Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation

Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature

A crucial step in the transition from mechanical ventilation to extubation is the successful performance of a spontaneous breathing trial (SBT). The American College of Chest Physicians (ACCP) Guidelines recommend removal of the endotracheal tube upon successful completion of a SBT. However, this does not guarantee successful extubation as there remains a risk of re-intubation. Guidelines have outlined ventilator liberation protocols, selected use of non-invasive ventilation on extubation, early mobilization, and dynamic ventilator metrics to prevent and better predict extubation failure. However, a significant percentage of patients still fail mechanical ventilation discontinuation. A common reason for re-intubation is having a weak cough strength, which reflects the inability to protect the airway.

Evaluation of cough strength via objective measures using peak expiratory flow rate is a non-invasive and easily reproducible assessment which can predict extubation failure. We conducted a narrative review of the literature regarding use of cough strength as a predictive index for extubation failure risk. Results of our review show that cough strength, quantified objectively with a cough peak expiratory flow measurement (CPEF), is strongly associated with extubation success. Furthermore, various cutoff thresholds have been identified and can provide reasonable diagnostic accuracy and predictive power for extubation failure.

These results demonstrate that measurement of the CPEF can be a useful tool to predict extubation failure in patients on MV who have passed a SBT. In addition, the data suggest that this diagnostic modality may reduce ICU length of stay, ICU expenditures, and morbidity and mortality.

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.

Cumulative Probability and Time to Reintubation in U.S. ICUs

OBJECTIVE

Reintubation after liberation from mechanical ventilation is viewed as an adverse event in ICUs. We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cutoff for reporting of reintubation events.

DESIGN AND SETTING

We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the United States.

PATIENTS

We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation.

MEASUREMENTS AND MAIN RESULTS

We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation. Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range, 2-45 hr). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients) and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs).

CONCLUSIONS

The reintubation rate for ICU patients liberated from mechanical ventilation in U.S. ICUs is approximately 10%. We propose a time cutoff of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur.

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.

Intermittent noninvasive ventilation after extubation in patients with chronic respiratory disorders: a multicenter randomized controlled trial (VHYPER)

PURPOSE

Early noninvasive ventilation (NIV) after extubation decreases the risk of respiratory failure and lowers 90-day mortality in patients with hypercapnia. Patients with chronic respiratory disease are at risk of extubation failure. Therefore, it could be useful to determine the role of NIV with a discontinuous approach, not limited to patients with hypercapnia. We assessed the efficacy of early NIV in decreasing respiratory failure after extubation in patients with chronic respiratory disorders.

METHODS

A prospective randomized controlled multicenter study was conducted. We enrolled 144 mechanically ventilated patients with chronic respiratory disorders who tolerated a spontaneous breathing trial. Patients were randomly allocated after extubation to receive either NIV (NIV group, n = 72), performed with a discontinuous approach, for the first 48 h, or conventional oxygen treatment (usual care group, n = 72). The primary endpoint was decreased respiratory failure within 48 h after extubation. Analysis was by intention to treat. This trial was registered with ClinicalTrials.gov (NCT01047852).

RESULTS

Respiratory failure after extubation was less frequent in the NIV group: 6 (8.5%) versus 20 (27.8%); p = 0.0016. Six patients (8.5%) in the NIV group versus 13 (18.1%) in the usual care group were reintubated; p = 0.09. Intensive care unit (ICU) mortality and 90-day mortality did not differ significantly between the two groups (p = 0.28 and p = 0.33, respectively). Median postrandomization ICU length of stay was lower in the usual care group: 3 days (IQR 2-6) versus 4 days (IQR 2-7; p = 0.008). Patients with hypercapnia during a spontaneous breathing trial were at risk of developing postextubation respiratory failure [adjusted odds ratio (95% CI) = 4.56 (1.59-14.00); p = 0.006] and being intubated [adjusted odds ratio (95% CI) = 3.60 (1.07-13.31); p = 0.04].

CONCLUSIONS

Early NIV performed following a sequential protocol for the first 48 h after extubation decreased the risk of respiratory failure in patients with chronic respiratory disorders. Reintubation and mortality did not differ between NIV and conventional oxygen therapy.

Association Between Deep Sedation from Continuous Intravenous Sedatives and Extubation Failures in Mechanically Ventilated Patients in the Pediatric Intensive Care Unit

OBJECTIVE The primary objective of this study was to determine whether an association exists between deep sedation from continuous infusion sedatives and extubation failures in mechanically ventilated children. Secondary outcomes evaluated risk factors associated with deep sedation.

METHODS This was a retrospective cohort study conducted between January 1, 2009, and October 31, 2012, in the pediatric intensive care unit (PICU) at Duke Children's Hospital. Patients were included in the study if they had been admitted to the PICU, had been mechanically ventilated for ≥48 hours, and had received at least one continuous infusion benzodiazepine and/or opioid infusion for ≥24 hours. Patients were separated into 2 groups: those deeply sedated and those not deeply sedated. Deep sedation was defined as having at least one documented State Behavioral Scale (SBS) of −3 or −2 within 72 hours prior to planned extubation.

RESULTS A total of 108 patients were included in the analysis. Both groups were well matched with regard to baseline characteristics. For the primary outcome, there was no difference in extubation failures in those who were deeply sedated compared to those not deeply sedated (14 patients [22.6%] versus 7 patients [15.2%], respectively; p = 0.33). After adjusting for potential risk factors, patients with a higher weight percentile for age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03), lower Glasgow Coma Score (GCS) score prior to intubation (OR 0.85; 95% CI 0.74–0.97), and larger maximum benzodiazepine dose (OR 1.93; 95% CI 1.01–3.71) were associated with greater odds of deep sedation. A higher GCS prior to intubation was significantly associated with increased odds of extubation failure (OR 1.19; 95% CI 1.02–1.39).

CONCLUSIONS While there was no statistically significant difference in extubation failures between the 2 groups included in this study, considering the severe consequences of extubation failure, the numerical difference reported may be clinically important.

Cuff Leak Test for the Diagnosis of Post-Extubation Stridor: A Multicenter Evaluation Study

BACKGROUND:

Cuff leak test was developed to predict the occurrence of post-extubation stridor (PES). This study evaluated the diagnostic performance of this test in unselected critically ill patients.

METHODS:

Multicenter prospective study including unselected ventilated patients at the time of their first planned extubation. The diagnostic performance of 4 different cuff leak tests was assessed.

RESULTS:

Post-extubation stridor occurred in 34 (9.4%) of 362 included patients. Compared to patients without PES, patients with PES required more frequently reintubation (6 [17.6%] vs 26 [7.9%], P = .041), prolonged duration of ventilation (6 [3-13] vs 5 [2-9] days, P = .029), and longer intensive care unit (ICU) stay (12 [6-17.5] vs 7.5 [4-13] days, P = .018). However, ICU mortality was similar in both groups (1 [2.9%] vs 23 [7.0%], P = .61). The 4 cuff leak tests display poor diagnostic accuracy: sensitivities ranging from 27% to 46%, specificities from 70% to 88%, positive predictive values from 14% to 19%, and negative predictive values from 92% to 93%.

CONCLUSION:

Post-extubation stridor occurs in less than 10% of unselected critically ill patients. The several cuff leak tests display limited diagnostic performance for the detection of PES. Given the high rate of false positives, routine cuff leak test may expose to undue prolonged mechanical ventilation.

Impact of fiber-optic laryngoscopy on the weaning process from mechanical ventilation in high-risk patients for postextubation stridor

The objective of this study was to assess the impact of fiber-optic laryngoscopy (FOL) on the weaning process from mechanical ventilation in critically ill patients with a positive cuff leak test (CLT) as compared with the current recommended strategy based on corticosteroids.In this prospective observational pilot study conducted over a 1-year period in a 15-bed ICU, CLT was systematically performed before extubation in all intubated patients having passed a spontaneous breathing trial (SBT). After the endotracheal tube cuff was deflated, cuff leak volume (CLVol) was assessed during assisted controlled ventilation. When CLT was positive (CLVol < 110 mL), patients either were evaluated using FOL by our half-time FOL-practitioner when present, or received corticosteroids.Among the 233 patients included, 34 (14.6%) had a positive CLT that hampered extubation. Seventeen were treated by corticosteroids and 17 were evaluated by FOL. In the corticosteroids group, the CLVol was still <110 mL at 24 hours in 9 patients (53%). Corticosteroids strategy merely prolonged the total duration of mechanical ventilation (7 [4-11] vs 4 [2-6] days, P = 0.01) by increasing the time between successful SBT and the moment when extubation was effectively achieved (30 [24-60] vs 1.5 [1-2] hours, P < 0.001). This resulted in 2 self-extubations (12%) and 9 FOL-guided extubations (53%) in the corticosteroids group. Massive swelling of the arytenoids was the most common feature shown by FOL. The patients evaluated by FOL who exhibited the thin anterior V-shaped opening of the vocal cords-the V sign-(n = 26, 100%) were immediately extubated without any stridor or respiratory failure afterward.In this pilot study, a FOL-based extubation strategy was feasible and reliable, and significantly reduced the duration of mechanical ventilation in patients with a positive CLT. We describe the "V sign" of FOL that safely allows a successful prompt extubation in patients considered at high risk for postextubation stridor.

Controversies in Weaning from Mechanical Ventilation

Invasive mechanical ventilation can successfully support the patient with acute respiratory failure, but it is associated with considerable risks. Numerous complications of invasive mechanical ventilation have been identified, and these may contribute to increased mortality. Therefore after clinical improvement has occurred, considerable emphasis is placed on expeditiously freeing the patient from the ventilator. This process of getting a patient off mechanical ventilation has been variably termed weaning, liberation, or discontinuation (terms which may be used interchangeably), and can be further divided into “readiness testing” and “progressive withdrawal.” Over the last decade, new developments in our understanding of the process of weaning have provided investigators with the tools to address a number of key questions: How should readiness for weaning (and trials of spontaneous breathing) be determined? What is the role of weaning parameters in deciding when to initiate the weaning process? What is the best mode for conducting a spontaneous breathing trial and how should the patient be monitored? What are the mechanisms for weaning (and spontaneous breathing trial) failure? What is the best technique to facilitate progressive withdrawal? What other factors can facilitate liberation from mechanical ventilation? What are the risks of extubation failure and how can extubation outcome best be predicted? What is the role for protocols in facilitating weaning from mechanical ventilation?.

Impact and Challenges of a Policy Change to Early Track Extubation in the Operating Room for Fontan

While policy changes toward early extubation in the operating room (OR) have been commonly seen in palliative surgeries in single ventricle anatomy, no systematic assessment of their impact on patient outcome has been reported. All patients aged 0-17 years admitted to a PICU in a quaternary children's hospital for post-operative management following a primary Fontan procedure between 2005 and 2011 were included. Patients for revision of Fontan or patients admitted to adult Cardiovascular Intensive Care Unit were excluded. Practice policy was changed from routine extubation in the PICU to early extubation in OR in January 2008. Data were compared between the pre-policy-change era (2005-2007) and the post-policy-change era (2008-2011) to assess the impact of the change on patient outcomes. Generalized linear regression (GLM) and interrupted time series (ITS) analysis were used to access the effect of policy change on PICU length of stay and post-operative fluid balance, adjusting for potential confounders using propensity scores. Root cause analysis (RCA) was conducted to describe causes of failed extubation and challenges of this policy change. One hundred twenty-seven children met inclusion criteria. Average body weight was 14.7 kg [standard deviation (SD) 3.9], and age was 3.5 years (SD 1.9). A clear change in extubation practice occurred between the pre- versus post-policy-change eras: 97.5 % were extubated in the PICU in the pre-policy-change era, as compared to 15.0 % in the post-policy-change era. The average PICU length of stay was shortened by 4.1 days from the pre-policy-change era to the post-policy-change era [95 % CI -1.2 to -6.9, p < 0.01] in the GLM, whereas the ITS analysis did not show a statistically significant difference [95 % CI 1.8 to -2.5] (p = 0.23). No statistically significant difference was observed in the fluid balance in the 24 h post-operation in both analyses. Sixteen patients (16/127, 12.6 %) were reintubated mainly for hemodynamic instability in the pre-policy-change era (6/39, 15.4 %) and excessive bleeding or respiratory etiologies in the post-policy-change era (10/88, 11.4 %). Significant reduction of PICU length of stay was achieved without any evidence of worsening of patient outcomes. RCA suggests watchful observations with respect to bleeding and respiratory etiologies are the key to prevent failure of extubation in the current practice.

Ultrasound-guided laryngeal air column width difference and the cuff leak volume in predicting the effectiveness of steroid therapy on postextubation stridor in adult. Are they useful?

OBJECTIVE

To evaluate the effectiveness of steroids therapy on postextubation stridor (PES) depending on the clinical response, the ultrasound guided laryngeal air column width difference (LACWD) and the cuff leak volume (CLV).

DESIGN

Prospective, observer-blinded study.

SETTING

Carried out in intensive care unit in Tanta university hospital.

PATIENTS

432 patients of both sexes received mechanical ventilation for more than 24 hours and met defined criteria for a weaning trial.

MEASUREMENTS

Ultrasound guided LACWD and CLV were conducted before extubation. Patients developing postextubation stridor were intravenously given 8 mg of dexamethasone every 8 hours for 3 days. The clinical response, ultrasounds guided LACWD and CLV before and after steroid therapy were analyzed. Primary outcome and secondary outcomes of our study were reported.

RESULTS

387 patients (89.5%) had no PES and 45 patients (10.5%) had PES. Risk factors for PES were longer duration of intubation, younger age and female gender. Both CLV and LACWD showed significant decrease (P< .05) in patients with PES in comparison with no PES patients. 45 patients with PES received dexamethasone treatment; 18 were completely recovered while 27 patients needed reintubation after 1 h. of these 27 patients; 19 patients had successful extubation while 8 patients had tracheostomy. In patients with PES, CLV and LACWD showed significant increase (P< .05) in comparison with before administration. Level of CLV <200 ml and LACWD <0.9 mm carry high sensitivity with high positive predictive value and high accuracy for presence of PES.

CONCLUSION

Steroids therapy improves postextubation stridor. Both LACWD and CLV are non-invasive and simple methods for monitoring of laryngeal edema regression after steroid therapy. We recommend administration of corticosteroids to patients with a lower level of leak volume and LACWD before extubation.

Change in Diaphragmatic Thickness During the Respiratory Cycle Predicts Extubation Success at Various Levels of Pressure Support Ventilation

PURPOSE

Ultrasonographic assessment of diaphragm function with patients on low levels of pressure support (PS) predicts extubation outcomes, but similar information regarding extubation success under other conditions is lacking. The purpose of this study was to determine whether ultrasound (US) measurements of the diaphragm made on various levels of PS can predict time until successful extubation.

METHODS

Fifty-six intubated patients underwent ultrasound of the right hemidiaphragm during a PS wean at varying levels of pressure support (PS 5/5 cm of H2O, 10/5 cm of H2O, and 15/5 cm of H2O). The diaphragm was visualized using a 7.5-10 mHz transducer in the zone of apposition of the diaphragm to the lower rib cage. The percent change in diaphragm thickness between end-expiration and end-inspiration (∆tdi%) was calculated at each level of PS.

RESULTS

∆tdi% >20 is a robust predictor of extubation success within 48 h of US at PS 5/5 cm of H2O and 10/5 cm of H2O (sensitivity 84.6 and 88.9 % and specificity 79.0 and 75.0 %, respectively). At PS greater than 10/5 cm of H2O, its predictive power was greatly diminished. Of nine patients who were extubated with ∆tdi% below the cutoff, 66.6 % required emergent reintubation in the next two days.

CONCLUSIONS

Diaphragm US is a valid predictor of extubation success at some but not all PS settings. Using a ∆tdi% of 20 % on PS levels up to 10/5 cm of H2O may reduce both unnecessarily prolonged intubations and prevent emergent reintubations.

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.

Risk factors associated with post-extubation stridor in the trauma intensive care unit

BACKGROUND

Post-extubation stridor is an uncommon complication in medical intensive care units (ICUs) but has not been well studied in trauma patients. We sought to determine the incidence of reintubation due to stridor in trauma patients and describe associated risk factors.

METHODS

A retrospective review of all intubated trauma patients was performed. Data collected included presence of stridor, demographic data, and details of intubation and extubation.

RESULTS

Of all trauma patients reintubated, 31% were for stridor. Although female gender, age less than 18, blunt mechanism, and duration of intubation 5 days or more were associated with reintubation for stridor, endotracheal tube diameter was not. Mortality was not increased with reintubation.

CONCLUSIONS

Trauma ICU patients are reintubated for stridor at a higher rate than medical ICU patients. Age, gender, blunt mechanism, and duration of intubation are risk factors for this complication.

The optimum timing to wean invasive ventilation for patients with AECOPD or COPD with pulmonary infection

COPD is characterized by a progressive decline in lung function and mental and physical comorbidities. It is a significant burden worldwide due to its growing prevalence, comorbidities, and mortality. Complication by bronchial-pulmonary infection causes 50%-90% of acute exacerbations of COPD (AECOPD), which may lead to the aggregation of COPD symptoms and the development of acute respiratory failure. Non-invasive or invasive ventilation (IV) is usually implemented to treat acute respiratory failure. However, ventilatory support (mainly IV) should be discarded as soon as possible to prevent the onset of time-dependent complications. To withdraw IV, an optimum timing has to be selected based on weaning assessment and spontaneous breathing trial or replacement of IV by non-IV at pulmonary infection control window. The former method is more suitable for patients with AECOPD without significant bronchial-pulmonary infection while the latter method is more suitable for patients with AECOPD with acute significant bronchial-pulmonary infection.

Cuff-leak test combined with interventional bronchoscopy benefits early extubation for patients who received tarp surgery

PURPOSE

This study explored the performance characteristics of a cuff-leak test (CLT) combined with interventional fiberoptic bronchoscopy (FBS) for evaluating whether early nasoendotracheal extubation was possible for patients who had received transoral atlantoaxial reduction plate (TARP) internal fixation surgery.

METHODS

318 patients who underwent surgery were retrospectively analyzed (between January 2006 and December 2012). Extubation was performed by conventional approach (CA group, until December 2008) and improved approach (IA group, from January 2009) including CLT and an interventional FBS procedure. The extubation success within 1-3 days after surgery, incidence of postextubation stridor and tracheal reintubation were examined.

RESULTS

More IA-treated patients experienced extubation during the first 2 days than those CA-treated, median extubation time was 3 (2, 3) days in the CA group and 2 (1, 2) days in the IA group (all P < 0.01). The incidence of stridor and reintubation was 5.69 and 0.57 % in IA and 11.98 and 4.93 % in CA, respectively (both P < 0.05). For the CLT-positive patients in the IA group that remained intubated until day 3-4, interventional FBS was applied for safe extubation and achieved 100 % success.

CONCLUSION

Early extubation through IA is safe and interventional FBS assists successful extubation for CLT-positive patients who underwent TARP surgery.

Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study

Background

While studies have suggested that prophylactic noninvasive ventilation (NIV) could prevent post-extubation respiratory failure in the intensive care unit, they appear inconsistent with regard to reintubation. We assessed the impact of a prophylactic NIV protocol on reintubation in a large population of at-risk patients.

Methods

Prospective before-after study performed in the medical ICU of a teaching referral hospital. In the control cohort, we determined that patients older than 65 years and those with underlying cardiac or respiratory disease were at high-risk for reintubation. In the interventional cohort, we implemented a protocol using prophylactic NIV in all patients intubated at least 24 h and having one of these risk factors. NIV was immediately applied after planned extubation during at least the first 24 hours. Extubation failure was defined by the need for reintubation within seven days following extubation.

Results

We included 83 patients at high-risk among 132 extubated patients in the control cohort (12-month period) and 150 patients at high-risk among 225 extubated patients in the NIV cohort (18-month period). The reintubation rate was significantly decreased from 28 % in the control cohort (23/83) to 15 % (23/150) in the NIV cohort (p = 0.02 log-rank test), whereas the non-at-risk patients did not significantly differ in the two periods (10.2 % vs. 10.7 %, p = 0.93). After multivariate logistic-regression analysis, the use of prophylactic NIV protocol was independently associated with extubation success.

Conclusions

The implementation of prophylactic NIV after extubation may reduce the reintubation rate in a large population of patients with easily identified risk factors for extubation failure.

Risk of reintubation in neurosurgical patients

BACKGROUND

Reintubation among neurosurgical patients is poorly characterized. The aim of this study was to delineate the rate of reintubation among neurosurgical patients. In addition, we seek to characterize the patient demographic features, comorbidities, and surgical characteristics that may be associated with reintubation among neurosurgical patients.

METHODS

This is a retrospective cohort study conducted in the setting of hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program between 2005 and 2010. All adult patients undergoing neurosurgery under general anesthesia were included. Exclusion criteria were preoperative mechanical ventilation or pneumonia prior to surgery. Reintubation was defined as placement of an endotracheal tube or mechanical ventilation within 48 h after surgery.

RESULTS

Among 17,483 eligible patients, 74 (0.42 %; 95 % CI 0.33-0.52 %) required reintubation within 48 h of surgery. In multiple logistic regression, the following were associated with increased risk of reintubation: age >65 years (OR 2.1; 95 % CI 1.3-3.4), preoperative renal failure (OR 2.9; 95 % CI 1.0-8.5), quadriplegia (OR 8.2; 95 % CI 3.3-20.3), COPD (OR 2.1; 95 % CI 1.0-4.3), operative time >3 h (OR 2.9; 95 % CI 1.8-4.8), and higher ASA class (OR per point, 2.1; 95 % CI 1.4-3.1). Spinal surgery was found to be protective relative to cranial neurosurgery or endarterectomy (OR 0.3; 95 % CI 0.2-0.5).

CONCLUSIONS

Reintubation after neurosurgery is associated with older patients with a greater number of comorbidities. In particular, renal, pulmonary, and severe neurologic comorbidities; longer operative duration; and cranial, rather than spinal, pathology were associated with increased risk for reintubation. These findings may be helpful in triage decisions regarding postoperative intensity of care and monitoring.

Role of Hematocrit Concentration on Successful Extubation in Critically Ill Patients in the Intensive Care Units

Background:

Hematocrit (Hct) is an important parameter for optimal oxygenation during discontinuation from ventilator, but there is no consensus about its concentration and effectiveness on successful extubation.

Objectives:

The current study aimed to determine the role of Hct concentration on extubation failure in critically ill patients.

Patients and Methods:

The current prospective cohort study investigated the effect of age, gender and Hct level on successful extubation of 163 mechanically ventilated patients in Imam Khomeini hospital intensive care units (ICUs), Tehran, Iran. Following successful weaning process, the patients were classified into two groups on the basis of Hct level; 62 with an Hct level of 21% - 27% and the other 101 patients with Hct levels above 27%. The data were analyzed by chi-square test and multiple logistic regressions. A probability value of less than 0.05 was considered significant.

Results:

There was no significant association between the level of Hct concentration and extubation failure (8.9% vs. 9.2%, P = 0.507). Gender and age were significantly associated with extubation failure (OR = 9.1, P = 0.034, OR = 12.5, P = 0.014, respectively). Although the differences between, before and after extubation of PaO₂ and P/F ratio, were of significant values between the two different groups of Hct (P = 0.001, P = 0.004 respectively), they had no effect on the failure of extubation (P= 0.259, P = 0.403, respectively).

Conclusions:

Although some studies showed association between anemia and extubation failure, the current study could not confirm it. The study showed that males, regardless of the Hct level, had a better extubation success rate than those of females.

Clinical efficacy of high-flow nasal cannula compared to noninvasive ventilation in patients with post-extubation respiratory failure

BACKGROUND/AIMS

Post-extubation respiratory failure (PERF) is associated with poor clinica l outcomes. High-f low nasa l cannula (HF NC) ox ygen therapy has been used in patients with respiratory failure, but the clinical benefit in patients with PERF remains unclear. The aim of this study was to evaluate the clinical efficacy of HFNC compared to noninvasive ventilation (NIV) in patients with PERF.

METHODS

A historic retrospective cohort analysis was performed in 28 beds in the medical Intensive Care Unit (ICU) at a single medical center in South Korea. In total, 73 patients with PERF were enrolled: 39 patients who underwent NIV from April 2007 to March 2009 and 34 patients who received HFNC from April 2009 to May 2011.

RESULTS

The rate of avoidance of reintubation was not different between the HFNC group (79.4%) and NIV group (66.7%, p = 0.22). All patients with HFNC tolerated the device, whereas five of those with NIV did not tolerate treatment (p = 0.057). The mean duration of ICU stay was significantly shorter in the HFNC group than in the NIV group (13.4 days vs. 20.6 days, p = 0.015). There was no difference in ICU or in-hospital mortality rate.

CONCLUSIONS

HFNC is likely to be as effective as, and better tolerated than, NIV for treatment of PERF.

Modified rapid shallow breathing index adjusted with anthropometric parameters increases predictive power for extubation failure compared with the unmodified index in postcardiac surgery patients

OBJECTIVE

The aim of this study was to determine the best predictors of successful extubation after cardiac surgery, by modifying the rapid shallow breathing index (RSBI) based on patients' anthropometric parameters.

DESIGN

Single-center prospective observational study.

SETTING

Two general intensive care units at a single research institute.

PARTICIPANTS

Patients who had undergone uncomplicated cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The following parameters were investigated in conjunction with modification of the RSBI: Actual body weight (ABW), predicted body weight, ideal body weight, body mass index (BMI), and body surface area. Using the first set of patient data, RSBI threshold and modified RSBI for extubation failure were determined (threshold value; RSBI: 77 breaths/min (bpm)/L, RSBI adjusted with ABW: 5.0 bpm×kg/mL, RSBI adjusted with BMI: 2.0 bpm×BMI/mL). These threshold values for RSBI and RSBI adjusted with ABW or BMI were validated using the second set of patient data. Sensitivity values for RSBI, RSBI modified with ABW, and RSBI modified with BMI were 91%, 100%, and 100%, respectively. The corresponding specificity values were 89%, 92%, and 93%, and the corresponding receiver operator characteristic values were 0.951, 0.977, and 0.980, respectively.

CONCLUSIONS

Modified RSBI adjusted based on ABW or BMI has greater predictive power than conventional RSBI.

Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review

Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor or respiratory difficulty or both. Ultimately, postextubation laryngeal edema may result in respiratory failure with subsequent reintubation. Risk factors for postextubation laryngeal edema include female gender, large tube size, and prolonged intubation. Although patients at low risk for postextubation respiratory insufficiency due to laryngeal edema can be identified by the cuff leak test or laryngeal ultrasound, no reliable test for the identification of high-risk patients is currently available. If applied in a timely manner, intravenous or nebulized corticosteroids can prevent postextubation laryngeal edema; however, the inability to identify high-risk patients prevents the targeted pretreatment of these patients. Therefore, the decision to start corticosteroids should be made on an individual basis and on the basis of the outcome of the cuff leak test and additional risk factors. The preferential treatment of postextubation laryngeal edema consists of intravenous or nebulized corticosteroids combined with nebulized epinephrine, although no data on the optimal treatment algorithm are available. In the presence of respiratory failure, reintubation should be performed without delay. Application of noninvasive ventilation or inhalation of a helium/oxygen mixture is not indicated since it does not improve outcome and increases the delay to intubation.

Impact of endotracheal intubation on septic shock outcome: A post hoc analysis of the SEPSISPAM trial

INTRODUCTION

The objective of the study to is to determine the characteristics associated with endotracheal intubation in septic shock patients.

METHODS

This is a post hoc analysis of the database of the SEPSISPAM study, including patients with septic shock.

RESULTS

Among the 776 patients, 633 (82%) were intubated within 12 hours of study inclusion (early intubation), 113 (15%) were never intubated, and 30 (4%) had delayed intubation. Intensive care units (ICUs) were classified according to frequency of early intubation: early intubation less than 80% of patients (lowest frequency: 7 ICUs, 254 patients), 80% to 90% (middle frequency: 5 ICUs, 170 patients), and greater than 90% (highest frequency: 6 ICUs, 297 patients). Type of ICU, pulmonary infection, lactate greater than 2 mmol/L, lower Pao2/fraction of inspired oxygen ratio, lower Glasgow score, and absence of immunosuppression were independently associated with early intubation. Patients never intubated had a lower initial severity and a low mortality rate. In comparison to patients intubated early, patients with delayed intubation had had fewer days alive without organ support by day 28. Intensive care units with the highest frequency of early intubation had a higher mortality rate in comparison to ICUs with middle frequency of early intubation. A nonsignificant increased mortality was observed in ICU with lowest frequency of early intubation.

CONCLUSIONS

Practices regarding the place of endotracheal intubation in septic shock may impact outcome.

Discontinuation of ventilatory support: new solutions to old dilemmas

PURPOSE OF REVIEW

Weaning from mechanical ventilation implies two separate but closely related aspects of care, the discontinuation of mechanical ventilation and removal of artificial airway, which implies routine clinical dilemmas. Extubation delay and extubation failure are associated with poor clinical outcomes. We sought to summarize recent evidence on weaning.

RECENT FINDINGS

Tolerance to an unassisted breathing does not require routine use of weaning predictors and can be addressed using weaning protocols or by implementing automatic weaning methods. Spontaneous breathing trial can be performed on low levels of pressure support, continuous positive airway pressure, or T-piece. Echocardiographic tools may help to prevent the failure of extubation. Noninvasive ventilation can prevent respiratory failure after extubation, when used in hypercapnic patients. Recently, sedation protocols and early mobilization in ventilated critically ill patients may decrease weaning period and duration of mechanical ventilation, and prevent extubation failure and complications such as ICU-acquired weakness. New techniques have been performed to identify patients with high risk for extubation failure.

SUMMARY

There is an interesting body of clinical research in the discontinuation of mechanical ventilation. Recent randomized controlled studies provide high-level evidence for the best approaches to weaning, especially in patients who fail the first spontaneous breathing trial or targeted populations.

Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study

OBJECTIVE

The influence of delirium, ICU-acquired paresis, and cardiac performance on extubation outcome has never been evaluated together. We aimed to assess the respective role of these factors on the risk of extubation failure and to assess the predictive accuracy of caregivers.

DESIGN AND SETTING

Prospective observational study of all planned extubations in a 13-bed medical ICU of a teaching hospital.

INTERVENTIONS

On the day of extubation, muscle strength of the four limbs, criteria for delirium, cardiac performance, cough strength, and the risk of extubation failure predicted by caregivers were prospectively assessed. Extubation failure was defined as the need for reintubation within the following 7 days.

MEASUREMENTS AND MAIN RESULTS

Over the 18-month study period, 533 patients required intubation. Among the 225 patients intubated for more than 24 hours who experienced a planned extubation attempt, 31 patients (14%) required reintubation within the 7 days following extubation. In multivariate analysis, duration of mechanical ventilation more than 7 days prior to extubation, ineffective cough, and severe systolic left ventricular dysfunction were the three independent factors associated with extubation failure. Although patients considered at high risk for extubation failure had higher reintubation rate, prediction of extubation failure by caregivers at time of extubation had high specificity but low sensitivity.

CONCLUSIONS

An ineffective cough, a prior duration of mechanical ventilation more than 7 days, and severe systolic left ventricular dysfunction were stronger predictors of extubation failure than delirium or ICU-acquired weakness. Only one-third patients who required reintubation were considered at high risk for extubation failure by caregivers.

Laryngeal air column width ratio in predicting post extubation stridor

Aim:

Correlation of upper air column width ratio in postextubation stridor patients.

Materials and Methods:

A prospective observational study was conducted in a tertiary hospital between January and December 2013. Patients who were admitted in Intensive Care Unit and intubated for >24 h were included (72 patients). The upper airway air column width ratio (air column width before extubation/air column width after intubation) was calculated and compared in patient with or without postextubation stridor.

Results:

The incidence of stridor was 6.9% (5/72). The duration of mechanical ventilation was 5.60 ± 1.14 days and 3.91 ± 1.45 days in stridor and nonstridor group respectively. In all 5 patients who had stridor, the upper airway air column width ratio was 0.8 or less.

Conclusion:

Air column width ratio of 0.8 or less may be helpful in predicting postextubation stridor, which should be confirmed by large observational studies.

Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications

BACKGROUND

Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU).

METHODS

This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation.

RESULTS

A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12).

CONCLUSIONS

After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.

Efficacy of noninvasive ventilation after planned extubation: A systematic review and meta-analysis of randomized controlled trials

The objective our meta-analysis is to update the evidence on the efficacy of noninvasive ventilation (NIV) compared with conventional oxygen therapy after planned extubation. We did a systematic literature review of database, including Pubmed, EMBASE, and Cochrane. We included randomized controlled trials comparing NIV with conventional oxygen therapy after planned extubation in medical intensive care unit (ICU) in our analysis. The results of our meta-analysis is consistent with the results of previous reviews and show that NIV decreased reintubation rate significantly as compared to conventional oxygen therapy in chronic obstructive pulmonary disease (COPD) and patients at high risk for extubation failure; COPD (RR, 0.33; 95% CI, 0.16-0.69; I2 = 0), high risk (RR, 0.47; 95% CI, 0.32-0.70; I2 = 0). However, in a mixed medical ICU population, there was no statistical difference of reintubation rate between the two groups (RR, 0.66; 95% CI, 0.25-1.73; I2 = 68%). Our study suggests that use of NIV after planned extubation significantly decreases the reintubation rate in COPD patients and patients at high risk for extubation failure, confirming the findings of previous reviews. There is no difference in the reintubation rate between the two groups in the mixed medical ICU population.

Variation in tracheal reintubations among patients undergoing cardiac surgery across Washington state hospitals

OBJECTIVES

The objectives of this study were to examine the variation in reintubations across Washington state hospitals that perform cardiac surgery, and explore hospital and patient characteristics associated with variation in reintubation.

DESIGN

Retrospective cohort study.

SETTING

All nonfederal hospitals performing cardiac surgery in Washington state.

PARTICIPANTS

A total of 15,103 patients undergoing coronary artery bypass grafting or valvular surgery between January 1, 2008 and September 30, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient and hospital characteristics were compared between hospitals that had a reintubation frequency ≥5% or<5%. Multivariate logistic regression was used to compare the odds of reintubation across the hospitals. The authors tested for heterogeneity of odds of reintubation across hospitals by performing a likelihood ratio test on the hospital factor. After adjusting for patient-level characteristics and procedure type, significant heterogeneity in reintubations across hospitals was present (p = 0.005). This exploratory analyses suggested that hospitals with lower reintubations were more likely to have more acute care days and teaching intensive care units (ICU).

CONCLUSIONS

After accounting for patient and procedure characteristics, significant heterogeneity in the relative odds of requiring reintubation was present across 16 nonfederal hospitals performing cardiac surgery in Washington state. The findings suggested that greater hospital volume and ICU teaching status were associated with fewer reintubations.

Prognosis and Patterns of Failure for the Extubation of Patients Who Remain Intubated After Head and Neck Surgery

Objective:

This study aimed to analyze the rate of failure, patterns of failure, and prognostic factors for patients who remain intubated after head and neck surgery and then undergo delayed extubation.

Methods:

Retrospective chart review of all otolaryngology patients who remained intubated after head and neck surgery and then underwent delayed extubation between 2006 and 2013. The incidence and patterns of extubation failure were analyzed. Univariable logistic regression analysis was performed to identify risk factors for postextubation failure.

Results:

Fifteen of the 129 patients (12%) who remained intubated after head and neck surgery and underwent delayed extubation subsequently failed and required either repeat intubation or an emergency surgical airway. The most common reasons for failure were hemorrhage (47%) and upper airway edema (33%). Failure typically occurred within 6 hours of extubation. Twenty-seven percent of the patients who failed extubation (4/15) required an emergency surgical airway. On univariable logistic regression analysis, ligation of a major neck vessel predicted extubation failure (odds ratio = 5.20; 95% confidence interval, 1.48-18.23).

Conclusion:

Postextubation failure in carefully selected patients undergoing delayed extubation after head and neck surgery is infrequent and most commonly due to postoperative bleeding. Prospective data are required to facilitate safe and quality care for these patients.

Predictors of reintubation in trauma intensive care unit: qatar experience

OBJECTIVES

To determine the causes, predictors and outcomes of re-intubation.

METHODS

Retrospective analysis of data collected from the trauma data base registry was conducted to identify the extubation failure cases in Trauma ICU at Hamad General Hospital, the only Level I trauma center in Qatar between January 2009 and December 2010. Demographics, mechanism of Injury, complications, injury severity score (ISS), Glasgow Coma Scale (GCS), ICU-length of stay (LOS), and mortality were analyzed among trauma patients who need reintubation within 48 hrs after extubation (group 1) compared to successfully extubated patients (group 2).

RESULT

A total of 954 patients were admitted to the trauma ICU, of which 343 were intubated orotracheally. The mean age of patients was 32±12 years with male predominance (95%). Motor vehicle crash (41%), pedestrian injury (20%) and falls (18%) were the most common mechanisms of injury. Reintubation (group 1) was required in 24 patients (7%). Patients in group 1 had higher rate of head injury mainly SAH (88%), pneumonia (79%) and pulmonary contusion (58%). The mean ICU-LOS was higher in the reintubated patients (p=0.010) in comparison to group 2. Forty-six percent of reintubated patients required tracheostomy. The mean age, ISS, GCS and tube size was comparable among the two groups. Furthermore, reintubation was not associated with higher mortality rate (p=0.910). However, Ventilator-associated pneumonia (VAP) (odd ratio=3.61 [95% CI 1.25-10.44]; p=0.020) and ventilator days (odd ratio=1.09 [95% CI 1.024-1.153]; p=0.006) were independent predictors of reintubation by multivariate analysis.

CONCLUSION

Re-intubation is associated with increased ICU-LOS and need for tracheostomy. VAP and prolonged intubation are independent predictors of re-intubation. Our finding addresses the value of prevention and early treatment of infection in intubated patients. This study may represent an audit of local practice as well.

Retrospective derivation and validation of a search algorithm to identify extubation failure in the intensive care unit

Background

Development and validation of automated electronic medical record (EMR) search strategies is important in identifying extubation failure in the intensive care unit (ICU). We developed and validated an automated search algorithm (strategy) for extubation failure in critically ill patients.

Methods

The EMR search algorithm was created through sequential steps with keywords applied to an institutional EMR database. The search strategy was derived retrospectively through secondary analysis of a 100-patient subset from the 978 patient cohort admitted to a neurological ICU from January 1, 2002, through December 31, 2011(derivation subset). It was, then, validated against an additional 100-patient subset (validation subset). Sensitivity, specificity, negative and positive predictive values of the automated search algorithm were compared with a manual medical record review (the reference standard) for data extraction of extubation failure.

Results

In the derivation subset of 100 random patients, the initial automated electronic search strategy achieved a sensitivity of 85% (95% CI, 56%-97%) and a specificity of 95% (95% CI, 87%-98%). With refinements in the search algorithm, the final sensitivity was 93% (95% CI, 64%-99%) and specificity increased to 100% (95% CI, 95%-100%) in this subset. In validation of the algorithm through a separate 100 random patient subset, the reported sensitivity and specificity were 94% (95% CI, 69%-99%) and 98% (95% CI, 92%-99%) respectively.

Conclusions

Use of electronic search algorithms allows for correct extraction of extubation failure in the ICU, with high degrees of sensitivity and specificity. Such search algorithms are a reliable alternative to manual chart review for identification of extubation failure.

Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury

OBJECTIVE

To evaluate the association between extubation failure and outcomes (clinical and functional) in patients with traumatic brain injury (TBI).

METHODS

A prospective cohort study involving 311 consecutive patients with TBI. The patients were divided into two groups according to extubation outcome: extubation success; and extubation failure (defined as reintubation within 48 h after extubation). A multivariate model was developed in order to determine whether extubation failure was an independent predictor of in-hospital mortality.

RESULTS

The mean age was 35.7 ± 13.8 years. Males accounted for 92.3%. The incidence of extubation failure was 13.8%. In-hospital mortality was 4.5% and 20.9% in successfully extubated patients and in those with extubation failure, respectively (p = 0.001). Tracheostomy was more common in the extubation failure group (55.8% vs. 1.9%; p < 0.001). The median length of hospital stay was significantly greater in the extubation failure group than in the extubation success group (44 days vs. 27 days; p = 0.002). Functional status at discharge was worse among the patients in the extubation failure group. The multivariate analysis showed that extubation failure was an independent predictor of in-hospital mortality (OR = 4.96; 95% CI, 1.86-13.22).

CONCLUSIONS

In patients with TBI, extubation failure appears to lengthen hospital stays; to increase the frequency of tracheostomy and of pulmonary complications; to worsen functional outcomes; and to increase mortality.

Daytime Versus Nighttime Extubations

Purpose:

Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time.

Methods:

A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm.

Results:

Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night ( P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night.

Conclusions:

Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

Weaning of mechanically ventilated chronic obstructive pulmonary disease patients by using non-invasive positive pressure ventilation: A prospective study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients frequently pose difficulty in weaning from invasive mechanical ventilation (MV). Prolonged invasive ventilation brings along various complications. Non-invasive positive pressure ventilation (NIPPV) is proposed to be a useful weaning modality in such cases.

OBJECTIVE

To evaluate the usefulness of NIPPV in weaning COPD patients from invasive MV, and compare it with weaning by conventional pressure support ventilation (PSV).

MATERIALS AND METHODS

For this prospective randomized controlled study, we included 50 COPD patients with type II respiratory failure requiring initial invasive MV. Upon satisfying weaning criteria and failing a t-piece weaning trial, they were randomized into two groups: Group I (25 patients) weaned by NIPPV, and group II (25 patients) weaned by conventional PSV. The groups were similar in terms of disease severity, demographic, clinical and biochemical parameters. They were compared in terms of duration of MV, weaning duration, length of intensive care unit (ICU) stay, occurrence of nosocomial pneumonia and outcome.

RESULTS

Statistically significant difference was found between the two groups in terms of duration of MV, weaning duration, length of ICU stay, occurrence of nosocomial pneumonia and outcome.

CONCLUSION

NIPPV appears to be a promising weaning modality for mechanically ventilated COPD patients and should be tried in resource-limited settings especially in developing countries.

Glucocorticoids in laryngology: a review

OBJECTIVES/HYPOTHESIS

To provide the otolaryngologist an evidence-based sound review of glucocorticoid use for laryngeal pathology.

STUDY DESIGN

Review of contemporary peer-reviewed literature as well as review articles.

METHODS

A review of the literature regarding glucocorticoids as a therapeutic intervention for the treatment of benign laryngeal pathology and laryngeal manifestations of systemic disease was performed. Review included both systemic administration as well as local injection.

RESULTS

Glucocorticoids, administered in the critical care setting for planned extubation, markedly reducing the risk of reintubation and remain a rudimentary pharmacologic adjunct in laryngeal manifestations of common autoimmune and inflammatory disorders. Intralesional injection has reduced the rate of surgical intervention for benign inflammatory primary laryngeal pathology.

CONCLUSIONS

Glucocorticoids are effective in the treatment of a number of laryngeal pathologies, through both systemic and intralesional administration. However, a clear consensus for utilization of glucocorticoids in the treatment of specific laryngeal disorders has yet to be published.

Evaluation of noninvasive positive pressure ventilation after extubation from moderate positive end-expiratory pressure level in patients undergoing cardiovascular surgery: a prospective observational study

BACKGROUND

It remains to be clarified if the application of noninvasive positive pressure ventilation (NPPV) is effective after extubation in patients with hypoxemic respiratory failure who require the sufficient level of positive end-expiratory pressure (PEEP). This study was aimed at examining the effect and the safety of NPPV application following extubation in patients requiring moderate PEEP level for sufficient oxygenation after cardiovascular surgery.

METHODS

With institutional ethic committee approval, the patients ventilated invasively for over 48 h after cardiovascular surgery were enrolled in this study. The patients who failed the first spontaneous breathing trial (SBT) at 5 cmH2O of PEEP, but passed the second SBT at 8 cmH2O of PEEP, received NPPV immediately after extubation following our weaning protocol. Respiratory parameters (partial pressure of arterial oxygen tension to inspiratory oxygen fraction ratio: P/F ratio, respiratory ratio, and partial pressure of arterial carbon dioxide: PaCO2) 2 h after extubation were evaluated with those just before extubation as the primary outcome. The rate of re-intubation, the frequency of respiratory failure and intolerance of NPPV, the duration of NPPV, and the length of intensive care unit (ICU) stay were also recorded.

RESULTS

While 51 postcardiovascular surgery patients were screened, 6 patients who met the criteria received NPPV after extubation. P/F ratio was increased significantly after extubation compared with that before extubation (325 ± 85 versus 245 ± 55 mmHg, p < 0.05). The other respiratory parameters did not change significantly. Re-intubation, respiratory failure, and intolerance of NPPV never occurred. The duration of NPPV and the length of ICU stay were 2.7 ± 0.7 (SD) and 7.5 (6 to 10) (interquartile range) days, respectively.

CONCLUSIONS

While further investigation should be warranted, NPPV could be applied effectively and safely after extubation in patients requiring the moderate PEEP level after cardiovascular surgery.

Clinical quality improvement: eliminating unplanned extubation in the CCU

PURPOSE

This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months.

DESIGN/METHODOLOGY/APPROACH

Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds.

FINDINGS

For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours.

PRACTICAL IMPLICATIONS

Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU.

ORIGINALITY/VALUE

There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.

Implementation of an evidence-based extubation readiness bundle in 499 brain-injured patients. a before-after evaluation of a quality improvement project

RATIONALE

Mechanical ventilation is associated with morbidity in patients with brain injury.

OBJECTIVES

This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in patients with brain injury.

METHODS

Before-after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated more than 24 hours were evaluated during two phases (a 3-yr control phase followed by a 22-mo intervention phase). Bundle components were protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia, and systematic approach to extubation. The primary endpoint was the duration of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

A total of 299 and 200 patients, respectively, were analyzed in the control and the intervention phases of this before-after study. The intervention phase was associated with lower tidal volume (P < 0.01), higher positive end-expiratory pressure (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The duration of mechanical ventilation was 14.9 ± 11.7 days in the control phase and 12.6 ± 10.3 days in the intervention phase (P = 0.02). The hazard ratio for extubation was 1.28 (95% confidence interval [CI], 1.04-1.57; P = 0.02) in the intervention phase. Adjusted hazard ratio was 1.40 (95% CI, 1.12-1.76; P < 0.01) in multivariate analysis and 1.34 (95% CI, 1.03-1.74; P = 0.02) in propensity score-adjusted analysis. ICU-free days at Day 90 increased from 50 ± 33 in the control phase to 57 ± 29 in the intervention phase (P < 0.01). Mortality at Day 90 was 28.4% in the control phase and 23.5% in the intervention phase (P = 0.22).

CONCLUSIONS

The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in patients with brain injury.

Rationale and study design of ViPS - variable pressure support for weaning from mechanical ventilation: study protocol for an international multicenter randomized controlled open trial

Background

In pressure support ventilation (PSV), a non-variable level of pressure support is delivered by the ventilator when triggered by the patient. In contrast, variable PSV delivers a level of pressure support that varies in a random fashion, introducing more physiological variability to the respiratory pattern. Experimental studies show that variable PSV improves gas exchange, reduces lung inflammation and the mean pressure support, compared to non-variable PSV. Thus, it can theoretically shorten weaning from the mechanical ventilator.

Methods/design

The ViPS (variable pressure support) trial is an international investigator-initiated multicenter randomized controlled open trial comparing variable vs. non-variable PSV. Adult patients on controlled mechanical ventilation for more than 24 hours who are ready to be weaned are eligible for the study. The randomization sequence is blocked per center and performed using a web-based platform. Patients are randomly assigned to one of the two groups: variable PSV or non-variable PSV. In non-variable PSV, breath-by-breath pressure support is kept constant and targeted to achieve a tidal volume of 6 to 8 ml/kg. In variable PSV, the mean pressure support level over a specific time period is targeted at the same mean tidal volume as non-variable PSV, but individual levels vary randomly breath-by-breath. The primary endpoint of the trial is the time to successful weaning, defined as the time from randomization to successful extubation.

Discussion

ViPS is the first randomized controlled trial investigating whether variable, compared to non-variable PSV, shortens the duration of weaning from mechanical ventilation in a mixed population of critically ill patients. This trial aims to determine the role of variable PSV in the intensive care unit.

Trial registration

clinicaltrials.gov NCT01769053

The role of non-invasive positive pressure ventilation in post-extubation respiratory failure: An evaluation using meta-analytic techniques

Background:

The use of non-invasive positive pressure ventilation (NIPPV) in post-extubation respiratory failure is not well-established. Meta-analytic techniques were used to assess the effects of prophylactic application of NIPPV (prior to the development of respiratory failure) and therapeutic application of NIPPV (subsequent to the development of respiratory failure).

Materials and Methods:

Randomized controlled trials (RCTs) from 1966 to May 2010 were identified using electronic databases. RCTs, which reported the use of NIPPV in post-extubation respiratory failure with defined assessable endpoints: reintubation, mortality and length of stay, were included.

Results:

Reintubation was the primary outcome, mortality and lengths of stay were the secondary outcomes. Risk ratios (RR) were calculated for discrete outcomes and weighted mean differences (WMD) for continuous measures. There were 13 trials with 1420 patients; 9 prophylactic with 861 patients and 4 therapeutic with 559 patients. In the prophylactic group, NIPPV was associated with lower rates of reintubation: RR 0.53 (95% confidence interval [CI], 0.28-0.98), P = 0.04. In the therapeutic group, NIPPV showed a null effect on reintubation: RR 0.79 (95% CI, 0.50-1.25), P = 0.31. The analysis on the secondary outcomes suggested significant reduction of hospital mortality with prophylactic application of NIPPV: RR 0.62 (95% CI 0.4-0.97), P = 0.03, with no effect on the other outcomes. Therapeutic application of NIPPV reduced intensive care unit length of stay: WMD −1.17 (95% CI −2.82 to −0.33), P = 0.006, but no effect on the other secondary outcomes.

Conclusions:

The results of this review suggested prophylactic NIPPV was beneficial with respect to reintubation and the therapeutic use of NIPPV showed a null effect.

Unsynchronized nasal intermittent positive pressure versus nasal continuous positive airway pressure in preterm infants after extubation

OBJECTIVE

To determine the effect of unsynchronized nasal intermittent positive pressure ventilation compared to continuous positive airway pressure in preterm infants after extubation.

METHODS

A total of 67 premature infants who were <35 weeks gestation and/or <2000 g birth weight and received mechanical ventilation because of respiratory distress syndrome (RDS) were studied. Infants were randomized to receive either unsynchronized nasal intermittent positive pressure ventilation (NIPPV) with shortened endotracheal tube (Group 1) or nasal continuous positive airway pressure (NCPAP) with binasal prongs (Group 2) after extubation. Extubation failure and neonatal outcomes were recorded in each group.

RESULTS

There were no significant differences in clinical characteristics between the two groups. The prevalence of re-intubation and post-extubation atelectasis were higher in CPAP group (p = 0.03 and p = 0.01). No differences were observed in the prevalence of IVH, ROP, PDA, NEC, sepsis, pneumothorax, BPD and BPD/death between the groups while the mortality was higher in NCPAP group (p < 0.01). Neither procedure had any serious side effects such as intestinal perforation.

CONCLUSION

NIPPV (although non-synchronized and delivered by single nasal prong) had a better effect than NCPAP after extubation of preterm infants on mechanical ventilation in respect to reducing the prevalence of post-extubation atelectasis, re-intubation and also death.