Abstract
BackgroundWhereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength.MethodsA secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation.ResultsAmong 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission.ConclusionICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.
Highlights
Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known
Study population Of the 416 patients included in the two prospective studies, 72 were excluded because they were at low-risk of extubation failure (n = 52) or had no assessment of cough strength or limb muscle strength (n = 20)
Statistical analysis Continuous variables were expressed as mean ± standard deviation (SD) or median [25th–75th percentiles], and qualitative variables were expressed as number and percentage
Summary
Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. The most recent international clinical practice guidelines recommend the use of non-invasive ventilation immediately after extubation to prevent respiratory failure in patients at high risk of reintubation [3]. In patients older than 65 years or having any underlying cardiac or respiratory disease, a recent large randomized clinical trial showed that a combination of high-flow nasal oxygen alternating with non-invasive ventilation was the most efficient strategy to prevent reintubation [4, 5]. ICU-acquired weakness combining polyneuropathy, myopathy, and muscle atrophy [20,21,22] is clinically diagnosed as limb paresis but may affect all respiratory muscles with an altered inspiratory and expiratory strength, as well pharyngeal muscles, and which can lead to overall respiratory muscle weakness [23, 24] and to swallowing disorders [25]
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