consisted of checklists across four evaluations: spontaneous breathing trial, extubation, prophylactic non-invasive positive pressure ventilation (NPPV), and evaluation after extubation. Observational data were collected after implementing the protocol in patients admitted to the Advanced Emergency and Critical Care Center of Shinshu University Hospital. Not only outcomes of patients but also influences of each component of the protocol on the clinical decision-making process were investigated. Further, a comparison between PERF and non-PERF patients was performed.

Results

A total of 464 consecutive patients received MV for more than 48 h, and 248 (77 women; mean age, 65 ± 17 years) were deemed eligible. The overall PERF and reintubation rates were 9.7% and 5.2%, respectively. Overall, 54.1% of patients with PERF received reintubation. Hospital stay and mortality were not significantly different between PERF and non-PERF patients (p = 0.16 and 0.057, respectively). As a result, the 28-day and hospital mortality were 1.2% and 6.9%, respectively.

Conclusions

We found that the rates of PERF, reintubation, and hospital mortality were lower than those in previous reports even with nearly the same degree of severity at extubation. The comprehensive protocol for ventilator weaning and extubation may prevent PERF and reintubation and reduce mortality in critically ill patients.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair

INTRODUCTION

Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR.

METHODS

OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables.

RESULTS

There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m², age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m², p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm², p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm³, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI.

CONCLUSION

The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty

OBJECTIVE

To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient.

METHODS

A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay.

RESULTS

Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2).

CONCLUSION

Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Noninvasive Ventilation and Oxygen Therapy after Extubation in Patients with Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials

Background

Role of noninvasive ventilation (NIV) following extubation in patients with acute respiratory failure is debatable. NIV may provide benefit in post surgical patients, but its role in nonsurgical patients is controversial.

Materials and methods

PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from 1946 to 20^th November 2017) to identify prospective randomized controlled trials, where postextubation NIV has been compared with standard oxygen therapy in adult patients with acute respiratory failure.

Results

Data of 1525 patients from 11 randomized trials have been included in this meta-analysis. Two trials used NIV to manage post-extubation respiratory failure. Pooled analysis found that mortality rate at longest available follow-up [OR (95% CI) 0.84 (0.50, 1.42); p = 0.52] and reintubation rate [OR (95% CI) 0.75 (0.51, 1.09); p = 0.13] were similar between NIV and standard oxygen therapy. NIV did not decrease intubation rate when used as preventive modality [OR (95% CI) 0.65 (0.40, 1.06); p = 0.08]. Duration of ICU stay was also similar in the two groups [MD (95% CI) 0.46 (-0.43, 1.36) days; p = 0.3].

Conclusion

Post extubation NIV in non- surgical patients with acute respiratory failure does not provide any benefit over conventional oxygen therapy.

How to cite this article

Maitra S, Bhattacharjee S, Som A. Noninvasive Ventilation and Oxygen Therapy after Extubation in Patients with Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2019;23(9):414-422.

An Open Label Randomized Controlled Trial to Compare Low Level Pressure Support and T-piece as Strategies for Discontinuation of Mechanical Ventilation in a General Surgical Intensive Care Unit

Objective

The purpose of this study was to compare the efficacy of continuous low pressure support (PSV) and T-piece as strategies for discontinuation of mechanical ventilation and extubation in a surgical ICU.

Patients and Methods

This was a prospective open label randomized control study in surgical ICU patients who were intubated, mechanically ventilated, and who met criteria for a spontaneous breathing trial. Eligible, enrolled patients were randomized to receive low-level pressure supportup to 7 cmH2O (PSV) or T-piece as the mode of their spontaneous breathing trial.

Results

A total of 520 patients were randomized (260 in PSV group and 260 in T-piece group). There were no differences between the groups in baseline characteristics except duration of MV before trial was longer in PSV group. There were also no differences in hemodynamic and respiratory measures between groups. The PSV had a significant higher number of SBT attempt before success and extubation. After extubation, the re-intubation within 48 hours had a lower trend in PSV group (PSV vs. T-piece: 10% vs. 14.6%; p=0.11). The pneumonia occurrence, hospital mortality, hospital and ICU length of stay were not significant different between groups. In multivariable analysis, PSV was associated with a lower risk of success at the first SBT (adjusted relative risk, RR 0.79 [95% confidence interval, CI, 0.70 - 0.88]; p<0.001], and a lower risk of re-intubation within 48 hours after extubation (adjusted RR 0.62 [95%CI 0.40 - 0.98]; p=0.04). There were no differences between groups in pneumonia after extubation and in hospital mortality rate.

Conclusion

Although PSV needs a higher number of SBT trial before success and extubation, the re-intubation within 48 hours is lower than T piece. However, there were no differences between the groups in term of pneumonia after extubation, hospital mortality as well as ICU and hospital length of stay.

Perioperative risk factors for postoperative respiratory failure

The study aimed to identify the risk factors for respiratory failure after surgery. Postoperative respiratory failure (PRF) was defined as prolonged intubation after surgery or reintubation after unsuccessful extubation. We conducted a retrospective analysis of the following risk factors: age, obesity as reflected by body mass index (BMI), gender, patient admitted to hospital (in-patient status) vs. outpatient surgery, smoking, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, abnormal liver function, anaemia, respiratory infection, physical condition as reflected by ASA class, case type (elective or emergency), anaesthesia type, and surgical duration. The incidence of PRF was found to be 2.4%. Independent risk factors were older age, inpatient status, hypertension, COPD, elective procedure, surgical duration >2 hours, and ASA class ≥3. The study concludes that PRF results in significant postoperative complications. Minimising these risks is essential in improving PRF and subsequently surgical outcomes.

FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients

BACKGROUND

A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk.

METHODS

FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation.

RESULTS

There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]).

CONCLUSIONS

Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Dependent functional status is associated with unplanned postoperative intubation after elective cervical spine surgery: a national registry analysis

PURPOSE

The impact of preoperative functional status on 30-day unplanned postoperative intubation and clinical outcomes among patients who underwent cervical spine surgery is not well-described. We hypothesized that functional dependence is associated with 30-day unplanned postoperative intubation and that among the reintubated cohort, functional dependence is associated with adverse postoperative clinical outcomes after cervical spine surgery.

METHODS

Utilizing the 2007-2016 American College of Surgeons National Surgical Quality Improvement Program database, we identified adult elective anterior and posterior cervical spine surgery patients by Current Procedural Terminology codes. We performed (1) a Cox Proportional Hazard analysis for the following outcomes: reintubation, prolonged ventilator use, and pneumonia and (2) an adjusted logistic regression analysis among patients that required postoperative reintubation to evaluate the association of functional status with adverse postoperative outcomes.

RESULTS

The sample size was 26,263, of which 550 (2.1%) were functionally dependent. The adjusted model suggested that when compared with functionally independent patients, dependent patients were at increased risk of unplanned 30-day intubation (HR 2.05, 95% CI 1.26-3.34; P = 0.003). The adjusted risk of 30-day postoperative pneumonia was significantly higher in patients with functional dependence (HR 1.61, 95% CI 1.02-2.54, P = 0.036). Among patients that required postoperative reintubation, the odds of 30-day mortality was significantly higher in patients with functional dependence (OR 5.82, 95% CI 1.59-23.4, P < 0.001).

CONCLUSION

Preoperative functional dependence is a good marker for estimating postoperative unplanned intubation following cervical spine surgery.

Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery

BACKGROUND

Standardized postoperative airway management is essential for patients undergoing anterior cervical spine surgery (ACSS). The paucity of clinical series evaluating these airway complications after ACSS has been resulted in a significant limitation in statistical analyses.

METHODS

A retrospective cohort study was performed regarding airway distress (intubation for more than 24 hours or unplanned reintubation within 7 days of operation) developed after ACSS. If prevertebral soft tissue swelling was evident after the operation, patients were managed with prolonged intubation (longer than 24 hours). Preoperative and intraoperative patient data, and postoperative outcome (time to extubation and reintubation) were analyzed.

RESULTS

Between 2008 and 2016, a total of 400 ACSS were performed. Of them, 389 patients (97.25%) extubated within 24 hours of surgery without airway complication, but 11 patients (2.75%) showed postoperative airway compromise; 7 patients (1.75%) needed prolonged intubation, while 4 patients (1.00%) required unplanned reintubation. The mean time for extubation were 2.75 hours (range: 0-23 hours) and 50.55 hours (range: 0-250 hours), respectively. Age (P = 0.015), diabetes mellitus (P = 0.003), operative time longer than 5 hours (P = 0.048), and estimated blood loss (EBL) greater than 300 mL (P = 0.042) were associated with prolonged intubation or reintubation. In prolonged intubation group, all patients showed no airway distress after extubation.

CONCLUSION

In ACSS, postoperative airway compromise is related to both patients and operative factors. We recommend a prolonged intubation for patients who are exposed to these risk factors to perform a safe and effective extubation.

Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial reduces reintubation in critically ill patients: a multicenter randomized controlled trial

BACKGROUND

Spontaneous breathing trials (SBT) can be exhausting, but the preventive role of rest has never been studied. This study aimed to evaluate whether reconnection to mechanical ventilation (MV) for 1 h after the effort of a successful SBT could reduce the need for reintubation in critically ill patients.

METHODS

Randomized multicenter trial conducted in 17 Spanish medical-surgical intensive care units (Oct 2013-Jan 2015). Patients under MV for longer than 12 h who fulfilled criteria for planned extubation were randomly allocated after a successful SBT to direct extubation (control group) or reconnection to the ventilator for a 1-h rest before extubation (rest group). The primary outcome was reintubation within 48 h. Analysis was by intention to treat.

RESULTS

We recruited 243 patients randomized to the control group and 227 to the rest group. Median time from intubation to SBT did not differ between groups [5.5 (2.7, 9.6) days in the control group vs. 5.7 (2.7, 10.6) in the rest group; p = 0.85]. Reintubation within 48 h after extubation was more common in the control than in the rest group [35 (14%) vs. 12 (5%) patients; OR 0.33; 95% CI 0.16-0.65; p < 0.001]. A multivariable regression model demonstrated that the variables independently associated with reintubation were rest [OR 0.34 (95%CI 0.17-0.68)], APACHE II [OR 1.04 (1.002-1.077)], and days of MV before SBT [OR 1.04 (1.001-1.073)], whereas age, reason for admission, and type and duration of SBT were not.

CONCLUSION

One-hour rest after a successful SBT reduced the rates of reintubation within 48 h after extubation in critically ill patients. Trial registration Clinicaltrials.gov identifier NCT01915563.

Analysis of Clinical Indicators of Quality in Patients with Endotracheal intubation

INTRODUCTION

Quality and safety in anaesthesia is usually monitored by analysis of perioperative mortality-morbidity and are influenced by anaesthetic and non-anaesthetic factors.

AIM

This study was conducted to analyse the incidence of clinical indicators of quality in endotracheally intubated patients undergoing general abdominal surgeries and obstetric and gynaecological procedures under general anaesthesia and to determine contributing factors for the same.

MATERIALS AND METHODS

This retrospective study was conducted at our institute over a period of 12 months and 709 case records of patients were reviewed. Patients aged 14 years and more belonging to all ASA groups undergoing abdominal surgeries for general and obstetric and gynaecological causes under General Anaesthesia (GA) with endotracheal intubation posted for both elective and emergency surgeries were included in the study. Demographic details including name, age, sex, hospital number, height, weight, body mass index, type of surgery, nature of surgery, duration, American Society of Anaesthesiologists (ASA) physical status were recorded and presence or absence of clinical indicators of quality (presence of cannot intubate cannot ventilate scenario, occurrence of dental injury, episode of non cardiogenic pulmonary oedema, incidents of residual neuromuscular blockade, existence of aspiration pneumonia, unplanned ICU/HDU admissions, interventions for respiratory/ cardiac arrest, occasions of respiratory distress in the recovery period, occurrence of respiratory arrest within 48 hours and re-intubation) were noted and analysed for all 709 patients.

RESULTS

Total 709 patients were analysed in our study. We found that incidence of ICU admission was 1.83% and that of respiratory distress which needed intervention were 0.56%. A total of 0.28% patients needed reintubation. Residual neuromuscular blockade was seen in 0.28% patients. We did not find any case of respiratory and cardiac arrest and also there was no Cannot Ventilate and Cannot Intubate (CVCI) situation encountered in our study. SPSS for windows (version 17.0) was used as statistical software. Chi-square test was the statistical test for significance. A p-value < 0.05 was considered significant.

CONCLUSION

Proper optimization of patients prior to surgery and optimal perioperative care will result in better quality of care and safety in anaesthesia. Documentation of events and its management during perioperative period will help to know the fields of inappropriate management and thereby improve the quality of care and detect the incidence rates with accuracy and help to formulate protocol for institution.

Extubation to high-flow nasal cannula in critically ill surgical patients

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used to reduce reintubations in patients with respiratory failure. Benefits include providing positive end expiratory pressure, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy.

METHODS

A retrospective review was conducted in the surgical intensive care unit of an academic center during August 2015 to February 2016. Data including demographics, ventilator days, oxygen therapy after extubation, reintubation rates, surgical intensive care unit and hospital length of stay, and mortality were collected. Self and palliative extubations were excluded. Characteristics and outcomes, with the primary outcome being reintubation, were compared between those extubated to HFNC versus cool mist/nasal cannula (CM/NC).

RESULTS

Of the 184 patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation before extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, sex, and had a similar prevalence of cardiopulmonary diagnoses at admission. Although prior to extubation HFNC had lengthier ventilation requirements (7.1 versus 3.4 days, P < 0.01) and ICU stays (7.8 versus 4.1 days, P < 0.01), the rate of reintubation was similar to CM/NC (6.5% versus 13.8%, P = 0.19). Multivariable analysis demonstrated HFNC to be associated with a lower risk of reintubation (adjusted odds ratio = 0.15, P = 0.02). Mortality rates were similar.

CONCLUSIONS

Ventilated patients at risk for recurrent respiratory failure have reduced reintubation rates when extubated to HFNC. Patients with prolonged intubation or those with high-risk comorbidities may benefit from extubation to HFNC.

Outcomes of Mechanically Ventilated Critically Ill Geriatric Patients in Intensive Care Unit

INTRODUCTION

Increase in life expectancy across the globe has led to rise in geriatric population. Geriatric population is now living longer and healthier. This rise in geriatric population has also led to increase in the geriatric ailments leading to increased number of geriatric patients requiring intensive care including mechanical ventilation. Data on outcomes of geriatric patients requiring mechanical ventilation from India is scarce.

AIM

To study the profile and outcome of geriatric patients more than equal to 60 years requiring mechanical ventilation in Intensive Care Unit (ICU).

MATERIALS AND METHODS

The data of all the geriatric patients, more than 60 years of age, admitted to ICU between January 2008 to August 2014 requiring mechanical ventilation for various reasons were extracted from the hospital records. Various reasons for ventilation, duration of ventilation/hospital stay, mortality and associated comorbidities were recorded and analysed.

RESULTS

Total 140 geriatric patients were mechanically ventilated in the study period, out of which 43.5% (61/140) were above 70 years of age and 67.8% (95/140) were above 65 years of age. Chronic Obstructive Pulmonary Disease (COPD) was the most common cause for mechanical ventilation constituting 20% of patients followed by severe sepsis (17.8%), cerebro-vascular accident (12.8%), post-surgical patients (12.8%) and Coronary Artery Disease (CAD) in 10%. In our study, 44.28% of the geriatric patients requiring mechanical ventilation in the ICU were successfully weaned off the ventilator. Early tracheostomy helped in weaning off from ventilator as 83.33% (5/6) of patients requiring tracheostomy could be weaned off the ventilator suggesting that tracheostomy may help in improving the outcome. Reintubation carried a very poor prognosis and increased mortality, as 80% (4/5) of the patients who were reintubated in our study could not survive.

CONCLUSION

Our study revealed that in appropriate intensive care setting and with standard protocol based therapy for primary ailments, outcomes with mechanical ventilation in geriatric population can be comparable to outcomes in younger population.

Emergent reintubation following elective cervical surgery: A case series

AIM

To review cases of emergent reintubation after cervical surgery.

METHODS

Patients who were emergently intubated in the post-operative period following cervical surgery were identified. The patients’ prospectively documented demographic parameters, medical history and clinical symptoms were ascertained. Pre-operative radiographs were examined for the extent of their pathology. The details of the operative procedure were discerned.

RESULTS

Eight hundred and eighty patients received anterior- or combined anterior-posterior cervical surgery from 2008-2013. Nine patients (1.02%) required emergent reintubation. The interval between extubation to reintubation was 6.2 h [1-12]. Patients were kept intubated after reintubation for 2.3 d [2-3]. Seven patients displayed moderate postoperative edema. One patient was diagnosed with a compressive hematoma which was subsequently evacuated in the OR. Another patient was diagnosed with a pulmonary effusion and treated with diuretics. One patient received a late debridement for an infected hematoma. Six patients reported residual symptoms and three patients made a complete recovery.

CONCLUSION

Respiratory compromise is a rare but potentially life threatening complication following cervical surgery. Patients at increased risk should be monitored closely for extended periods of time post-operatively. If the airway is restored adequately in a timely manner through emergent re-intubation, the outcome of the patients is generally favorable.

The effect of reintubation on ventilator-associated pneumonia and mortality among mechanically ventilated patients with intubation: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis summarized the risks that reintubation impose on ventilator-associated pneumonia (VAP) and mortality.

BACKGROUND

Extubation failure increases the probability of poor clinical outcomes pertaining to mechanical ventilation.

METHODS

Literature published during a 15-year period was retrieved from PubMed, Web of Knowledge databases, the Embase (Excerpa Medica database), and the Cochrane Library. Data involving reintubation, VAP, and mortality were extracted for a meta-analysis.

RESULTS

Forty-one studies involving 29,923 patients were enrolled for the analysis. The summary odds ratio (OR) between VAP and reintubation was 7.57 (95% confidence interval [CI] = 3.63-15.81). The merged ORs for mortality in hospital and intensive care unit were 3.33 (95% CI = 2.02-5.49) and 7.50 (95% CI = 4.60-12.21), respectively.

CONCLUSIONS

Reintubation can represent a threat to survival and increase the risk of VAP. The risk of mortality after reintubation differs between planned and unplanned extubation. Extubation failure is associated with a higher risk of VAP in the cardiac surgery population than in the general population.

High-flow nasal cannula to prevent postextubation respiratory failure in high-risk non-hypercapnic patients: a randomized multicenter trial

Background

Extubation failure is associated with increased morbidity and mortality, but cannot be safely predicted or avoided. High-flow nasal cannula (HFNC) prevents postextubation respiratory failure in low-risk patients.

Objective

To demonstrate that HFNC reduces postextubation respiratory failure in high-risk non-hypercapnic patients compared with conventional oxygen.

Methods

Randomized, controlled multicenter trial in patients who passed a spontaneous breathing trial. We enrolled patients meeting criteria for high-risk of failure to randomly receive HFNC or conventional oxygen for 24 h after extubation. Primary outcome was respiratory failure within 72-h postextubation. Secondary outcomes were reintubation, intensive care unit (ICU) and hospital lengths of stay, and mortality. Statistical analysis included multiple logistic regression models.

Results

The study was stopped due to low recruitment after 155 patients were enrolled (78 received high-flow and 77 received conventional oxygen). Groups were similar at enrollment, and all patients tolerated 24-h HFNC. Postextubation respiratory failure developed in 16 (20%) HFNC patients and in 21 (27%) conventional patients [OR 0.69 (0.31–1.54), p = 0.2]. Reintubation was needed in 9 (11%) HFNC patients and in 12 (16%) conventional patients [OR 0.71 (0.25–1.95), p = 0.5]. No difference was found in ICU or hospital length of stay, or mortality. Logistic regression models suggested HFNC [OR 0.43 (0.18–0.99), p = 0.04] and cancer [OR 2.87 (1.04–7.91), p = 0.04] may be independently associated with postextubation respiratory failure.

Conclusion

Our study is inconclusive as to a potential benefit of HFNC over conventional oxygen to prevent occurrence of respiratory failure in non-hypercapnic patients at high risk for extubation failure.

Registered at Clinicaltrials.gov NCT01820507.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0270-9) contains supplementary material, which is available to authorized users.

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

BACKGROUND

Both delayed and premature extubation increase complication rate, the need for tracheostomy (TT), the duration of intensive care unit stay, and mortality. In this study, we therefore investigated factors associated with primary TT and predictors for extubation failure (EF) in a sample of severely affected ventilated stroke patients.

METHODS

One hundred eighty five intubated stroke patients were prospectively analyzed in this observational study. Patients not meeting predefined clinical and respiratory extubation criteria received a TT. All other patients were extubated and followed up for the need of reintubation. Characteristics of patients with and without extubation attempt were examined. Additionally, within the group of extubated patients, subgroups of successfully vs. unsuccessfully extubated patients were compared. Clinical factors associated with reintubation, including a previously established semi-quantitative airway score, were determined and predictors of EF were assessed.

RESULTS

Ninety-eight of 185 patients (53%) were primarily extubated; EF rate was 37% (36 patients). Eighty-seven (47%) were tracheostomized without a prior extubation attempt. Primarily tracheostomized patients had more severe strokes, which were more often hemorrhagic, presented with a lower level of consciousness, needed neurosurgical intervention more often, had a higher rate of obesity, and were more frequently intubated because of suspicion of compromised protective reflexes. EF was independently predicted by prior neurosurgical treatment and low airway management scores. No differences were found for the ability to follow simple commands and classical weaning criteria.

CONCLUSION

Airway management decisions in intubated stroke patients represent a clinical challenge. Classical weaning criteria and parameters reflecting the patient's state of consciousness are not reliably predictive of extubation success. Criteria more closely related to airway safety and secretion handling may provide the most relevant information and should therefore be assessed by specific clinical scoring systems.

Factors predicting failure of noninvasive ventilation assist for preventing reintubation among medical critically ill patients

PURPOSE

Reintubation after failed extubation is associated with high mortality. Noninvasive ventilation (NIV) has been used to prevent reintubation, but the results have been inconclusive. We investigated the factors predicting failure of NIV-assisted extubation among medical critically ill patients.

MATERIALS AND METHODS

This retrospective cohort study enrolled patients who were admitted to medical intensive care units at Siriraj Hospital between March 2012 and August 2015 who required more than 48 hours of mechanical ventilation and who received NIV after endotracheal extubation. NIV was considered to have failed if the patient required reintubation during intensive care unit admission.

RESULTS

A total of 105 patients (57 male; mean age, 63.3±17.9 years) were enrolled. The reintubation rate was 45.7%. Univariate analysis identified pre-NIV Sepsis-related Organ Failure Assessment score >3.5, respiratory failure caused by pneumonia, heart rate after NIV for 1 hour of more 100 beats per minute, fluid accumulation greater than 100 mL/kg, and NIV duration more than 96 hours as factors associated with reintubation. However, multivariate analysis identified pneumonia as the only predictive factor for failure of NIV-assisted extubation among critically ill patients. Reintubated patients had significantly higher hospital mortality than successfully extubated patients.

CONCLUSIONS

Respiratory failure caused by pneumonia is predictive of failure of NIV-assisted extubation.

Noninvasive ventilation for avoidance of reintubation in patients with various cough strength

Background

Reintubation is associated with high mortality. Identification of methods to avoid reintubation is needed. The aim of this study was to assess whether prophylactic noninvasive ventilation (NIV) would benefit patients with various cough strengths.

Methods

We prospectively enrolled 356 patients who successfully passed a spontaneous breathing trial in a respiratory intensive care unit. Before extubation, cough peak flow was measured. After extubation, attending physicians determined whether the patients would receive prophylactic NIV or conventional oxygen treatment (control group). Patients were followed up to 90 days postextubation or death, whichever came first.

Results

The median value of cough peak flow was 70 L/minute. Among the patients with cough peak flow ≤70 L/minute, 108 received NIV and 72 received conventional oxygen treatment. In this cohort, NIV reduced reintubation (9 % vs. 35 % at postextubation 72 h, p < 0.01; and 24 % vs. 49 % at postextubation 7 days, p < 0.01) and postextubation 90-day mortality (43 % vs. 61 %, p = 0.02) compared with the control group. Further, use of NIV was an independent protective factor for reintubation (OR = 0.19, p < 0.01 at 72 h postextubation; and OR = 0.33, p < 0.01 at 7 days postextubation) and for death at 90 days postextubation (OR = 0.40, p = 0.02). Among patients with cough peak flow >70 L/minute, 71 received NIV and 105 received conventional oxygen treatment. In this cohort, NIV did not reduce reintubation (6 % vs. 6 % at 72 h postextubation, p > 0.99; and 9 % vs. 9 % at 7 days postextubation, p > 0.99) or postextubation 90-day mortality (21 % vs. 15 %, p = 0.32) compared with the control group. Further, use of NIV was not associated with reintubation or postextubation 90-day mortality.

Conclusion

In a planned extubated population, prophylactic NIV benefited patients with weak cough but possibly not in patients with strong cough.

Ventilator-Associated Pneumonia: Incidence, Risk Factors and Outcome in Paediatric Intensive Care Units at Cairo University Hospital

INTRODUCTION

Ventilator-Associated Pneumonia (VAP) is a major cause of hospital morbidity, mortality and increased health care costs. Although the epidemiology, pathogenesis and outcome of VAP are well described in adults; few data exist regarding VAP in paediatric patients, especially in developing countries.

AIM

To determine the incidence, risk factors and outcome of VAP in two Paediatric Intensive Care Units (PICUs) at Cairo University Hospital.

MATERIALS AND METHODS

A total of 427 patients who received Mechanical Ventilation (MV) were included in this prospective study during the period from September 2014 till September 2015. Patients were observed daily till VAP occurrence, discharge from the unit or death, whichever came first. Demographic, clinical characteristics, laboratory results, radiographic and microbiological reports were recorded for all patients.

RESULTS

Nearly 31% patients developed VAP among the entire cohort. The incidence density was 21.3 per 1000 ventilator days. The most frequently isolated organisms from VAP patients were Pseudomonas aeruginosa (47.7%), Acinetobacter (18.2%) and Methicillin-resistant Staphylococcus aureus (MRSA) (14.4%). VAP patients were significantly younger than non-VAP ones. The incidence of VAP in comatose patients and those with MOSF was significantly higher. Prior antibiotic use for > 48 h before MV, supine body positioning and reintubation were significantly associated with VAP. On multiple logistic regression analysis, MOSF; prior antibiotic use > 48h; reintubation; coma; and age remained independent predictors of VAP. Mortality rate among the VAP group was significantly higher compared to the non-VAP one (68.2% vs. 48.5%, p<0.001). Survival curve analysis showed a shorter median survival time in VAP patients.

CONCLUSION

Identification of risk factors and outcome of VAP in PICUs may help in reducing the incidence and improving patients' outcomes. The incidence of VAP in this study was relatively high. The most prominent risk factors for occurrence of VAP were MOSF, prior antibiotic use for > 48 h before MV, reintubation, coma and age. Proper use of antibiotics before MV in PICUs is essential. Also, adequate training of nurses and strict supervision of infection control protocols are crucial. Lack of a gold standard for the diagnosis of VAP and difficulty in sampling procedures were among the study limitations.

Rocuronium is associated with an increased risk of reintubation in patients with soft tissue infections

STUDY OBJECTIVE

To determine risk factors associated with reintubations in adult patients with soft tissue infections.

DESIGN

A retrospective case-control design.

SETTING

Operating room and postoperative recovery area.

PATIENTS

There were 39 patients who presented for surgical intervention of their soft tissue infection and 222 controls having general surgery who were matched for age, sex, and body mass index. All patients were older than the age of 18 years and mostly American Society of Anesthesiologists physical status of III to IV and presented to our level 1 trauma center.

INTERVENTIONS

Reintubation within 2 hours after planned extubation.

MEASUREMENTS

The following data were collected: reintubation rates, train of four ratio, reversal agents, age, sex, creatinine, smoking history, transfusion requirements, Sequential Organ Failure Assessment score, hemoglobin, and lactate.

MAIN RESULTS

The use of rocuronium was independently associated with increased odds of reintubation. Patients with a higher train of four ratio were more likely to be reintubated and less likely to be reversed as compared to those with a lower train of four ratio.

CONCLUSIONS

Soft tissue patients who have received rocuronium are at increased risk for reintubation, particularly those with renal failure. In addition, this article supports the use of neuromuscular blockade reversals, even in patients with a strong train of four ratio.

Staged extubation to manage the airway after operations on the head and neck

Management of the airway after operations on the head and neck is potentially problematic. We describe leaving a guidewire in the trachea after successful extubation in two patients, to make reintubation easier if the airway was later compromised.

Efficacy of noninvasive mechanical ventilation in prevention of intubation and reintubation in the pediatric intensive care unit

PURPOSE

To determine the efficiency of noninvasive mechanical ventilation (NIV) both in protection from intubation and in preventing reintubation of postextubation in patients in the pediatric intensive care unit (PICU).

METHODS

A prospective observational study was conducted in a multidisciplinary 10-bed tertiary PICU of a university hospital. All patients were admitted to our unit from June 2012 to May 2014 and deemed to be candidates to receive continuous positive airway pressure or bilevel positive airway pressure.

MEASUREMENTS AND RESULTS

We performed 160 NIV episodes in 137 patients. Their median age was 9 months (range, 1-240 months), and their median weight was 7.5 kg (range, 2.5-65 kg). Fifty-seven percent of patients were male. Noninvasive mechanical ventilation was successful in 70% (112 episodes) of patients. There was an underlying illness in 83.8% (134 episodes) of the patients. Bilevel positive airway pressure support was given to 57.5% (92 episodes) of the patients, whereas the remaining 42.5% (68 episodes) received continuous positive airway pressure support. Among the causes of respiratory failure in our patients, the most frequent were postextubation, pneumonia, bronchiolitis, atelectasia, and cardiogenic pulmonary edema. Sedation was applied in 43.1% of the episodes. Complications were detected in 29 episodes (18.1 %). The NIV failure group showed higher Pediatric Risk of Mortality III-24 score, shorter NIV duration, more frequent underlying disease, lower number fed, longer length of PICU stay, and hospital stay, and mortality was higher.

CONCLUSIONS

Noninvasive mechanical ventilation effectively and reliably reduced endotracheal intubation in the treatment of respiratory failure due to different clinical situations. Our results suggest that NIV can play an important role in PICUs in helping to avoid intubation and prevent reintubation. Although there were serious underlying diseases in most of our patients, such as immunosuppression, 70% avoided intubation with use of NIV.