Cause Of Extubation Failure Research Articles

The usefulness of ultrasonographic measurement of the laryngeal air column width difference before extubation as a predictor of secondary airway obstruction after extubation in children

Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for >24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (>3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use.

Mechanical insufflation-exsufflation to promote extubation success in critically ill adults on intensive care: protocol for a randomised controlled feasibility trial

BackgroundExtubation failure, defined as reintubation within 48 h, is associated with increased intensive care unit (ICU) length of stay and higher mortality risk. One cause of extubation failure is secretion retention, resulting from an inability to cough effectively. Mechanical insufflation-exsufflation (MI-E) simulates a cough aiding secretion clearance. However, MI-E is not routinely used in the ICU for invasively ventilated patients. This study aims to determine feasibility and acceptability of a randomised controlled trial (RCT) examining MI-E use to promote extubation success in intubated, ventilated adults.MethodsIt is a single-centre, feasibility RCT with semi-structured interviews, economic scoping, and exploratory physiology study.The feasibility RCT (n = 50) will compare standard care to a MI-E protocol including a minimum of two MI-E sessions via the endotracheal tube prior to extubation. Post-extubation, MI-E will be delivered via facemask or mouthpiece up to two times/day for 48 h. MI-E settings will be individualised. All patients will receive standard care (no MI-E) in relation to mechanical ventilation, weaning, rehabilitation, physiotherapy techniques such as positioning, manual airway clearance techniques, manual/ventilator hyperinflation, endotracheal suctioning, and nebulisation. Clinical data collection will occur before, on completion, and 5-min post-physiotherapy sessions (intervention/control arms). Resource use will be calculated for each 24-h period. Analyses will be descriptive and address feasibility outcomes including participant recruitment and attrition, proportion of MI-E treatment sessions completed, dataset completeness, and frequency of adverse events and acceptability.Semi-structured online interviews informed by the Theoretical Framework of Acceptability (TFA) with patients, clinicians, and family members will explore the acceptability of the MI-E intervention and study processes.Interview data will be analysed using reflexive thematic analysis based on TFA domains through first-level coding.The embedded physiology study will use electrical impedance tomography and lung ultrasound to explore lung recruitment and de-recruitment during MI-E in a subset of 5–10 patients.DiscussionThis study will examine feasibility and acceptability of a RCT protocol of MI-E to promote extubation success. Study findings will inform design modification and conduct of a future adequately powered trial. Furthermore, the study will contribute and advance the understanding of MI-E use in critically ill intubated adults.Trial registrationISRCTN 24603037; IRAS 303674

SEROPOSITIVE MYASTHENIA GRAVIS AS THE CAUSE OF MULTIPLE FAILED EXTUBATIONS AND A PROLONGED ICU STAY FOR COVID-19 PNEUMONIA: A CASE REPORT AND BRIEF LITERATURE REVIEW

SEROPOSITIVE MYASTHENIA GRAVIS AS THE CAUSE OF MULTIPLE FAILED EXTUBATIONS AND A PROLONGED ICU STAY FOR COVID-19 PNEUMONIA: A CASE REPORT AND BRIEF LITERATURE REVIEW

Pooled Analysis of Central Venous Pressure and Brain Natriuretic Peptide Levels in Patients With Extubation Failure

Purpose: Cardiac insufficiency has been considered to be a common cause of extubation failure. Some studies have shown that central venous pressure (CVP) and brain natriuretic peptide (BNP) are able to predict extubation outcomes. Therefore, we conducted a pooled analysis to evaluate the potential of CVP and BNP levels as predictors of extubation outcomes, using a cohort of critically ill patients who were on mechanical ventilation (MV). Methods: We searched three online electronic databases up to October 2021. All data were analyzed using Review Manager 5.4. For each study, the analysis was performed using standardized mean differences (SMD) with 95% confidence intervals (CI). Results: The pooled analysis of seven studies on CVP levels and extubation outcomes showed that elevated CVP levels were significantly associated with extubation failure (SMD:0.47, 95% CI: 0. 43–0.51, p < 0.00001). This association also appeared before extubation (SMD:0.47, 95% CI: 0. 43–0.51, p < 0.00001), but it did not appear after extubation (SMD: 0.63, 95% CI: −0.05–1.31, p=0.07). Similarly, pooled analysis of eight studies on BNP levels and extubation outcomes showed that increased BNP levels are closely related to extubation failure (SMD:0.68, 95% CI: 0.49–0.86, p < 0.00001). This relationship also occurs before (SMD: 0.57, 95% CI: 0.35–0.79, p < 0.00001) and after (SMD: 0.91, 95% CI: 0.59–1.23, p < 0.00001) extubation. Conclusions: This study showed that elevated CVP and BNP levels are associated with extubation failure in critically ill patients. However, BNP levels are more valuable than CVP levels in predicting extubation outcomes.

Low BALF CD4 T cells count is associated with extubation failure and mortality in critically ill covid-19 pneumonia

Background Critically ill COVID-19 pneumonia is one of the main causes of extubation failure and mortality. Understanding clinical characteristics, laboratory profiles and bronchoalveolar lavage fluid (BALF) immunopathology may help improve outcomes in critically ill COVID-19 pneumonia. We aimed to describe clinical characteristics, laboratory profiles and BALF immunopathology based on lung severity in critically ill COVID-19 pneumonia patients. Materials and methods Forty critically ill severe pneumonia patients requiring invasive mechanical ventilation in Cipto Mangunkusumo General (National Tertiary Referral Hospital), Indonesia within November 2020–January 2021 were enrolled in this study. Early BALF collection was performed after patients’ intubation. Clinical characteristics, laboratory profiles and BALF biomarkers (sTREM-1, alveolar macrophage amount and function, IL-6, IL-17, CD4 T-cells, Tregs, SP-A and Caspase-3) were observed and analysed. Outcomes were measured based on extubation failure (within 19 days) and 28-days mortality. Univariate and bivariate analyses were performed. Results Early bronchoscopy was performed in an average of 4 h (SD = 0.82) after patients’ intubation. Twenty-three and twenty-two patients had extubation failure (within 19 days) and 28-days mortality, respectively. In the baseline clinical characteristics of critically ill COVID-19 patients, we found no significant differences in the extubation and mortality status groups. In the laboratory profiles of critically ill COVID-19 patients, we found no significant differences in the extubation status groups. In critically ill COVID-19 pneumonia patients, there was a significant high D-dimer levels in survived group (p = .027), a significant low BALF CD4 T-cells count in the right lung (p = .001) and a significant low BALF CD4 T-cells count (p = .010 and p = .018) in severely affected lung with extubation failure and mortality. Conclusions BALF CD4 T-cells count evaluation of severely affected lung is associated with early extubation failure and mortality in critically ill COVID-19 pneumonia patients. KEY MESSAGE Few studies have been conducted during the peak COVID-19 period analysing combined bronchoalveolar lavage fluid (BALF) immunopathology biomarkers within four hours of intubation to assess extubation failure and mortality. In this study, we reported eight BALF immunopathology biomarkers (sTREM-1, alveolar macrophage, IL-6, IL-17, CD4 T-cells, Tregs, SP-A and Caspase-3). We found significantly low BALF CD4 T-cells count in the right lung, and low BALF CD4 T-cells count in severely affected lung of critically ill COVID-19 pneumonia patients in extubation failure and mortality.

Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children.

Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction. Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children's Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation. Single center, tertiary, 391-bed children's hospital. From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation. None. New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50-9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67-11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36-8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46-8.34) remained independently associated with the diagnosis of new airway anomalies. Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.

P0332 / #807: FAILED EXTUBATION - RATE AND CAUSES IN A PAEDIATRIC CARDIAC INTENSIVE CARE UNIT IN UNITED KINGDOM

Aims & Objectives: To determine the rate of failed extubation and to find out the common causes in a paediatric cardiac intensive care. Methods: Design: Descriptive study with prospective data collection from medical documentation over 9 months (01/04/2019 till 31/12/2019) Place: Paediatric cardiac intensive care unit, Glenfield Hospital,UK Study Population: All children who were mechanically ventilated in PICU during the study period were included. Children who had failed extubation(defined as re-intubation within 48 hours of planned extubation)were analysed to find out the causes of extubation failure. Main outcome: Rate of Failed extubation Results: 258 patients admitted during the study period required mechanical ventilation. Among them, 15 patients required re-intubation within 48 hours(15/258= 5.8%). Among these 15 patients, 4 had failed extubation more than once. Among these 15 patients, airway problems(n=4), lung issues(n=4), infection(n=3) and cardiac lesions(n=4) were the main reasons for re-intubation. Among airway issues, pre-existent airway problems in 3 patients required further optimisation, and 1 had airway oedema from intubation. Lung collapse/consolidation and pneumothorax were the lung problems leading to re-intubation. Abdominal distension from infection and bacteraemia were infectious complications causing extubation failure. Cardiac causes included increased pulmonary blood flow due to various cardiac lesions in 3 children and poor ventricular function in one. Conclusions: Rate of failed extubation was comparable to available published data. Airway problems, lung issues, infection and cardiac lesions were found to be the causes leading to failed extubation. Addressing these issues and having a plan during the peri-extubation period will help in improving outcome of these patients.

Endoscopic management of pediatric extubation failure in the intensive care unit

ObjectivesThis study investigated the endoscopic findings associated with pediatric extubation failure (EF) and evaluated the prognosis of endoscopic procedures. MethodsWe retrospectively reviewed the data of children with EF in the intensive care unit from January 1, 2013 to December 31, 2019. Fifty-one children receiving endoscopic examination were enrolled in this study. EF was defined as the need for reintubation within 72 h of the first attempted extubation. ResultsThirty-three children (65%) were successfully extubated after endoscopic procedures, and 18 children (35%) failed in extubation. There was a higher percentage of children transferred from other hospitals with intubation in the failure group (56% vs 12%, p = 0.002). Subglottic stenosis (SGS) (35%) and laryngeal and tracheal granulation (33%) were two of the most common findings. Fourteen patients (82%) with granulation were successfully extubated. Two children in the failure group were diagnosed with mitochondrial myopathies (chrM:3243) and congenital myasthenic syndrome (CHAT). The success rate in cases of SGS reached 83% (15/18). Five patients diagnosed with laryngomalacia and another 3 patients with tracheomalacia failed extubation after supraglottoplasty and needed a temporary tracheostomy. ConclusionGranulation and subglottic stenosis were the leading causes of extubation failure. Patients transferred with intubation might have a poor prognosis after endoscopic procedures. Neuromuscular and metabolic disorders could be a hidden reason for extubation failure.

PRINCIPAIS CAUSAS DE FALHA NA EXTUBAÇÃO DE PACIENTES INTERNADOS EM UM CENTRO DE TERAPIA INTENSIVA ADULTO DE UM HOSPITAL DO INTERIOR DE MINAS GERAIS

Mechanical ventilation (MV) or ventilatory support is considered a vital treatment method in (ICUs). Furthermore, it is considered a valuable support in the care of patients with acute and chronic respiratory failure. There is evidence that the sooner the clinical condition of this patient is established, according to a protocol, the shorter his extubation will be. The aim of this research was to determine the main causes of extubation failure in patients in an adult intensive care unit (ICU). The study carried out was descriptive, retrospective and longitudinal, 58 medical records of patients who were admitted to the ICU of a hospital in the interior of Minas Gerais were analyzed. The sample consisted of 58 patients, 32 men and 26 women, of whom 23 died. The main clinical diagnosis was neurological diseases followed by respiratory diseases. The main cause of extubation failure in females was laryngospasm; increased respiratory work; and lowering the level of consciousness associated with increased respiratory work. In males, it was due to respiratory failure; lowering the level of consciousness associated with increased respiratory work. The study revealed that 23 of these medical records evolved to death. The time that the patient remained on mechanical ventilation corresponds to 5 days. Nine female patients and six male patients were considered unfit by the protocol and extubated. Of these, 5 patients died, which shows the lack of adherence, and the team's resistance to following protocols.

Prevalence of extubation and associated risk factors at a tertiary care pediatric intensive care unit.

Extubation failure (EF) is associated with a higher risk for pneumonia, hospital stay, and mortality. To determine the prevalence of EF and identify the associated factors in our population. Observational and retrospective design. All patients aged 1 month old to 18 years old who required mechanical ventilation for more than 12 hours and underwent at least one scheduled extubation during their stay in the 2012-2016 period were included. The aspects related to ventilation and the causes of failure were recorded. Seven hundred and thirty-one patients were extubated and the prevalence of EF was 19.3 %. The causes of failure included upper airway obstruction (51.4 %), muscle fatigue (20.1 %), respiratory center depression (14.6 %), and inability to protect the airways (9.7 %). As per the multivariate analysis, the independent factors that accounted for EF were neurological complex chronic condition (odds ratio [OR] = 2.27; 95 % confidence interval [CI] = 1.21-4.26); acute lower respiratory tract infection in a patient with prior sequelae (OR = 1.87, 95 % CI = 1.113.15); acute neurological injury (OR = 1.92, 95 % CI = 1.03-3.57); unplanned extubation (OR = 2.52, 95 % CI = 1.02-6.21), and presence of stridor (OR = 5.84, 95 % CI = 3.66-9.31). The main cause of EF was upper airway obstruction. Neurological sequelae, acute neurological injury, unplanned extubation, and the presence of postextubation stridor were identified as risk factors associated with EF.

Endoscopic cricoid split in a tertiary referral paediatric centre.

Anterior cricoid split is performed for grade 2 and 3 subglottic stenosis, which can be a cause of extubation failure. It can be performed endoscopically or as an open procedure. This paper describes a case series of endoscopic cricoid split procedures performed using a bespoke sickle knife. Nine patients (six pre-term infants) underwent endoscopic cricoid split in a tertiary referral paediatric unit between August 2012 and March 2015. Six patients (67 per cent; four pre-term and two term infants) were on oxygen pre-operatively. Mean age at operation was 30 weeks (range, 11-104 weeks). Mean number of days' intubation was 5.6 days (range, 4-9 days). All five patients intubated pre-operatively were extubated. Seven patients required repeat dilatations. One patient required tracheostomy. The extubation rates for endoscopic cricoid split are comparable to the open procedure. It is a safe and efficient method for managing subglottic stenosis, whether acquired or congenital. The main advantage is the shorter operative time, in addition to the avoidance of an external scar and drain.

The Impact of Extubation Failure in Patients with Good-Grade Subarachnoid Hemorrhage

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. 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). 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. 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.

Pseudo bulbar palsy: A rare cause of extubation failure

Pseudo bulbar palsy: A rare cause of extubation failure

Neural breathing pattern in newborn infants pre‐ and postextubation

To describe the neural breathing pattern before and after extubation in newborn infants. Prospective, observational study. In infants deemed ready for extubation, the diaphragm electrical activity (EAdi) was continuously recorded from 30 minute before to two hours after extubation. Total of 25 neonates underwent 29 extubations; 10 extubations resulted in re-intubation within 72 hours. Postextubation, there was an increase in peak EAdi (EAdi-max) and EAdi-delta (peak minus minimum EAdi) in both groups. The pre- to postextubation change in EAdi-max (8.9-11.1 μv) and EAdi-delta (6-8 μv) was less in the failure group in comparison with the change in EAdi-max (10.2-13.4 μv) and EAdi-delta (6.3-10.6 μv) in the success group, (p = 0.02 and 0.01, respectively). In our neonatal cohort, extubation failure was associated with a smaller increase in peak and delta EAdi after extubation. If confirmed, these findings indicate an important cause of extubation failure in preterm infants.

Invited Commentary

Dr d'Udekem discloses a financial relationship with Actelion and MSD.As surgeons, we often see the timing of extubation as the result of a battle between intensivists and surgeons, the surgeons pushing for earlier extubation and the intensivists looking for safety and prolonging unnecessarily, in our opinion, the length of ventilation. With this perspective, we tend to look at early failure of extubation as a phenomenon depending on an arbitrary decision. The current work from Shizuoka Children’s Hospital [1Miura S. Hamamoto N. Osaki M. Nakano S. Miyakoshi C. Extubation failure in neonates after cardiac surgery: prevalence, etiology, and risk factors.Ann Thorac Surg. 2017; 103: 1293-1299Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] makes us understand that extubation failure in neonates is more surely related to intrinsic patient characteristics than to external arbitrary factors. In this very well-conducted study of all the neonates operated on over the course of 6 years, causes of early extubation failure were prospectively collected. The current rate of extubation failure of 16% in neonates fits within the range reported in the current literature [2Laudato N. Gupta P. Walters III, H.L. Delius R.E. Mastropietro C.W. Risk Factors for extubation failure following neonatal cardiac surgery.Pediatr Crit Care Med. 2015; 16: 859-867Crossref PubMed Scopus (30) Google Scholar, 3Thiagarajan R.R. Bratton S.L. Martin L.D. Brogan T.V. Taylor D. Predictors of successful extubation in children.Am J Respir Crit Care Med. 1999; 160: 1562-1566Crossref PubMed Scopus (79) Google Scholar]. The authors claim that the severity of the disease was not a predictive factor for extubation failure. One could nonetheless remain suspicious that sicker patients will more often experience failure of a first attempt at extubation, because prolonged ventilation, younger age at operation, and delayed sternal closure were predictive of early extubation failure. Dr d'Udekem discloses a financial relationship with Actelion and MSD. There are several striking findings in this study. Half of the patients in whom extubation failed ended up requiring reoperation. The predominant reasons for early failure of extubation were respiratory causes. Even though only a quarter of these patients needed an intervention to solve their respiratory issues, the identification of the exact cause for failure of extubation seems to have helped in their subsequent management. There is no doubt that extubation failure is linked to higher mortality, prolonged hospital stays, higher burden of complications, and last but not least, higher hospital costs [4Gaies M. Tabbutt S. Schwartz S.M. et al.Clinical epidemiology of extubation failure in the pediatric cardiac ICU: A report from the Pediatric Cardiac Critical Care Consortium.Pediatr Crit Care Med. 2015; 16: 837-845Crossref PubMed Scopus (80) Google Scholar, 5Gupta P. Rettiganti M. Gossett J.M. et al.Risk factors for mechanical ventilation and reintubation after pediatric heart surgery.J Thorac Cardiovasc Surg. 2016; 151: 451-453Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. After reading this article by Miura and coworkers [1Miura S. Hamamoto N. Osaki M. Nakano S. Miyakoshi C. Extubation failure in neonates after cardiac surgery: prevalence, etiology, and risk factors.Ann Thorac Surg. 2017; 103: 1293-1299Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar], I will no longer attribute early extubation failure to mishandling of patients by my colleague intensivists. I will push for speedy investigation for causes of extubation failure because I now know that half of these patients may require an intervention that may remediate the situation and that the remaining will likely benefit in their management from the identification of this cause. I am now convinced that prompt extensive investigation of these patients will shorten their hospital stays. Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk FactorsThe Annals of Thoracic SurgeryVol. 103Issue 4PreviewThe purpose of this study was to explore the prevalence, etiology, and risk factors of extubation failure (EF) in post–cardiac surgery neonates. Full-Text PDF

Bloqueo de la vía aérea tras la extubación. Revisión bibliográfica

Introduction and objective: airway obstruction after extubation in any surgery is a critical event with low incidence, which may require reintubation or tracheostomy, which often otolaryngologist is required. Objective: To determine the prevalence of BVA and its causes through systematic literature review. Method: Literature review in PubMed, Scopus and Cochrane clinical trials, meta-analysis, reviews and case series and control over airway obstruction after extubation that requires reintubation in adults. Results: 6 studies and one clinical practice guidelines were selected. The most common cause of extubation failure is blocking the airway for various reasons (pharyngeal muscle weakness residual effect -often farmacologycal-, laryngospasm, vocal cord paralysis, edema of upper respiratory tract, cervical postoperative hematoma, foreign bodies or secretions). Most cases of re-intubation occurred within 2 hours after extubation. Conclusions: The most common cause of failure after general anesthesia extubation is blocking the airway generally caused by residual neuromuscular blocking effect. Airway obstruction risk increases in airway and head and neck surgery. Difficult intubation guidlines have improved performance and reduced adverse events and similar strategies must be implemented in extubation. The procedure extubation and reintubation should be documented. Working groups airway must be multidisciplinary and include specialists in otolaryngology.

Causes and risk factors of reintubation in Shahid Madani cardiac surgery ICU during 2012-2013

Background: Extubation failure rate is one of the criteria for assessing the quality of care in intensive care unit (ICU) and higher or lower extubation failure rates indicate longer mechanical ventilation or inappropriate weaning criteria of patients, respectively. The aim of the present study was to evaluate the rate and causes of extubation failure in the cardiac surgery ICU of Tabriz Shahid Madani hospital during 2012-2013. Methods: In a cross-sectional study during 2012-2013, all intubated adult patients (over 18 years old) after cardiac surgery admitted to ICU who were re-intubated within 72 hours after extubation were studied. Results: Overall, 31 patients had the inclusion criteria. Extubation failure rate during one year was 2.45%. Extubation failure causes were hypoxemia, cardiopulmonary arrest, sepsis, acute renal failure, re-operation, shock, acute respiratory distress syndrome, pneumonia, seizures, decreased level of consciousness, copious secretion, and severe agitation. Re-intubation risk factors included chronic obstructive pulmonary disease, diabetes mellitus, renal failure, heart failure, ARDS, pneumonia, intra-aortic balloon pump, acute coronary syndrome and shock. The mean duration of mechanical ventilation before extubation was 2.3±3.1 days. The overall mortality rate of studied patients was 26% with coronary artery bypass grafting surgery as the most common cause. Conclusions: During 2012 and 2013, the extubation failure rate in the cardiac surgery ICU was 2.45%. The most common causes of extubation failure in this setting were hypoxemia and pneumonia. Moreover, the most common risk factors for re-intubation were diabetes mellitus and renal failure. Keywords: Airway Extubation failure; Cardiac surgery; ICU

Tracheal extubation.

Tracheal extubation in both the critical care and anesthesia setting is not only an important milestone for patient recovery, but also a procedure that carries a considerable risk of complication or failure. Mechanical ventilation is associated with significant complications that are time-dependent in nature, with a longer duration of intubation resulting in a higher incidence of complications, including ventilator-associated pneumonia, and increased mortality. Extubation failure and subsequent re-intubation are associated with an overall increase in the duration of mechanical ventilation, increased mortality, a greater need for tracheostomy, and higher medical costs. These risks demand that the process of extubation be managed by practitioners with a detailed understanding of the causes of extubation failure and the potential complications. A pre-established extubation plan with considerations made for the possible need for re-intubation is of the utmost importance.

Preventive Use of Noninvasive Ventilation After Extubation: A Prospective, Multicenter Randomized Controlled Trial

The effectiveness of noninvasive ventilation (NIV) after extubation in preventing post-extubation respiratory failure is still controversial. We conducted a prospective, multicenter randomized controlled study involving patients on mechanical ventilation for > 48 hours who tolerated a 2-hour spontaneous breathing trial and were subsequently extubated. The patients were randomized to NIV or standard medical therapy. Re-intubation rate within 72 hours was the primary outcome measure. Multivariable logistic regression analysis was used to determine predictors for extubation failure. We randomized 406 patients to either NIV (no. = 202) or standard medical therapy (no. = 204). The 2 groups had similar baseline clinical characteristics. There were no differences in extubation failure (13.2% in control and 14.9% in NIV), intensive care unit or hospital mortality. Cardiac failure was a more common cause of extubation failure in control than in NIV. There was no difference in rapid shallow breathing index (RSBI) in extubation failure patients between control (80) and NIV (73). When using data from all patients, we found Acute Physiology and Chronic Health Evaluation (APACHE II) scores (odds ratio [OR] 1.13, 95% CI 1.07-1.20, P < .001), maximal inspiratory pressure (OR 1.04, 95% CI 1.00-1.08, P = .03), and RSBI (OR 1.03, 95% CI 1.02-1.05, P < .001) to be predictors of extubation failure. Abundant secretions were the most common reason (35.1%) for extubation failure identified by attending physicians. Preventive use of NIV after extubation in patients who passed spontaneous breathing trial did not show benefits in decreasing extubation failure rate or the mortality rate.

Perioperative care following complex laryngotracheal reconstruction in infants and children

Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.