Physiological predictors of respiratory and cough assistance needs after extubation

Nicolas Terzi,David Orlikowski,Bertrand Sauneuf,Djillali Annane,Frédéric Lofaso,Edith Dumanowski,Hervé Normand,Romain Masson,Line Falaize,Jean-Jacques Parienti,Cédric Daubin,Jennifer Brunet,Pascal Beuret

doi:10.1186/s13613-018-0360-3

Abstract

BackgroundIdentifying patients at high risk of post-extubation acute respiratory failure requiring respiratory or mechanical cough assistance remains challenging. Here, our primary aim was to evaluate the accuracy of easily collected parameters obtained before or just after extubation in predicting the risk of post-extubation acute respiratory failure requiring, at best, noninvasive mechanical ventilation (NIV) and/or mechanical cough assistance and, at worst, reintubation after extubation.MethodsWe conducted a multicenter prospective, open-label, observational study from April 2012 through April 2015. Patients who passed a weaning test after at least 72 h of endotracheal mechanical ventilation (MV) were included. Just before extubation, spirometry and maximal pressures were measured by a technician. The results were not disclosed to the bedside physicians. Patients were followed until discharge or death.ResultsAmong 3458 patients admitted to the ICU, 730 received endotracheal MV for longer than 72 h and were then extubated; among these, 130 were included. At inclusion, the 130 patients had mean ICU stay and endotracheal MV durations both equal to 11 ± 4.2 days. After extubation, 36 patients required curative NIV, 7 both curative NIV and mechanical cough assistance, and 8 only mechanical cough assistance; 6 patients, all of whom first received NIV, required reintubation within 48 h. The group that required NIV after extubation had a significantly higher proportion of patients with chronic respiratory disease (P = 0.015), longer endotracheal MV duration at inclusion, and lower Medical Research Council (MRC) score (P = 0.02, P = 0.01, and P = 0.004, respectively). By multivariate analysis, forced vital capacity (FVC) and peak cough expiratory flow (PCEF) were independently associated with (NIV) and/or mechanical cough assistance and/or reintubation after extubation. Areas under the ROC curves for pre-extubation PCEF and FVC were 0.71 and 0.76, respectively.ConclusionIn conclusion, FVC measured before extubation correlates closely with FVC after extubation and may serve as an objective predictor of post-extubation respiratory failure requiring NIV and/or mechanical cough assistance and/or reintubation in heterogeneous populations of medical ICU patients.ClinicalTrials.gov as #NCT01564745

Highlights

Identifying patients at high risk of post-extubation acute respiratory failure requiring respiratory or mechanical cough assistance remains challenging
Pre-extubation lung function test (LFT) variables significantly associated with post-extubation noninvasive mechanical ventilation (NIV) and/ or mechanical cough assistance were P aCO2, Vital capacity (VC), forced vital capacity (FVC), Maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), peak expiratory flow (PEF), and peak cough expiratory flow (PCEF) (Table 2)
Our study provides the first evidence that FVC correlates well with PCEF and outperforms PCEF for predicting a need for NIV and/or mechanical cough assistance after extubation

Summary

Introduction

Identifying patients at high risk of post-extubation acute respiratory failure requiring respiratory or mechanical cough assistance remains challenging. Our primary aim was to evaluate the accuracy of col‐ lected parameters obtained before or just after extubation in predicting the risk of post-extubation acute respiratory failure requiring, at best, noninvasive mechanical ventilation (NIV) and/or mechanical cough assistance and, at worst, reintubation after extubation. Terzi et al Ann. Intensive Care (2018) 8:18 mechanical ventilation (NIV) can help to prevent postextubation respiratory failure. Intensive Care (2018) 8:18 mechanical ventilation (NIV) can help to prevent postextubation respiratory failure As these techniques are time-consuming, criteria for selecting those patients most likely to benefit would be useful. These criteria would be objective, measured parameters obtained immediately before and/or after extubation. The tracheal tube can alter PCEF values via two mechanisms: it elevates airway resistance [13]; and it eliminates the role of the glottis in coughing [14]

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