Extubation Attempt Research Articles

Extravascular lung water assessment by lung ultrasound in infants following pediatric cardiac surgery.

Lung edema is a significant factor in prolonged mechanical ventilation and extubation failure after cardiac surgery. This study assessed the predictive capability of point-of-care Lung Ultrasound (LUS) for the duration of mechanical ventilation and extubation failure in infants following cardiac procedures. We conducted a prospective observational trial on infants under 1 year, excluding those with pre-existing conditions or requiring extracorporeal membrane oxygenation. LUS was performed upon intensive care unit (ICU) admission and prior to extubation attempts. B-line density was scored by two independent observers. The primary outcomes included the duration of mechanical ventilation and extubation failure, the latter defined as the need for reintubation or non-invasive ventilation within 48 h post-extubation. The study included 42 infants, with findings indicating no correlation between initial LUS scores and extubation timing. Extubation failure occurred in 21% of the patients, with higher LUS scores observed in these cases (p = 0.046). However, interobserver variability was high, impacting the reliability of LUS scores to predict extubation readiness. LUS was ineffective in determining the length of postoperative ventilation and extubation readiness, highlighting the need for further research and enhanced training in LUS interpretation.

Weaning from mechanical ventilation during myasthenic crisis, a monocentric retrospective study

Mechanical ventilation in myasthenic crisis is not standardized and is at high risk of failure. We investigated liberation from mechanical ventilation during myasthenic crisis using a prolonged spontaneous breathing trials (SBT) and sequential pulmonary function tests (PFT). In this retrospective monocenter study, we included patients admitted for a first episode of myasthenic crisis between January 2001 and January 2018. The primary outcome was the incidence of weaning failure upon first extubation in our cohort of patients with MC. Secondary objectives were to determine risk factors and outcome associated with weaning failure upon first extubation in MC. We also compared the characteristics of patients with prolonged weaning. 126 episodes of MC were analyzed. Patient’s age was 64 [42–76] years with 72/126 (56.5%) being women. The median delay between weaning initiation and first extubation was 6 [3–10] days and the median total length of MV was 14 [10–23] days. 118/126 (93.7%) patients underwent prolonged SBT of 8 h or more prior to first extubation. The overall weaning failure rate was 18/126 (14.3%). Extubation was more often successful when the factor precipitating the myasthenic crisis was identified (86/108 (79.6%) vs. 8/18 (44.4%); p = 0.004), whereas PFT was similar in failure or successes. Most weaning failures upon first extubation attempt (11/18; 61%) were attributed to an insufficient stabilization of myasthenia gravis. Duration of mechanical ventilation, an infectious trigger and maximal inspiratory pressure upon intubation were independent risk factors for prolonged weaning. In myasthenic crisis, a standardized protocol including prolonged SBT and respiratory function tests might improve the success of first extubation without prolonging mechanical ventilation. The results of this single center study warrant further evaluation in interventional trials.

Subglottic Stenosis in a 3-Year-Old Child Following Prolonged Intubation - A Case Report

Subglottic stenosis is a serious complication of prolonged intubation in pediatric patients and Over 90% of acquired cases are iatrogenically caused and result from endotracheal intubation. Subglottic stenosis is an unanticipated problem that needs to be diagnosed and treated immediately. The majority of pediatric subglottic stenosis occurrences are mild to moderate. This case highlights the challenges and outcomes associated with this condition. Here, we present a 3-year-old child presented with high fever and scrotal pain with swelling, diagnosed as scrotal cellulitis. Laboratory results showed anemia, leukocytosis, and metabolic acidosis, and the child's condition deteriorated due to respiratory distress, requiring intubation and PICU admission. Following a scrotal abscess drainage, the child was discharged but returned with severe respiratory distress, cyanosis, and subglottic stenosis, confirmed by laryngobronchoscopy and imaging. After failed extubation attempts and further complications, a tracheostomy and endoscopic subglottic dilation were performed. The child was successfully decannulated after eight days, with near-complete recovery except for a slight change in voice tone. The case highlights the challenges in managing complex respiratory complications in pediatric patients. This case underscores the importance of monitoring for subglottic stenosis in children who have undergone prolonged intubation and demonstrates the efficacy of endoscopic dilatation in managing this complication.

Development and Validation of a Deep Learning Classifier Using Chest Radiographs to Predict Extubation Success in Patients Undergoing Invasive Mechanical Ventilation.

The decision to extubate patients on invasive mechanical ventilation is critical; however, clinician performance in identifying patients to liberate from the ventilator is poor. Machine Learning-based predictors using tabular data have been developed; however, these fail to capture the wide spectrum of data available. Here, we develop and validate a deep learning-based model using routinely collected chest X-rays to predict the outcome of attempted extubation. We included 2288 serial patients admitted to the Medical ICU at an urban academic medical center, who underwent invasive mechanical ventilation, with at least one intubated CXR, and a documented extubation attempt. The last CXR before extubation for each patient was taken and split 79/21 for training/testing sets, then transfer learning with k-fold cross-validation was used on a pre-trained ResNet50 deep learning architecture. The top three models were ensembled to form a final classifier. The Grad-CAM technique was used to visualize image regions driving predictions. The model achieved an AUC of 0.66, AUPRC of 0.94, sensitivity of 0.62, and specificity of 0.60. The model performance was improved compared to the Rapid Shallow Breathing Index (AUC 0.61) and the only identified previous study in this domain (AUC 0.55), but significant room for improvement and experimentation remains.

Effectiveness of corticosteroids and epinephrine use in neonates for the first extubation attempt: A retrospective study

BackgroundThis study aimed to analyze the use of corticosteroids and epinephrine in neonates for the first extubation attempt and compared clinical characteristics of infants with successful and failed extubation events. MethodsThis was a retrospective cohort study conducted at a single level III neonatal intensive care unit in Taiwan. The study included 215 infants born between 2020 and 2021 who had been intubated for more than 48 h before their first extubation attempt. We compared perinatal and peri-extubation characteristics and outcomes between the two groups. Successful extubation was defined as freedom from invasive ventilatory support 72 h after extubation. The relationship between corticosteroids, local epinephrine, and successful extubation was determined using multivariate logistic regression analysis. ResultsIn the univariate analysis, the failed extubation group received a significantly higher proportion of intravenous dexamethasone (p = 0.006) than the successful extubation group. Furthermore, the failed extubation group had a longer duration of nebulized epinephrine (p = 0.034) and more episodes of local application of epinephrine to the superior larynx (p = 0.003) than the successful extubation group. Multivariate analysis revealed that the absence of lung atelectasis, tachycardia 72 h after extubation, and lower post-extubation PCO2 were the key factors associated with successful extubation. ConclusionsThere were trends toward systemic dexamethasone, local application of epinephrine to the superior larynx, and longer duration of nebulized epinephrine in the reintubation group. However, corticosteroid or local epinephrine use was not significantly associated with successful extubation. Lung atelectasis, elevated levels of carbon dioxide, and tachycardia were identified as risk factors for extubation failure.

Implementation of an Extubation Readiness Guideline for Preterm Infants.

Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU. This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

Spinal Muscular Atrophy Mortality Despite Novel Medications: Case Reports.

Despite new effective medications, patients with spinal muscular atrophy types 1-3 can continue to have inadequate cough flows to prevent episodes of acute respiratory failure. Ventilator unweanable intubated patients are thought to require tracheostomy tubes. As a result, potentially beneficial medications may be discontinued and patients die despite receiving these medications. Three cases are presented of medically treated, physically strengthening children, with spinal muscular atrophy type 1. All three subsequently died or underwent tracheotomy. However, there is no evidence of extubation attempts to noninvasive ventilatory support settings or optimal mechanical insufflation-exsufflation despite this option being described to be over 98% successful for extubating unweanable medically untreated children with spinal muscular atrophy 1.

Hemi-diaphragmatic paralysis

Introduction: Diaphragmatic paralysis (DP) involving the phrenic nerve is related to brachial plexus injury in 80–90% of the cases. Other causes include iatrogenic procedure involving the cardiopulmonary area. It causes respiratory distress which can be severe requiring prolonged need for respiratory support. Recovery can be spontaneous, typically by the first 6–12 months of life though some infants may require surgical intervention if no improvement in DP is noted by 1–2 months of life in the setting of compromised quality of life. Case Report: We present a preterm infant, 31 completed weeks of gestational age, birth weight 1440 g born via emergency C-section due to preterm labor in breech presentation. During delivery, the patient suffered a left brachial plexus injury with phrenic nerve involvement. He developed respiratory distress requiring endotracheal intubation and mechanical ventilation. His clinical course involved multiple failed extubation attempts. Chest X-ray (CXR) and chest fluoroscopy confirmed the diagnosis of left hemi-diaphragmatic paralysis. The patient had a prolonged respiratory support course but was finally weaned to room air by three months of age. Conclusion: Preterm infants can sustain perinatal brachial plexus injury like term or near-term infants in the setting of a traumatic birth irrespective of birth weight. The time and indications for conservative (non-surgical) versus surgical intervention remains debatable. Each case should be tailored to the child’s severity of injury and quality of life and growth. Clinical recovery can occur even with considerable persistence weakness on radiography or chest ultrasound.

Spinal Muscular Atrophy Type 1 Survival Without New Pharmacotherapies: Two Treatment Paradigms.

The aims of the study are to present noninvasive respiratory management outcomes using continuous noninvasive ventilatory support and mechanical in-exsufflation from infancy for spinal muscular atrophy type 1 and to consider bearing on new medical therapies. Noninvasive ventilatory support was begun for consecutively referred symptomatic infants with spinal muscular atrophy type 1 from 1 to 10 mos of age. Intercurrent episodes of respiratory failure were managed by intubation then extubation to continuous noninvasive ventilatory support and mechanical in-exsufflation despite failing ventilator weaning and extubation attempts. Intubations, tracheotomies, and survival were monitored. Of 153 patients with spinal muscular atrophy 1 consecutively referred since 1995, 37 became continuous noninvasive ventilatory support dependent, almost half before 10 yrs of age. Of the 37, 18 required continuous noninvasive ventilatory support for a mean 18.6 ± 3.3 yrs to a mean 25.3 (range, 18-30) yrs of age, dependent from as young as 4 mos of age with 0 to 40 ml of vital capacity. One of the 18 died from COVID-19 acute respiratory distress syndrome at age 24 after 23 yrs of continuous noninvasive ventilatory support. Extubation success rate of 85% per attempt (150/176) resulted in only one undergoing tracheotomy. Medical treatments begun during the first 6 wks of age convert spinal muscular atrophy 1 into spinal muscular atrophy 2 or 3 but cough flows remain inadequate to avoid many pneumonias that, once resolved by a treatment paradigm of extubation to continuous noninvasive ventilatory support and mechanical in-exsufflation, eliminates need to resort to tracheotomies.

Development and validation of a prediction model for evaluating extubation readiness in preterm infants

Successful early extubation has advantages not only in terms of short-term respiratory morbidities and survival but also in terms of long-term neurodevelopmental outcomes in preterm infants. However, no consensus exists regarding the optimal protocol or guidelines for extubation readiness in preterm infants. Therefore, the decision to extubate preterm infants was almost entirely at the attending physician's discretion. We identified robust and quantitative predictors of success or failure of the first planned extubation attempt before 36 weeks of post-menstrual age in preterm infants (<32 weeks gestational age) and developed a prediction model for evaluating extubation readiness using these predictors. Extubation success was defined as the absence of reintubation within 72 h after extubation. This observational cohort study used data from preterm infants admitted to the neonatal intensive care unit of Seoul National University Bundang Hospital in South Korea between July 2003 and June 2019 to identify predictors and develop and test a predictive model for extubation readiness. Data from preterm infants included in the Medical Informative Medicine for Intensive Care (MIMIC-III) database between 2001 and 2008 were used for external validation. From a machine learning model using predictors such as demographics, periodic vital signs, ventilator settings, and respiratory indices, the area under the receiver operating characteristic curve and average precision of our model were 0.805 (95% confidence interval [CI], 0.802–0.809) and 0.917, respectively in the internal validation and 0.715 (95% CI, 0.713–0.717) and 0.838, respectively in the external validation. Our prediction model (NExt-Predictor) demonstrated high performance in assessing extubation readiness in both internal and external validations.

Tracheostomy experiences in chronic respiratory failure after congenital heart surgery

Introduction&#x0D; A small number of children with repaired congenital heart defects may require a tracheostomy for ongoing ventilatory support. Congenital airway anomalies, laryngomalacia, postoperative airway complications and genetic syndromes associated with airway and facial anomalies, such as DiGeorge Syndrome (22q11 deletion), can be counted among the reasons why patients are unable to be weaned from the ventilator. In this study, we aimed to define the outcomes of patients who required a tracheostomy due to chronic respiratory failure after congenital heart surgery, and the existing risk factors for in-hospital and post-discharge mortality.&#x0D; Materials and methods&#x0D; The files of 1382 patients who underwent surgery due to CHD in the Pediatric Cardiovascular Surgery Clinic in ……………., between February 2019 and February 2023, were retrospectively scanned. Patients’ age, gender, body weight, cardiac diagnosis, surgical intervention, length of stay in the intensive care unit, number of extubation attempts, total length of stay on the ventilator, need for ventilator at discharge, rates of weaning from tracheostomy and time of weaning from tracheostomy and mortality rates, were obtained from patient files and hospital database.&#x0D; Results&#x0D; Tracheostomy was performed in 15 of 1382 patients who underwent surgery during the four year study period. Mean (SD) duration of ventilation prior to tracheostomy was 35 days (IQR= 19 – 47). The median follow up time in patients was 224 days (IQR=116-538). Three patients were decannulated and six had died. Causes of death in six patients included sepsis (2), cardiac instability (1), neurological complications (2) and pulmonary haemorraghia (1). &#x0D; The median time to discharge after tracheostomy in patients was 51 days (IQR= 33.50 – 147). &#x0D; Eight patients (53.3%) were discharged on home ventilation. Causes of deaths were often multifactorial for children who died during their initial hospital stay. Mortality was seen in six patients, a rate of 40%. &#x0D; Conclusion&#x0D; The need for tracheostomy after cardiac surgery plays an important role in early and late mortality in children. Ventilator-dependent chronic respiratory failure is the most common cause of childhood tracheostomies. We believe that determining the optimal timing for tracheostomy in the pediatric population will be effective in reducing prolonged ventilation and tracheostomy-related morbidities.

Association of patent ductus arteriosus with extubation failure among preterm infants.

Mechanical ventilation is associated with mortality/morbidities in preterm infants. Nearly a third of these infants fail extubation, and this may increase morbidities. To evaluate the association of moderate to large symptomatic patent ductus arteriosus (PDA) with failure of extubation among preterm infants. This was a retrospective study on preterm infants (birth weight <1250 g and gestational age ≥23 weeks) born between January 2009 and December 2016, who were mechanically ventilated and extubated within the first 60 days of age. Three hundred and sixty infants were evaluated, of these, 26% failed, and 74% succeeded in the initial extubation attempt. On adjusted analysis, symptomatic PDA was associated with an increased risk of extubation failure. The presence of symptomatic patent ductus arteriosus was associated with extubation failure. Further investigations are needed to establish whether there is a causal relationship between PDA and extubation failure and whether proactive screening for presence of PDA and treatment of the same, before extubation among these infants, improves chances of successful extubation and cardiorespiratory outcomes.

Characteristics and Outcomes in Preterm Infants with Extubation Failure in the First Week of Life.

This study aimed to evaluate characteristics and outcomes in preterm infants with extubation failures in their first week of life. Retrospective chart review of infants born between 24 and 27 weeks' gestational age at the Sharp Mary Birch Hospital for Women and Newborns between January 2014 and December 2020 who had an extubation attempt within the first 7 days of life. Infants that were successfully extubated were compared with those who required reintubation in the first 7 days. Maternal and neonatal outcome measures were analyzed. A total of 215 extremely preterm infants had an extubation attempt in the first 7 days of life. Forty-six infants (21.4%) failed extubation and were reintubated within the first 7 days. Infants who failed extubation had a lower pH (p < 0.01), increased base deficit (p < 0.01), and more surfactant doses prior to first extubation (p < 0.01). Birth weight, Apgar scores, antenatal steroid doses, and maternal risk factors such as preeclampsia, chorioamnionitis, and duration of ruptured membranes were not different between success and failure groups. Rates of moderate to large patent ductus arteriosus (p < 0.01), severe intraventricular hemorrhage (p < 0.01), posthemorrhagic hydrocephalus (p < 0.05), periventricular leukomalacia (p < 0.01), and retinopathy of prematurity stage 3 or greater (p < 0.05) were higher in the failure group. In this cohort of extremely preterm infants that failed extubation in the first week of life, there were as increased risk of multiple morbidities. Base deficit, pH, and number of surfactant doses prior to first extubation may be useful tools in predicting which infants are likely to have early extubation success, but this needs prospective study. · Predicting extubation readiness in preterm infants remains challenging.. · Extubation failure is associated with multiple neonatal morbidities.. · Infant clinical characteristics may help predict extubation failure..

Predictive factors of extubation failure in pediatric cardiac intensive care unit: A single-center retrospective study from Thailand.

Extubation failure increases morbidity and mortality in pediatric cardiac patients, a unique population including those with congenital heart disease or acquired heart disease. This study aimed to evaluate the predictive factors of extubation failure in pediatric cardiac patients and to determine the association between extubation failure and clinical outcomes. We conducted a retrospective study in the pediatric cardiac intensive care unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, from July 2016 to June 2021. Extubation failure was defined as the re-insertion of the endotracheal tube within 48 hours after extubation. Multivariable log-binomial regression with generalized estimating equations (GEE) was performed to explore the predictive factors associated with extubation failure. We collected 318 extubation events from 246 patients. Of these, 35 (11%) events were extubation failures. In physiologic cyanosis, the extubation failure group had significantly higher SpO2 than the extubation success group (P < 0.001). The predictive factors associated with extubation failure included a history of pneumonia before extubation (RR 3.09, 95% CI 1.54-6.23, P = 0.002), stridor after extubation (RR 2.57, 95% CI 1.44-4.56, P = 0.001), history of re-intubation (RR 2.24, 95% CI 1.21-4.12, P = 0.009), and palliative surgery (RR 1.87, 95% CI 1.02-3.43, P = 0.043). Extubation failure was identified in 11% of extubation attempts in pediatric cardiac patients. The extubation failure was associated with a longer duration of PCICU stay but not with mortality. Patients with a history of pneumonia before extubation, history of re-intubation, post-operative palliative surgery, and post-extubation stridor should receive careful consideration before extubation and close monitoring afterward. Additionally, patients with physiologic cyanosis may require balanced circulation via regulated SpO2.

Associations between unit workloads and outcomes of first extubation attempts in extremely premature infants below a gestational age of 26 weeks.

The objective was to explore whether high workloads in neonatal intensive care units were associated with short-term respiratory outcomes of extremely premature (EP) infants born <26 weeks of gestational age. This was a population-based study using data from the Norwegian Neonatal Network supplemented by data extracted from the medical records of EP infants <26 weeks GA born from 2013 to 2018. To describe the unit workloads, measurements of daily patient volume and unit acuity at each NICU were used. The effect of weekend and summer holiday was also explored. We analyzed 316 first planned extubation attempts. There were no associations between unit workloads and the duration of mechanical ventilation until each infant's first extubation or the outcomes of these attempts. Additionally, there were no weekend or summer holiday effects on the outcomes explored. Workloads did not affect the causes of reintubation for infants who failed their first extubation attempt. Our finding that there was no association between the organizational factors explored and short-term respiratory outcomes can be interpreted as indicating resilience in Norwegian neonatal intensive care units.

The safety of immediate extubation, and factors associated with delayed extubation, in cardiac surgical patients receiving fast-track cardiac anesthesia: An integrative review.

Early extubation (EE), within 8 h of cardiac surgery, is associated with improved resource utilization. Studies have demonstrated that for patients receiving low-dose, fast-track opioid cardiac anesthesia (FTCA) protocols, EE is as safe as conventional care. To date, it is unclear when the earliest timepoints for safe extubation might be. Additionally, some authors pointed out that certain patients receiving FTCA protocols frequently experience delays during extubation attempts. Understanding the factors associated with delayed extubation is crucial for perioperative planning and resource management. This review seeks to 1) determine whether immediate extubation (IE) in the operating room is as safe as EE and 2) identify factors associated with delayed extubation. MEDLINE, Cochrane Library, EMBASE and CINAHL (up to March 2022) were searched. Studies pertaining to FTCA, IE, EE or factors associated with delayed extubation were included. All authors extracted, appraised and synthesized data. The primary outcome measures were treatment results and factors associated with delayed extubation. Six studies investigated treatment outcomes associated with FTCA and IE. One randomized controlled trial reported that outcomes associated with IE were comparable to those with EE. Five observational studies reported incidence for 19 treatment outcomes associated with IE, but no comparisons were made to EE. Six observational studies assessed pre- and intraoperative factors associated with delayed extubation in FTCA patients. In at least one study, 37 factors were investigated and 22 were identified. The most frequently reported factors were pre-existing cardiac insufficiency or renal disease, time on pump and cross-clamp time. Obesity and stroke were investigated but were not associated with delayed extubation. No study examined the influence of race, ethnicity or gender on outcomes. Evidence pertaining to treatment outcomes associated with FTCA and IE is weak. Observational studies cannot determine causation. Large multicentre randomized control trials are required to determine the safety of IE. Although numerous factors have been associated with delayed extubation, several studies do not describe how or which factors were selected for examination. Therefore, certain factors may have yet to be evaluated. Future studies should comprehensively define all factors under investigation.

Management of Critically Ill Patients With Spinal Muscular Atrophy Admitted With Acute Respiratory Failure.

Spinal muscular atrophy (SMA) is a neurodegenerative disease that results in progressive muscular atrophy and weakness. The primary cause of morbidity and mortality in these children is pulmonary disease due to poor airway clearance that leads to acute respiratory failure. There is a paucity of literature on the treatment of children with SMA and acute respiratory failure. We performed a retrospective chart review of pediatric patients with SMA type I or II admitted to the PICU in a tertiary-care children's hospital with acute respiratory failure who required mechanical ventilation and/or aggressive airway clearance. The study included 300 unique encounters among 137 unique subjects. All the subjects received airway clearance at home before admission, and 257 encounters (85.7%) were supported with noninvasive ventilation (NIV) before admission. Sixty-eight subjects (49.6%) required endotracheal intubation on admission or at some point during their PICU stay. The median (interquartile range [IQR]) time to intubation was 0 (0-20) h, and the median (IQR) duration of mechanical ventilation was 2 (1-5) d on invasive mechanical ventilation with no statistical difference between type I and type II (P = .89). Of those, 65 (91.1%) were successfully extubated to NIV on the first attempt, whereas 4 subjects (5.8%) required multiple extubation attempts and 3 subjects (4.4%) required subsequent tracheostomy. For the subjects who were intubated, both PICU and hospital length of stay were longer (P < .001) when compared with the subjects managed by NIV alone. The subjects with SMA type I had a longer PICU length of stay, with a median (IQR) of 5 (3-11) d versus 4 (2-7) d (P = .002). The hospital length of stay and duration of invasive mechanical ventilation were not statistically different (P = .055 and P = .068, respectively). The subjects with SMA types I or II can be treated successfully with NIV and aggressive airway clearance during acute respiratory failure. Similarly, when intubation is required, successful extubation can be achieved with NIV transitional support combined with aggressive airway clearance maneuvers.

Noninvasive Respiratory Support Does Not Prevent Extubation Failure in High-Risk Norwood Patients.

OBJECTIVES:This study aims to determine whether bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) effectively mitigate the risk of extubation failure in children status post-Norwood procedure.DESIGN:Single-center, retrospective analysis. Extubation events were collected from January 2015 to July 2021. Extubation failure was defined as the need for reintubation within 48 hours of extubation. Demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations.SETTING:Pediatric cardiovascular ICU.PATIENTS:Neonates following Norwood procedure.INTERVENTIONS:Extubation following the Norwood procedure.MEASUREMENTS AND MAIN RESULTS:The analysis included 311 extubations. Extubation failure occurred in 31 (10%) extubation attempts within the first 48 hours. On univariate analysis, higher rate of extubation failure was observed when patients were extubated to CPAP/BiPAP relative to patients who were extubated to either high-flow nasal cannula (HFNC) or nasal cannula (NC) (16% vs 7.8%; p = 0.027). On multivariable analysis, the presence of vocal cord anomaly (odds ratio, 3.08; p = 0.005) and lower pre-extubation end-tidal co2 (odds ratio, 0.91; p = 0.006) were simultaneously associated with extubation failure while also controlling for the post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC).CONCLUSIONS:Clinicians should not rely on CPAP or BiPAP as the only supportive measure for a patient at increased risk of extubation failure. CPAP or BiPAP do not mitigate the risk of extubation failure in the Norwood patients. A multisite study is needed to generalize these conclusions.

NT-proBNP and Zlog-transformed NT-proBNP values predict extubation failure in critically ill neonates with pulmonary hypertension and ventricular dysfunction.

Critically ill neonates with a history of pulmonary hypertension (PH) or ventricular dysfunction are at risk to experience an extubation failure (EF) after liberation from mechanical ventilation (MV). Due to insufficient data from neonatal cohorts, it remains unclear whether NT-proBNP is an appropriate biomarker to predict EF in this cohort. The Zlog-transformation of NT-proBNP (further named NT-proBNPZlog ) is an additional tool to optimize the interpretation of NT-proBNP since absolute NT-proBNP values are varying with the age of these infants. This was a retrospective single-center analysis at the University Children's Hospital, Bonn, Germany, during the study period from January 2020 until December 2021. Forty-three neonates met the inclusion criteria and were screened for study participation. prolonged (>24 h) MV with at least one extubation attempt, with a history of PH and/or ventricular dysfunction in the echocardiographic assessment at admission to the neonatal intensive care unit or during the period of MV, NT-proBNP measurements before (max. 24 h, baseline) and after (max. 24 h, follow-up) the first extubation attempt. The primary clinical endpoint was defined as EF with need for reintubation (0-72 h).Neonates with an EF were allocated to group A and neonates with successful liberation from MV to group B. The primary clinical endpoint (EF) was reached in 21% (nine infants). Absolute mean NT-proBNP values (NT-proBNPabs ) at baseline did not differ significantly in infants of group A and B (6931 vs. 7136 pg/ml, p = 0.227). NT-proBNPZlog values at baseline (2.35 vs. 1.57, p = 0.073) tended to higher values in group A. NT-proBNPabs values measured at follow-up were significantly higher in infants allocated to group A (11120 vs. 7570 pg/ml, p = 0.027). Likewise, NT-proBNPZlog values at follow-up were significantly higher in infants allocated to group A (3.05 vs. 1.93, p = 0.009). NT-proBNPabs values at follow-up and NT-proBNPZlog values at baseline correlated significantly with the severity of PH. Regarding the receiver operating characteristic-analysis, a NT-proBNPabs value at follow-up of ≥4622 pg/ml was calculated as optimal cut-off value for the prediction of EF (area under the curve[AUC] 0.742, p = 0.001). A NT-proBNPZlog value at baseline of ≥1.63 and at follow-up of ≥2.14 was calculated as optimal cut-off for the prediction of EF (AUC: 0.690/p = 0.027, and 0.781/p = 0.000, respectively). NT-proBNPabs and NT-proBNPZlog might be valuable biomarkers for the prediction of EF in critically ill neonates. The Zlog-transformation of NT-proBNP allows an age-independent interpretation of NT-proBNP and should be considered for clinical routine.

Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury – Assessing the initial response in the first US epicenter

To investigate the pandemic’s impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, ‘PUI’). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.