Extubation failure in pediatric intensive care incidence and outcomes

Weaning and extubation readiness in pediatric patients

OBJECTIVE

A systematic review of weaning and extubation for pediatric patients on mechanical ventilation.

DATA SELECTION

Pediatric and adult literature, English language.

STUDY SELECTION

Invited review.

DATA SOURCES

Literature review using National Library of Medicine PubMed from January 1972 until April 2008, earlier cross-referenced article citations, the Cochrane Database of Systematic Reviews, and the Internet.

CONCLUSIONS

Despite the importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are even less clear, although a trial of spontaneous breathing would seem a prerequisite. Several indices have been developed in an attempt to predict weaning and extubation success but the available literature would suggest they offer no improvement over clinical judgment. Extubation failure rates range from 2% to 20% and bear little relationship to the duration of mechanical ventilation. Upper airway obstruction is the single most common cause of extubation failure. A reliable method of assessing readiness for weaning and predicting extubation success is not evident from the pediatric literature.

The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients

OBJECTIVE

Endotracheal tube air leak pressures are used to predict postextubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine whether the absence of an endotracheal tube air leak (air leak test >/=30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children.

DESIGN

Prospective, blinded cohort.

SETTING

Multidisciplinary pediatric intensive care unit of a university hospital.

PATIENTS

Patients younger than or equal to 18 yrs and intubated >/=24 hrs.

INTERVENTIONS

The pressure required to produce an audible endotracheal tube air leak was measured within 12 hrs of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during air leak test measurements.

MEASUREMENTS AND MAIN RESULTS

The need for reintubation (i.e., extubation failure) was recorded during the 24-hr postextubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9 of 59). Seven patients were treated for postextubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hrs, p = 0.03. Extubation success was associated with the use of postextubation noninvasive ventilation (p = 0.04). The air leak was absent for the duration of mechanical ventilation (i.e., >/=30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value 27%, 95% confidence interval 6-60). The air leak test was >/=30 cm H2O before extubation in 47% (28 of 59) of patients yet 23 patients extubated successfully (negative predictive value 18%).

CONCLUSIONS

An endotracheal tube air leak pressure >/=30 cm H2O measured in the nonparalyzed patient before extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube.

Arterial Switch Operation: Troponin T Does Not Predict Ventilation Requirements

The aim of this study was to assess whether postoperative cardiac troponin T levels could predict ventilation requirements in infants undergoing the arterial switch operation. Cardiac troponin T was measured 6 hours after aortic cross clamping and prior to tracheal extubation in 20 consecutive patients; 10 had simple and 10 had complex (with ventricular septal defect) transposition of the great arteries. The mean plasma troponin T level prior to extubation did not differ significantly in patients who were re-intubated and those who were successfully extubated. The initial cardiac troponin T levels in the complex defect group was significantly higher than in the simple transposition group. There was no correlation between initial cardiac troponin T levels and the duration of mechanical ventilation. There was no difference in mean duration of ventilation between the 2 groups. It was concluded that the postoperative cardiac troponin T level is not a predictor of successful extubation or prolonged artificial ventilation in this subset.

Medical errors affecting the pediatric intensive care patient: incidence, identification, and practical solutions

The complexity of patient care and the potential for medical error make the pediatric ICU environment a key target for improvement of outcomes in hospitalized children. This article describes several event-specific errors as well as proven and potential solutions. Analysis of pediatric intensive care staffing, education, and administration systems, although a less "traditional" manner of thinking about medical error, may reveal further opportunities for improved pediatric ICU outcome.

Medida da freqüência respiratória e do volume corrente para prever a falha na extubação de recém-nascidos de muito baixo peso em ventilação mecânica

OBJETIVO: Verificar se a freqüência respiratória (FR), o volume corrente (VC) e a relação FR/VC poderiam prever a falha na extubação em recém-nascidos de muito baixo peso submetidos à ventilação mecânica. MÉTODOS: Estudo prospectivo, observacional, de recém-nascidos com idade gestacional <37 semanas, peso ao nascer <1.500g, ventilados desde o nascimento por 48 horas a 30 dias. Após a indicação da retirada da ventilação mecânica, o neonato foi colocado em pressão positiva contínua (CPAP) por via traqueal por dez minutos, avaliando-se FR, VC e relação FR/VC por meio de um pneumotacógrafo conectado entre a cânula traqueal e o circuito do ventilador. Em seguida, o recém-nascido foi extubado e colocado em CPAP nasal, considerando-se falha na extubação a necessidade de reintubação em 48 horas. RESULTADOS: Das 35 crianças estudadas, 20 (57%) foram extubadas com sucesso e 15 (43%) necessitaram de reintubação. A FR e a relação FR/VC tenderam a ser maiores no grupo que falhou na extubação; o VC foi similar nos dois grupos. A sensibilidade e a especificidade para falha na extubação foram, respectivamente, 50 e 67% para FR, 40 e 67% para o VC e 40 e 73% para a relação FR/VC. CONCLUSÕES: A FR, o VC e a relação FR/VC apresentaram baixa sensibilidade e especificidade para prever a falha na extubação em recém-nascidos de muito baixo peso.

Extubation after cardiothoracic surgery in neonates, children, and young adults: One year of institutional experience

OBJECTIVE:: Describe risk factors associated with successful and early extubation in the pediatric cardiac intensive care unit. DESIGN:: Retrospective chart review. SETTING:: University hospital, cardiac intensive care unit. MEASUREMENTS AND MAIN RESULTS:: Review of 212 consecutive surgical admissions from January 2003 to January 2004, excluding deaths. Preoperative, intraoperative, and postoperative variables were studied. Successful extubation was defined as no reintubation at any time during the cardiac intensive care unit course and early extubation was defined as mechanical ventilation </=24 hrs. Median subject age was 8 months (range, 1 day-25 yrs), with 57% <1 yr of age and 22% neonates. Fifty-eight (27%) were extubated in the operating room and 122 (58%) were extubated at <24 hrs (mean, 6.1 +/- 7.7 hrs). Only seven patients failed extubation: three in the operating room because of upper airway obstruction and four in the cardiac intensive care unit for acute respiratory failure associated with atelectasis (n = 2), ventricular dysfunction (n = 1), and arrhythmia (n = 1). There were no extubation failures in patients extubated >24 hrs after surgery. A history of prematurity (odds ratio [OR], 5.84, 2.29-14.9; p < .001), base excess (OR, 1.47, 1.27-1.70; p < .001), cardiopulmonary bypass time (OR, 1.01, 1.01 to -1.2; p < .05), and the need for surgical reintervention (OR, 18.29, 2.78 to -120.07; p < .05) were associated with intubation for >24 hrs. CONCLUSION:: Extubation without the need for reintubation can be achieved in nearly all children following cardiothoracic surgery. The majority of successful extubations can be achieved within 24 hrs of surgery.

Insights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning

PURPOSE OF REVIEW

Mechanical ventilation is a common intervention provided by pediatric intensivists. This fact notwithstanding, the management of mechanical ventilation in pediatrics is largely guided by a few pediatric trials along with careful interpretation and application of adult data.

RECENT FINDINGS

A low tidal volume, pressure limited approach to mechanical ventilation as established by the Acute Respiratory Distress Syndrome Network investigators, has become the prevailing practice in pediatric intensive care. Studies by these investigators suggest that high positive end expiratory pressure and recruitment maneuvers are not uniformly beneficial. High frequency oscillatory ventilation continues to be evaluated in an attempt to provide 'open lung' ventilation. Airway pressure release ventilation is a newer mode of ventilation that may combine the 'open lung' approach with spontaneous breathing. Prone positioning was demonstrated in a recent pediatric trial to have no effect on outcome, while calfactant was found to potentially improve outcomes in pediatric acute respiratory distress syndrome. Ventilator weaning protocols may not be as useful in pediatrics as in adults. Systemic corticosteroids decrease the incidence of post extubation stridor and may reduce reintubation rates.

SUMMARY

Mechanical ventilation with pressure limitation and low tidal volumes has become customary in pediatric intensive care units, and this lung protective approach will continue into the foreseeable future. Further investigation is warranted regarding use of high frequency oscillatory ventilation, airway pressure release ventilation, and surfactant to assist pediatric intensivists in application of these therapies.