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Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Xu SS, Tian Y, Ma YJ, Zhou YM, Tian Y, Gao R, Yang YL, Zhang L, Zhou JX. Development of a Prediction Score for Evaluation of Extubation Readiness in Neurosurgical Patients with Mechanical Ventilation. Anesthesiology 2023; 139:614-627. [PMID: 37535470 PMCID: PMC10566588 DOI: 10.1097/aln.0000000000004721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND There is no widely accepted consensus on the weaning and extubating protocols for neurosurgical patients, leading to heterogeneity in clinical practices and high rates of delayed extubation and extubation failure-related health complications. METHODS In this single-center prospective observational diagnostic study, mechanically ventilated neurosurgical patients with extubation attempts were consecutively enrolled for 1 yr. Responsive physicians were surveyed for the reasons for delayed extubation and developed the Swallowing, Tongue protrusion, Airway protection reflected by spontaneous and suctioning cough, and Glasgow Coma Scale Evaluation (STAGE) score to predict the extubation success for neurosurgical patients already meeting other general extubation criteria. RESULTS A total of 3,171 patients were screened consecutively, and 226 patients were enrolled in this study. The rates of delayed extubation and extubation failure were 25% (57 of 226) and 19% (43 of 226), respectively. The most common reasons for the extubation delay were weak airway-protecting function and poor consciousness. The area under the receiver operating characteristics curve of the total STAGE score associated with extubation success was 0.72 (95% CI, 0.64 to 0.79). Guided by the highest Youden index, the cutoff point for the STAGE score was set at 6 with 59% (95% CI, 51 to 66%) sensitivity, 74% (95% CI, 59 to 86%) specificity, 90% (95% CI, 84 to 95%) positive predictive value, and 30% (95% CI, 21 to 39%) negative predictive value. At STAGE scores of 9 or higher, the model exhibited a 100% (95% CI, 90 to 100%) specificity and 100% (95% CI, 72 to 100%) positive predictive value for predicting extubation success. CONCLUSIONS After a survey of the reasons for delayed extubation, the STAGE scoring system was developed to better predict the extubation success rate. This scoring system has promising potential in predicting extubation readiness and may help clinicians avoid delayed extubation and failed extubation-related health complications in neurosurgical patients. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Shan-Shan Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ye Tian
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Juan Ma
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ran Gao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Taran S, Angeloni N, Pinto R, Lee S, McCredie VA, Schultz MJ, Robba C, Taccone FS, Adhikari NKJ. Prognostic Factors Associated With Extubation Failure in Acutely Brain-Injured Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:401-412. [PMID: 36583622 DOI: 10.1097/ccm.0000000000005769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Extubation failure in brain-injured patients is associated with increased morbidity. Our objective was to systematically review prognostic factors associated with extubation failure in acutely brain-injured adult patients receiving invasive ventilation in an ICU. DATA SOURCES MEDLINE, Embase, and Cochrane Central were searched from inception to January 31, 2022. STUDY SELECTION Two reviewers independently screened citations and selected English-language cohort studies and randomized trials examining the association of prognostic factors with extubation failure. Studies were considered if they included greater than or equal to 80% adult patients with acute brain injury admitted to the ICU and mechanically ventilated for greater than or equal to 24 hours. DATA EXTRACTION Two reviewers extracted data on population, prognostic factors, extubation outcomes, and risk of bias (using the quality in prognostic factors tool). DATA SYNTHESIS In the primary analysis, adjusted odds ratios (aOR) for each prognostic factor were pooled using random-effects models. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The search identified 7,626 citations, of which 21 studies met selection criteria. Moderate-certainty evidence suggested increased risk of extubation failure with older age (aOR, 3.0 for upper vs lower tertile; 95% CI, 1.78-5.07) and longer duration of mechanical ventilation (aOR, 3.47 for upper vs lower tertile; 95% CI, 1.68-7.19). Presence of cough (aOR, 0.40; 95% CI, 0.28-0.57) and intact swallow (aOR, 0.34; 95% CI, 0.21-0.54) probably decreased risk of extubation failure (moderate certainty). Associations of other factors with extubation failure were informed by low or very low certainty evidence. CONCLUSIONS Patient age, duration of mechanical ventilation, and airway reflexes were associated with extubation failure in brain-injured patients with moderate certainty. Future studies are needed to determine the optimal application of these variables in clinical practice.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Natalia Angeloni
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Shawn Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Chiara Robba
- Department of Surgical Science and Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Brusssels, Belgium
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Li W, Zhang Y, Wang Z, Jia D, Zhang C, Ma X, Han X, Zhao T, Zhang Z. The risk factors of reintubation in intensive care unit patients on mechanical ventilation: A systematic review and meta-analysis. Intensive Crit Care Nurs 2023; 74:103340. [PMID: 36369190 DOI: 10.1016/j.iccn.2022.103340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Wenrui Li
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Ying Zhang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Zhenzhen Wang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Donghui Jia
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Caiyun Zhang
- School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China; Outpatient Department, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Xiujuan Ma
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Xinyi Han
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Tana Zhao
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Zhigang Zhang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China.
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Weaning Outcomes in Patients with Brain Injury. Neurocrit Care 2022; 37:649-659. [PMID: 36050534 DOI: 10.1007/s12028-022-01584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/18/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons. METHODS We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28. RESULTS Among the 20,929 patients enrolled, we included 12,618 (60%) who started the weaning from MV, of whom 1722 (14%) were patients with acute brain injury. In the acutely brain-injured cohort, 538 patients (31%) did not undergo planned extubation, defined as the need for a tracheostomy without an attempt of extubation, accidental extubation, and death. Among the 1184 planned extubated patients with acute brain injury, 202 required reintubation (17%). Patients with acute brain injury had a higher odds for unplanned extubation (odds ratio [OR] 1.35, confidence interval for 95% [CI 95%] 1.19-1.54; p < 0.001), a higher odds of failure after the first attempt of weaning (spontaneous breathing trial or gradual reduction of ventilatory support; OR 1.14 [CI 95% 1.01-1.30; p = 0.03]), and a higher odds for reintubation (OR 1.41 [CI 95% 1.20-1.66; p < 0.001]) than patients without brain injury. Patients with hemorrhagic stroke had the highest odds for unplanned extubation (OR 1.47 [CI 95% 1.22-1.77; p < 0.001]), of failed extubation after the first attempt of weaning (OR 1.28 [CI 95% 1.06-1.55; p = 0.009]), and for reintubation (OR 1.49 [CI 95% 1.17-1.88; p < 0.001]). In relation to weaning evolution over time in patients with acute brain injury, the risk for unplanned extubation showed a downward trend; the risk for reintubation was not associated to time; and there was a significant increase in the percentage of patients who underwent extubation after the first attempt of weaning from MV. CONCLUSIONS Patients with acute brain injury, compared with patients without brain injury, present higher odds of undergoing unplanned extubated after weaning was started, lower odds of being extubated after the first attempt, and a higher risk of reintubation.
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Muzette FM, Lima RBH, de Araújo Silva J, Comin TFB, Saraiva EF, Seki KLM, Christofoletti G. Accuracy and Sensitivity of Clinical Parameters in Predicting Successful Extubation in Patients with Acute Brain Injury. Neurol Int 2022; 14:619-627. [PMID: 35893285 PMCID: PMC9332386 DOI: 10.3390/neurolint14030050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Brain injuries are frequent causes of intubation and mechanical ventilation. The aim of this study was to investigate the accuracy and sensitivity of clinical parameters in predicting successful extubation in patients with acute brain injury. Methods: Six hundred and forty-four patients assisted at a high-complexity hospital were recruited. Patients were divided as for successful or failed extubation. The VISAGE score, maximum inspiratory and expiratory pressures, peak cough flow, and airway occlusion pressure at 0.1 s were used as predictors. Logistic regression analyses using ROC-curve identified values of accuracy and sensitivity. The Hosmer–Lemeshow test and the stepwise method calibrated the statistical model. Results: VISAGE score (odds ratio of 1.975), maximum inspiratory pressure (odds ratio of 1.024), and peak cough flow (odds ratio of 0.981) are factors consistent in distinguishing success from failure extubation. The ROC curve presented an accuracy of 79.7% and a sensitivity of 95.8%. Conclusions: VISAGE score, maximum inspiratory pressure and peak cough flow showed good accuracy and sensitivity in predicting successful extubation in patients with acute brain injury. The greater impact of VISAGE score indicates that patients’ neurological profile should be considered in association with ventilatory parameters in the decision of extubation.
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Affiliation(s)
- Flávia Manhani Muzette
- Faculty of Medicine, Institute of Health, Federal University of Mato Grosso do Sul, UFMS, Campo Grande 79060-900, Brazil; (F.M.M.); (R.B.H.L.); (E.F.S.); (K.L.M.S.)
| | - Rayssa Bruna Holanda Lima
- Faculty of Medicine, Institute of Health, Federal University of Mato Grosso do Sul, UFMS, Campo Grande 79060-900, Brazil; (F.M.M.); (R.B.H.L.); (E.F.S.); (K.L.M.S.)
| | | | | | - Erlandson Ferreira Saraiva
- Faculty of Medicine, Institute of Health, Federal University of Mato Grosso do Sul, UFMS, Campo Grande 79060-900, Brazil; (F.M.M.); (R.B.H.L.); (E.F.S.); (K.L.M.S.)
| | - Karla Luciana Magnani Seki
- Faculty of Medicine, Institute of Health, Federal University of Mato Grosso do Sul, UFMS, Campo Grande 79060-900, Brazil; (F.M.M.); (R.B.H.L.); (E.F.S.); (K.L.M.S.)
| | - Gustavo Christofoletti
- Faculty of Medicine, Institute of Health, Federal University of Mato Grosso do Sul, UFMS, Campo Grande 79060-900, Brazil; (F.M.M.); (R.B.H.L.); (E.F.S.); (K.L.M.S.)
- Correspondence:
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Wen J, Chen J, Chang J, Wei J. Pulmonary complications and respiratory management in neurocritical care: a narrative review. Chin Med J (Engl) 2022; 135:779-789. [PMID: 35671179 PMCID: PMC9276382 DOI: 10.1097/cm9.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.
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Affiliation(s)
- Junxian Wen
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Dongcheng District, Beijing 100730, China
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Joffe A, Barnes CR. Extubation of the potentially difficult airway in the intensive care unit. Curr Opin Anaesthesiol 2022; 35:122-129. [PMID: 35191402 DOI: 10.1097/aco.0000000000001119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE). RECENT FINDINGS Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE. SUMMARY Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.
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Affiliation(s)
- Aaron Joffe
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
- Banner MD Anderson Cancer Center, Gilbert, Arizona, USA
| | - Christopher R Barnes
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
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Effect of Early Tracheostomy on Mortality of Mechanically Ventilated Patients with Guillain-Barré Syndrome: A Nationwide Observational Study. Neurocrit Care 2021; 33:759-768. [PMID: 32291575 PMCID: PMC7223482 DOI: 10.1007/s12028-020-00965-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Patients with Guillain–Barré syndrome (GBS) who require mechanical ventilation (MV) are regarded as candidates for early tracheostomy because of the high risk of prolonged MV; however, the association between early tracheostomy and favorable outcomes in patients with GBS remains unclear. In this study, we evaluated the association between early tracheostomy and outcomes in mechanically ventilated patients with GBS. Methods This retrospective observational study included adult patients with GBS identified in the Japanese Diagnosis Procedure Combination national inpatient database from July 1, 2010, to March 31, 2018, who initiated MV within the first week of admission and who received MV for more than 1 week. Early tracheostomy was defined as tracheostomy performed within 7 days of MV. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, nosocomial pneumonia, length of hospital stay, length of intensive care unit (ICU) stay, duration of MV, duration of sedation, duration of analgesia, duration of delirium, and total hospitalization costs. Propensity scores for early tracheostomy were calculated using a logistic regression model on the following variables: age; sex; body mass index; Japan Coma Scale status at admission; Charlson comorbidity index score; comorbidity of chronic pulmonary disease; complication of pneumonia at admission; complication of hyponatremia at admission; neurological presentation at admission; ambulance use; referral from other hospitals; treatment year; days from hospital admission to MV initiation; ICU admission until the day of MV initiation; and treatments until the day of MV initiation. Stabilized inverse probability of treatment weighting analyses was performed to compare the outcomes between patients with and without early tracheostomy. Results Among 919 eligible patients, 654 patients (71%) underwent tracheostomy, with 136 patients (15%) receiving early tracheostomy. Overall, the median time from initiation of MV to tracheostomy was 12 days (interquartile range 8–15 days). After stabilized inverse probability of treatment weighting, early tracheostomy was not associated with lower in-hospital mortality (risk difference 0.4%; 95% confidence interval − 5.6 to 6.7%) compared with patients without early tracheostomy. There were no significant differences in 28-day mortality (risk difference − 1.3%; 95% confidence interval − 3.5 to 0.9%) and incidence of nosocomial pneumonia (risk difference − 2.6%; 95% confidence interval − 9.1 to 4.2%) between the two groups. None of the other secondary outcomes differed significantly between the groups. Conclusions Early tracheostomy was not significantly associated with decreased mortality or morbidity in patients with GBS requiring MV for more than 1 week.
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Kansal A, Dhanvijay S, Li A, Phua J, Cove ME, Ong WJD, Puah SH, Ng V, Tan QL, Manalansan JS, Zamora MSN, Vidanes MC, Sahagun JT, Taculod J, Tan AYH, Tay CK, Chia YW, Sewa DW, Chew M, Lew SJW, Goh S, Tan JJE, Ramanathan K, Mukhopadhyay A, See KC. Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:467-473. [PMID: 34195753 DOI: 10.47102/annals-acadmedsg.2020564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed post-extubation HFNC. METHODS We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. RESULTS Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83-3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P<0.001), ICU mortality (14.6% versus 2.0%, P<0.001) and hospital mortality (29.3% versus 12.3%, P=0.006). CONCLUSION Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.
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Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore
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11
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Abedini M, Froutan R, Bagheri Moghaddam A, Mazloum SR. Comparison of "cough peak expiratory flow measurement" and "cough strength measurement using the white card test" in extubation success: A randomized controlled trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:52. [PMID: 32765622 PMCID: PMC7377116 DOI: 10.4103/jrms.jrms_939_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/07/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
Background: Failed extubation and subsequent re-intubation in ventilated patients can lead to many adverse consequences, including organizational and personal expenditures. Extubation decisions based on subjective methods are a major contributor to extubation failure. This study compared the effect of cough peak expiratory flow (PEF) measurement and cough strength measurement using the white card test (WCT) on extubation success. Materials and Methods: This randomized clinical trial was conducted in two groups in 2018 on 88 ventilated patients in intensive care units of Imam Reza Hospital in Mashhad, Iran. Ninety patients were divided into two groups of 45, but two were excluded from the white card group. The criteria established for extubation included PEF ≥60 L/min during coughing in the cough PEF group and noticing card humidity in the WCT group. In both groups, extubation success was determined as the sole outcome and was compared with the standard PEF and cough strength. The researcher who assessed the outcome and statistician were blinded about group allocation. Results: Extubation success was measured as 97.8% in the cough PEF group and 76.7% in the WCT group (P = 0.003) during the first 24 h. In the second 24 h, however, successful extubation was reported as 90.9% in the cough PEF group and 60.6% in the WCT group (P = 0.002). Conclusion: Using the cough PEF rate increases the likelihood of extubation success and reduces adverse effects, and is recommended to be used for extubation decision-making.
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Affiliation(s)
- Mohsen Abedini
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Razieh Froutan
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.,Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Bagheri Moghaddam
- Department of Anesthesiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Reza Mazloum
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.,Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Keyal N, Amatya R, Shrestha G, Pradhan S, Agrawal K, Paneru H. Factors associated with extubation failure in the intensive care unit patients after spontaneous breathing trial. CHRISMED JOURNAL OF HEALTH AND RESEARCH 2020. [DOI: 10.4103/cjhr.cjhr_39_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Robba C, Bonatti G, Battaglini D, Rocco PRM, Pelosi P. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:388. [PMID: 31791375 PMCID: PMC6889568 DOI: 10.1186/s13054-019-2662-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Abstract
Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure—depending on the location and type of stroke—when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (VT) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (VT = 6–8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Giulia Bonatti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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14
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Ibrahim AS, Aly MG, Abdel-Rahman KA, Mohamed MA, Mehany MM, Aziz EM. Semi-quantitative Cough Strength Score as a Predictor for Extubation Outcome in Traumatic Brain Injury: A Prospective Observational Study. Neurocrit Care 2019; 29:273-279. [PMID: 29644564 DOI: 10.1007/s12028-018-0539-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Between 25 and 40% of extubated patients with traumatic brain injury (TBI) in the intensive care unit at our hospital (Assiut University Hospital-Assiut-Egypt) require reintubation. This reflects the importance of developing better criteria for predicting successful extubation in TBI. We evaluated the accuracy of semi-quantitative cough strength score (SCSS) and Glasgow coma scale (GCS) in predicting extubation outcomes in TBI. METHODS This prospective observational study included patients (18-65 years), with TBI on mechanical ventilation more than 24 h who were ready to be weaned off. Three tools were used. Tool I: Patient assessment sheet, this tool used to assess socio-demographic and clinical data of patients. Tool II: Semi-quantitative cough strength score (0-5). Tool III: Factors affecting successful extubation, this tool used to confirm the presence or absence of factors that can interfere with the results of extubation outcomes. After extubation, patient was followed up for 72 h to check for extubation success. Multivariate logistic binary regression test was used to calculate odds ratio for different clinical data collected before extubation as independent factors and successful extubation as a dependent factor. RESULTS Among 80 patients of mean age 40.6 (± 16.1), 34% were female, median admission GCS was 8 (4-13), extubation occurred on mean post-injury day 6.5 (± 4), and 46.3% required reintubation. Successfully extubated patients had higher semi-quantitative cough scores and GCS. 81.3% patients with SCSS 5 were successfully extubated, while all patients with SCSS 0 were reintubated. All patients with GCS 15 were successfully extubated, and all patients with GCS < 12 required intubation. CONCLUSION SCSS has shown promise in predicting successful extubation in TBI.
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Affiliation(s)
- Abdelrady S Ibrahim
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt.
| | - Mohamed G Aly
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt
| | - Khaled A Abdel-Rahman
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt
| | - Mona A Mohamed
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
| | - Mogedda M Mehany
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
| | - Eman M Aziz
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
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15
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Mullaguri N, Khan Z, Nattanmai P, Newey CR. Extubating the Neurocritical Care Patient: A Spontaneous Breathing Trial Algorithmic Approach. Neurocrit Care 2019; 28:93-96. [PMID: 28948503 DOI: 10.1007/s12028-017-0398-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delaying extubation in neurologically impaired patients otherwise ready for extubation is a source for significant morbidity, mortality, and costs. There is no consensus to suggest one spontaneous breathing trial (SBT) over another in predicting extubation success. We studied an algorithm using zero pressure support and zero positive end-expiratory pressure (ZEEP) SBT followed by 5-cm H2O pressure support and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT in those who failed ZEEP SBT. METHODS This is a retrospective analysis of intubated patients in a neurosciences intensive care unit. All eligible patients were initially challenged with ZEEP SBT. If failed, a 5/5 SBT was immediately performed. If passed either the ZEEP SBT or the subsequent 5/5 SBT, patients were liberated from mechanical ventilation. RESULTS In total, 108 adult patients were included. The majority of patients were successfully liberated from mechanical ventilation using ZEEP SBT alone (82.4%; p = 0.0007). Fifteen (13.8%) patients failed ZEEP SBT but immediately passed 5/5 SBT (p = 0.0005). One patient (0.93%) required reintubation. We found high sensitivity of this extubation algorithm (100; 95% CI 95.94-100%) but poor specificity (6.67; 95% CI 0.17-31.95%). CONCLUSION This study showed that the majority of patients could be successfully liberated from mechanical ventilation after a ZEEP SBT. In those who failed, a 5/5 SBT increased the successful liberation from mechanical ventilation.
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Affiliation(s)
- Naresh Mullaguri
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Zalan Khan
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Premkumar Nattanmai
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Christopher R Newey
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA.
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16
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Standardized Unloading of Respiratory Muscles during Neurally Adjusted Ventilatory Assist: A Randomized Crossover Pilot Study. Anesthesiology 2019; 129:769-777. [PMID: 30045094 DOI: 10.1097/aln.0000000000002335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Currently, there is no standardized method to set the support level in neurally adjusted ventilatory assist (NAVA). The primary aim was to explore the feasibility of titrating NAVA to specific diaphragm unloading targets, based on the neuroventilatory efficiency (NVE) index. The secondary outcome was to investigate the effect of reduced diaphragm unloading on distribution of lung ventilation. METHODS This is a randomized crossover study between pressure support and NAVA at different diaphragm unloading at a single neurointensive care unit. Ten adult patients who had started weaning from mechanical ventilation completed the study. Two unloading targets were used: 40 and 60%. The NVE index was used to guide the titration of the assist in NAVA. Electrical impedance tomography data, blood-gas samples, and ventilatory parameters were collected. RESULTS The median unloading was 43% (interquartile range 32, 60) for 40% unloading target and 60% (interquartile range 47, 69) for 60% unloading target. NAVA with 40% unloading led to more dorsal ventilation (center of ventilation at 55% [51, 56]) compared with pressure support (52% [49, 56]; P = 0.019). No differences were found in oxygenation, CO2, and respiratory parameters. The electrical activity of the diaphragm was higher during NAVA with 40% unloading than in pressure support. CONCLUSIONS In this pilot study, NAVA could be titrated to different diaphragm unloading levels based on the NVE index. Less unloading was associated with greater diaphragm activity and improved ventilation of the dependent lung regions.
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17
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Suntrup-Krueger S, Schmidt S, Warnecke T, Steidl C, Muhle P, Schroeder JB, Labeit B, Minnerup J, Dziewas R. Extubation Readiness in Critically Ill Stroke Patients. Stroke 2019; 50:1981-1988. [PMID: 31280655 DOI: 10.1161/strokeaha.118.024643] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background and Purpose- Predicting safe extubation represents a clinical challenge in acute stroke patients. Classical respiratory weaning criteria have not proven reliable. Concerning the paramount relevance of postextubation dysphagia in this population, criteria related to airway safety seem to perform better, but diagnostic standards are lacking. We compare clinical and instrumental swallowing examination tools to assess extubation readiness and propose a simple Determine Extubation Failure in Severe Stroke score for decision making. Methods- Data of 133 orally intubated acute stroke patients were prospectively collected in this observational study. Classical extubation criteria, a modified semiquantitative airway score, and an oral motor function score were assessed before extubation. A 3-ounce water swallow test and validated 6-point fiberoptic endoscopic dysphagia severity scoring were performed thereafter. Association of demographic and clinical parameters with extubation failure (EF) was investigated. Independent predictors of EF were translated into a point scoring system. Ideal cutoff values were determined by receiver operator characteristics analyses. Results- Patients with EF (24.1% after 24±43 hours) performed worse in all swallowing assessments (P<0.001). Fiberoptic endoscopic dysphagia severity scoring was the only independent predictor of EF (adjusted odds ratio, 4.2; P<0.007) with optimal cutoff ≥5 (sensitivity 84.6% and specificity 76.5%). Restricting regression analysis to parameters collected before extubation, a 4-item Determine Extubation Failure in Severe Stroke score (duration of ventilation, the examination of oral motor function, infratentorial lesion, and stroke severity) was derived. The score demonstrated excellent discrimination (area under the curve 0.89; 95% CI, 0.83-0.95) and calibration (Nagelkerkes R2=0.54) with an ideal cutoff ≥4 (sensitivity: 81.3% and specificity: 78.2%). Conclusions- Risk of EF is strongly correlated with postextubation dysphagia severity in stroke. Fiberoptic endoscopic examination of swallowing best predicts necessity of reintubation but requires a trial of extubation. The Determine Extubation Failure In Severe Stroke score is based on easy to collect clinical data and may guide extubation decision making in critically ill stroke patients.
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Affiliation(s)
- Sonja Suntrup-Krueger
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Sarah Schmidt
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Tobias Warnecke
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | | | - Paul Muhle
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Jens B Schroeder
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Bendix Labeit
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Jens Minnerup
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Rainer Dziewas
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
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18
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Bowry R, Ramadan AR. Extubation Success in Stroke Patients. Stroke 2019; 50:1946-1947. [PMID: 31280656 DOI: 10.1161/strokeaha.119.025867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ritvij Bowry
- From the Department of Neurosurgery, Division of Neurocritical care, McGovern Medical School, University of Texas Health Science Center, Houston (R.B.)
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Wojak JF, Ditz C, Abusamha A, Smith E, Gliemroth J, Tronnier V, Küchler J. The Impact of Extubation Failure in Patients with Good-Grade Subarachnoid Hemorrhage. World Neurosurg 2018; 117:e335-e340. [PMID: 29908380 DOI: 10.1016/j.wneu.2018.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/05/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the clinical impact of extubation failure (EF) in patients with good-grade subarachnoid hemorrhage (SAH), in whom a good clinical course usually is expected. PATIENTS AND METHODS We reviewed the clinical data from 141 patients with SAH and 1) initial Hunt & Hess grade 1-3; 2) induction of general anesthesia for intervention; and 3) the presence of data about the functional outcome. Patients were divided into 3 groups: 1) primary tracheotomized patients (PT); 2) patients with successful extubation (ES); and 3) patients with EF (reintubation within 48 hours). RESULTS EF occurred with a rate of 0.12. The leading cause of EF was respiratory insufficiency (n = 7), followed by impaired consciousness (n = 5). Multivariate logistic regression did not show any neurologic predictor of EF. Patients with ES showed an excellent outcome after 6 months (favorable outcome: 95.7%), whereas the outcome of patients with EF and PT was significantly (P < 0.05) poorer. The case fatality rate was nonsignificantly greater in the EF group (0.15 vs. 0.03). Hospitalization was significantly reduced for patients with ES, whereas the occurrence of symptomatic cerebral vasospasms and vasospastic cerebral infarction was similar between patients with EF, ES, or PT. CONCLUSIONS We showed that EF is a frequent condition in good grade-SAH but is not predictable using common neurologic parameters. Regarding the functional outcome, we were able to show that the result of an extubation trial clearly delineates the patients in 2 distinct groups, in which ES predicts an excellent outcome.
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Affiliation(s)
- Jann F Wojak
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | | | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Volker Tronnier
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany.
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Sanson G, Sartori M, Dreas L, Ciraolo R, Fabiani A. Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment. Eur J Cardiovasc Nurs 2018; 17:751-759. [PMID: 29879852 DOI: 10.1177/1474515118782103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched. AIM To identify variables that are predictive of ExtF and related outcomes. METHOD Prospective observational longitudinal study. Consecutively presenting patients ( n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU. RESULTS The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO2/FiO2 was <150 and 11 times when it was ≥450. Also, a reassuring PaO2/FiO2 value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function. CONCLUSION The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.
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Affiliation(s)
- Gianfranco Sanson
- 1 School of Nursing, University of Trieste, Italy
- 2 Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | | | - Lorella Dreas
- 3 Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | | | - Adam Fabiani
- 3 Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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Extubation Failure in Brain-injured Patients: Risk Factors and Development of a Prediction Score in a Preliminary Prospective Cohort Study. Anesthesiology 2017; 126:104-114. [PMID: 27749290 DOI: 10.1097/aln.0000000000001379] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The decision to extubate brain-injured patients with residual impaired consciousness holds a high degree of uncertainty of success. The authors developed a pragmatic clinical score predictive of extubation failure in brain-injured patients. METHODS One hundred and forty brain-injured patients were prospectively included after the first spontaneous breathing trial success. Assessment of multiparametric hemodynamic, respiratory, and neurologic functions was performed just before extubation. Extubation failure was defined as the need for ventilatory support during intensive care unit stay. Extubation failure within 48 h was also analyzed. Neurologic outcomes were recorded at 6 months. RESULTS Extubation failure occurred in 43 (31%) patients with 31 (24%) within 48 h. Predictors of extubation failure consisted of upper-airway functions (cough, gag reflex, and deglutition) and neurologic status (Coma Recovery Scale-Revised visual subscale). From the odds ratios, a four-item predictive score was developed (area under the curve, 0.85; 95% CI, 0.77 to 0.92) and internally validated by bootstrap. Cutoff was determined with sensitivity of 92%, specificity of 50%, positive predictive value of 82%, and negative predictive value of 70% for extubation failure. Failure before and beyond 48 h shared similar risk factors. Low consciousness level patients were extubated with 85% probability of success providing the presence of at least two operating airway functions. CONCLUSIONS A simplified clinical pragmatic score assessing cough, deglutition, gag reflex, and neurologic status was developed in a preliminary prospective cohort of brain-injured patients and was internally validated (bootstrapping). Extubation appears possible, providing functioning upper airways and irrespective of neurologic status. Clinical practice generalizability urgently needs external validation.
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Steidl C, Bösel J, Suntrup-Krueger S, Schönenberger S, Al-Suwaidan F, Warnecke T, Minnerup J, Dziewas R. Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients. Cerebrovasc Dis 2017; 44:1-9. [PMID: 28395275 DOI: 10.1159/000471892] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/20/2017] [Indexed: 12/30/2022] Open
Abstract
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.
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Hsiung Lee ES, Jiann Lim DT, Taculod JM, Sahagun JT, Otero JP, Teo K, Loh WNH, Hui Tan AY. Factors Associated with Reintubation in an Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2017; 21:131-137. [PMID: 28400683 PMCID: PMC5363101 DOI: 10.4103/ijccm.ijccm_452_16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: The objective of the study was to determine the incidence of failed extubations in our Intensive Care Unit (ICU) and identify associated clinical factors. Materials and Methods: A prospective observational study of mechanically ventilated patients who underwent extubation attempts in our (predominantly surgical) ICU was undertaken from July 2012 to August 2013. The primary endpoint was the need for nonelective reintubation within 72 h of extubation. Clinical data of the reintubated patients were compared with those who were successfully extubated to identify factors associated with reintubation. Results: Five hundred and eight extubation attempts were documented, 38 (7.5%) of which were unsuccessful. On multivariate analysis, the following clinical factors were found to be associated with an increased risk of failed extubation: unplanned extubations (adjusted odds ratio [OR] 5.8), the use of noninvasive ventilation (NIV) postextubation (adjusted OR 3.2), and sepsis (adjusted OR 2.9). Patient demographic factors, other premorbid and comorbid medical conditions, and differences of laboratory parameters did not appear to significantly influence reintubation rates in our study. Conclusions: Our study has demonstrated a relatively low reintubation rate, likely due to inclusion of elective admissions/intubations in our patient population. Unplanned extubations, the use of NIV postextubation, and sepsis were associated with increased reintubation risk, reinforcing the need for increased vigilance in this subgroup of patients after extubation.
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Affiliation(s)
- Eric Shih Hsiung Lee
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
| | - Danny Tse Jiann Lim
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
| | - Juvel Mabao Taculod
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
| | | | - Joerie Pasive Otero
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
| | - Kaimin Teo
- Department of Anesthesia, Singapore General Hospital, Outram Road, Singapore
| | - Will Ne-Hooi Loh
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
| | - Addy Yong Hui Tan
- Department of Anesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore
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Seder DB, Bösel J. Airway management and mechanical ventilation in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:15-32. [PMID: 28187797 DOI: 10.1016/b978-0-444-63600-3.00002-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Patients with acute neurologic disease often develop respiratory failure, the management of which profoundly affects brain physiology and long-term functional outcomes. This chapter reviews airway management and mechanical ventilation of patients with acute brain injury, offering practical strategies to optimize treatment of respiratory failure and minimize secondary brain injury. Specific concerns that are addressed include physiologic changes during intubation and ventilation such as the effects on intracranial pressure and brain perfusion; cervical spine management during endotracheal intubation; the role of tracheostomy; and how ventilation and oxygenation are utilized to minimize ischemia-reperfusion injury and cerebral metabolic distress.
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Affiliation(s)
- D B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA.
| | - J Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Said T, Chaari A, Hakim KA, Hamama D, Casey WF. Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study. Int J Crit Illn Inj Sci 2016; 6:172-177. [PMID: 28149821 PMCID: PMC5225759 DOI: 10.4103/2229-5151.195401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). Patients and Methods: All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures. Results: Eighty-six patients were included in the study. Median age was 63 (50–77) years. Sex–ratio (M/F) was 1.46. On admission, median GCS was 7 (3–10) while median FOUR score was 8.5 (2.3–11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790–0.944] and 0.832 CI: 95% [0.741–0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months. Conclusion: The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients.
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Affiliation(s)
- Tarek Said
- Department of Intensive Care Unit, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - Anis Chaari
- Department of Intensive Care Unit, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - Karim Abdel Hakim
- Department of Intensive Care Unit, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - Dalia Hamama
- Department of Intensive Care Unit, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - William Francis Casey
- Department of Intensive Care Unit, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
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