Extubation Failure In Children Research Articles

Association Between Dead Space to Tidal Volume Ratio and Duration of Respiratory Support After Extubation in Critically Ill Children.

The dead-space-to-tidal-volume ratio (VD/VT) has been used to successfully predict extubation failure in children who are critically ill. However, a singular reliable measure to predict the level and duration of respiratory support after liberation from invasive mechanical ventilation has remained elusive. The objective of this study was to evaluate the association between VD/VT and the duration of postextubation respiratory support. This was a retrospective cohort study of subjects who were mechanically ventilated and admitted to a single-center pediatric ICU between March 2019 and July 2021, and who had been extubated with a recorded VD/VT. A cutoff of 0.30 was chosen a priori, with subjects divided into 2 groups, VD/VT < 0.30 and VD/VT ≥ 0.30, and postextubation respiratory support was recorded at specified time intervals (24 h, 48 h, 72 h, 7 d, and 14 d). We studied 54 subjects. Those with VD/VT ≥ 0.30 had a significantly longer median (interquartile range) duration of respiratory support after extubation (6 [3-14] d vs 2 [0-4] d; P = .001) and longer median (interquartile range) ICU stay (14 [12-19] d vs 8 [5-22] d; P = .046) versus the subjects with VD/VT < 0.30. The distribution of respiratory support did not differ significantly between VD/VT at the time of extubation (P = .13) or at 14 d after extubation (P = .21) but was significantly different during the intervening time points after extubation (24 h [P = .01], 48 h [P < .001], 72 h [P < .001], and 7 d [P = .02]). VD/VT was associated with the duration and level of respiratory support needed after extubation. Prospective studies are needed to establish if VD/VT can successfully predict the level of respiratory support after extubation.

Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis.

There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children. A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters. In total, 41 of 11,663 publications screened were included (total patients, n = 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41, n = 1945), partial pressure of arterial carbon dioxide (10/41, n = 1379), tidal volume (13/41, n = 1945), rapid shallow breathing index (RBSI) (9/41, n = 1400), and spontaneous breathing trials (SBT) (13/41, n = 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity [0.57, 95% confidence interval (CI) 0.4-0.73] and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92-0.94). Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments.

Risk factors of tracheal extubation failure in children with spinal muscular atrophy combined with pneumonia

Objective: To summarize the risk factors of tracheal extubation failure in children with spinal muscular atrophy (SMA) combined with pneumonia. Methods: In this retrospective study, clinical data of 34 children with SMA combined with pneumonia who were hospitalized in Children's Hospital Affiliated to Capital Institute of Pediatrics from August 2018 to December 2021 were analyzed. According to whether the extubation was successful or not, they were divided into the success group and the failure group. The risk factors that may affect the success of extubation between two groups were derived by comparing the clinical characteristics by Mann-Whitney U test and Chi-square test, followed by multivariate Logistic regression. Results: Among the 34 cases, there were 14 males and 20 females, aged 10.8 (6.0,25.2) months at the time of hospitalization, 31 cases were type 1 SMA and 3 cases were type 2. Eleven children were unable to eat independently before intubation, 22 were treated with airway clearance techniques and 28 had multiple pulmonary infections. There were 21 cases in the success group and 13 cases in the failure group. The failure group had higher maximum partial pressure of arterial carbon dioxide level during intubation and higher rate of consolidation changes in chest images before extubation (81 (49,86) vs. 48 (43,56) mmHg (1 mmHg=0.133 kPa), 6/13 vs. 10%(2/21), Z=-2.55, χ2=5.99, both P<0.05). Multivariate Logistic regression analysis showed that tube feeding before intubation (OR =39.88, 95%CI 3.36-473.29, P=0.003) and not receiving airway clearance therapy (OR =14.55, 95%CI 1.35-156.78, P=0.027) were independent risk factors for extubation failure. Conclusions: The independent risk factors of tracheal extubation failure in children with SMA combined with pneumonia are unable to eat independently before intubation and not receiving airway clearance therapy. Therefore, the conditions to improve the success of extubation consist of having the ability to eat independently before intubation, using airway clearance techniques to improve ventilation and to make the chest images as clear as possible.

Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery.

Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT. Retrospective cohort study. CICU at a tertiary-care children's hospital. Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019. None. Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01). Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.

Risk factors associated with extubation in a pediatric intensive care unit

INTRODUCTION: Mechanical changes are the ventilatory support used to maintain lung function while the cause of intubation is reversed, and it has greatly contributed to increased survival in intensive care units, however, the need for orotracheal intubation, especially for prolonged periods, brought concerns about the failure to withdraw this support. Extubation failure is a worldwide problem, and a search for predictors, risk factors and therapies capable of preventing it has mobilized research groups. Objectives: We present the results of an observational study carried out in a pediatric intensive care unit for one year, which aimed to identify risk factors related to extubation failure in children and adolescents mechanically ventilated for at least 48 hours. METHODS: Eighty-five children aged between 29 days and 15 years of age were included, of which 11 (12.9%) required reintubation. RESULTS: In our sample, the risk factors found were age less than 3 months [OR: 2.71], mechanics for more than 15 days [OR: 7.30], fatal from shock [OR: 2.45], fatal of cardiorespiratory arrest [OR: 8.0] and those who were drilled to intubation cannula changes [1.97]. CONCLUSION: These conditions increased the risk of extubation failure in our sample.

Prediction of extubation failure in the paediatric cardiac ICU using machine learning and high-frequency physiologic data.

Cardiac intensivists frequently assess patient readiness to wean off mechanical ventilation with an extubation readiness trial despite it being no more effective than clinician judgement alone. We evaluated the utility of high-frequency physiologic data and machine learning for improving the prediction of extubation failure in children with cardiovascular disease. This was a retrospective analysis of clinical registry data and streamed physiologic extubation readiness trial data from one paediatric cardiac ICU (12/2016-3/2018). We analysed patients' final extubation readiness trial. Machine learning methods (classification and regression tree, Boosting, Random Forest) were performed using clinical/demographic data, physiologic data, and both datasets. Extubation failure was defined as reintubation within 48 hrs. Classifier performance was assessed on prediction accuracy and area under the receiver operating characteristic curve. Of 178 episodes, 11.2% (N = 20) failed extubation. Using clinical/demographic data, our machine learning methods identified variables such as age, weight, height, and ventilation duration as being important in predicting extubation failure. Best classifier performance with this data was Boosting (prediction accuracy: 0.88; area under the receiver operating characteristic curve: 0.74). Using physiologic data, our machine learning methods found oxygen saturation extremes and descriptors of dynamic compliance, central venous pressure, and heart/respiratory rate to be of importance. The best classifier in this setting was Random Forest (prediction accuracy: 0.89; area under the receiver operating characteristic curve: 0.75). Combining both datasets produced classifiers highlighting the importance of physiologic variables in determining extubation failure, though predictive performance was not improved. Physiologic variables not routinely scrutinised during extubation readiness trials were identified as potential extubation failure predictors. Larger analyses are necessary to investigate whether these markers can improve clinical decision-making.

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.

High Breath-by-Breath Variability Is Associated With Extubation Failure in Children.

Extubation failure is multifactorial, and most tools to assess extubation readiness only evaluate snapshots of patient physiology. Understanding variability in respiratory variables may provide additional information to inform extubation readiness assessments. Secondary analysis of prospectively collected physiologic data of children just prior to extubation during a spontaneous breathing trial. Physiologic data were cleaned to provide 40 consecutive breaths and calculate variability terms, coefficient of variation and autocorrelation, in commonly used respiratory variables (i.e., tidal volume, minute ventilation, and respiratory rate). Other clinical variables included diagnostic and demographic data, median values of respiratory variables during spontaneous breathing trials, and the change in airway pressure during an occlusion maneuver to measure respiratory muscle strength (maximal change in airway pressure generated during airway occlusion [PiMax]). Multivariable models evaluated independent associations with reintubation and prolonged use of noninvasive respiratory support after extubation. Acute care, children's hospital. Children were included from the pediatric and cardiothoracic ICUs who were greater than 37 weeks gestational age up to and including 18 years who were intubated greater than or equal to 12 hours with planned extubation. We excluded children who had a contraindication to an esophageal catheter or respiratory inductance plethysmography bands. Noninterventional study. A total of 371 children were included, 32 of them were reintubated. Many variability terms were associated with reintubation, including coefficient of variation and autocorrelation of the respiratory rate. After controlling for confounding variables such as age and neurologic diagnosis, both coefficient of variation of respiratory rate(p < 0.001) and low PiMax (p = 0.002) retained an independent association with reintubation. Children with either low PiMax or high coefficient of variation of respiratory rate had a nearly three-fold higher risk of extubation failure, and when these children developed postextubation upper airway obstruction, reintubation rates were greater than 30%. High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children, with very high rates of extubation failure when these children develop postextubation upper airway obstruction.

Incidence, predictors, and outcomes of extubation failure in children after orthotopic heart transplantation: a single-center experience.

The objective of this study is to describe the incidence, etiologies, predictors, and outcomes of extubation failure in children undergoing orthotopic heart transplantation (OHT). A Retrospective, observational study was designed to evaluate clinical outcomes. . The study was conducted in a cardiovascular intensive care unit (CVICU) setting at a single, tertiary care, academic children's hospital. We collected demographic, pre-operative, intra-operative, post-operative and peri-extubation data in a retrospective, observational format from patients who underwent OHT at our institution. Clinical outcomes evaluated included the success or failure of extubation, CVICU length of stay (LOS), hospital LOS, and in-hospital mortality. We utilized descriptive and univariate statistics to compare the group with extubation failure to the group with extubation success. There were no interventions in this study. During the study period, 127 patients qualified for inclusion. The median age of patients was 108 months [interquartile range (IQR): 25-169] and median weight was 23 kg (IQR: 10.6-48). Extubation failure occurred in 12.5 % (16/127) of the patients. Median duration of mechanical ventilation was 2 days (IQR: 1-4.5), median CVICU LOS was 7 days (IQR: 5-13), and the median hospital LOS was 36 days (IQR: 20-74). Overall in-hospital mortality was 2 % (2/127). There was a significant improvement in blood pressure (p < 0.001) with a decrease in inotropic score (p < 0.001) after removal of positive pressure ventilation among the patients with extubation success. Independent factors associated with extubation failure included lower body weight, need for mechanical ventilation prior to heart transplantation, renal failure prior to extubation attempt, and right ventricular diastolic dysfunction prior to extubation attempt. Our study demonstrates that extubation failure in patients after OHT is infrequent and the causes are diverse. Extubation success in children after OHT is associated with improvement in mean arterial blood pressure, decrease in inotropic support, and decrease in supplemental oxygen requirement.

Characteristics and Hemodynamic Effects of Extubation Failure in Children Undergoing Complete Repair for Tetralogy of Fallot

This study aimed to identify the prevalence, etiology, and outcomes of extubation failure in children after complete repair for tetralogy of Fallot at a single tertiary-care, academic children's hospital. The secondary aim of this study was to determine the cardiorespiratory effects of the transition from positive-pressure ventilation to spontaneous breathing in children with extubation success and extubation failure. For this study, extubation was defined as the need for reintubation within 96 h after extubation. Demographics as well as pre-, intra-, post-, and periextubation data were collected in a retrospective observational format for patients who underwent complete repair for tetralogy of Fallot during the period January 2001-June 2011. Patients with multiple aortopulmonary collateral arteries or associated complete atrioventricular septal defects were excluded from the study. The cardiorespiratory variables collected before and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near-infrared spectroscopy, oxygen saturations, and lactate levels. The clinical outcomes evaluated included the success or failure of extubation and the hospital length of stay. Descriptive and univariate statistics were used to compare the group with extubation failure and the group with extubation success. Extubation failure occurred for 7 % (12/164) of the 164 eligible patients during the study period. The median age of the patients at surgery was 200 days (range 98-356 days), and their median weight was 6.8 kg (range 5.2-8.5 kg). For 6 % (10/164) of the patients, intubation was performed before surgery. The median duration of mechanical ventilation was 33 h (range 19.5-73 h), and the median hospital stay was 10 days (range 7-15 days). Of the 12 patients with extubation failure, 2 had extubation failure in first 2 h after extubation, 6 had failure in 2-24 h, 3 had failure in 24-48 h, and 1 had failure in 48-96 h. The patients in the extubation success and extubation failure groups were similar in age, sex, and body weight at the time of surgery. All preexisting conditions also were similar in the two groups. The intraoperative variables and postoperative complications did not differ between the two groups. The hospital stay was longer for the children with extubation failure (p < 0.001). The partial pressure of oxygen in arterial blood (PaO2), tachycardia, mean arterial blood pressure, and inotrope score improved significantly at conversion from positive-pressure ventilation to spontaneous ventilation in the patients with extubation success. This study demonstrated that extubation failure in patients after complete repair for tetralogy of Fallot is low and that the etiology is diverse. The majority of extubation failures in these patients occurred in the first 24 h. Extubation success in the children after repair for tetralogy of Fallot was associated with improvement in PaO2, tachycardia, and mean arterial pressure, with a decrease in inotrope score. Extubation failure is associated with a longer hospital stay.

Dead space to tidal volume ratio (VD/VT) to explain extubation failure in children: the limitations of current evidence

Riou et al.1 apresentam um artigo que descreve o valor da razao entre espaco morto e volume corrente (VD/VT) para avaliar a probabilidade de sucesso na extubacao de criancas em ventilacao mecânica hospitalizadas em uma unidade de tratamento intensivo (UTI). Os metodos do estudo reproduzem os de dois trabalhos ja publicados sobre o assunto envolvendo criancas em estado critico2,3. Assim como no estudo de Hubble et al.2, Riou et al. observaram que uma VD/VT > 0,55, calculada pouco antes da extubacao, enquanto o paciente respira espontaneamente com pressao de suporte, e altamente associada a fracasso na extubacao, com razao de verossimilhanca (RV) positiva perto de 4 (relativamente alta para considerar fracasso na extubacao) e RV negativa 0,65, com RV positiva < 2, RV negativa = 0,45 e capacidade de discriminacao razoavel (area sob a curva ROC = 0,621; IC95% nao informado), demonstraram pouca associacao com fracasso na extubacao3.

Preditores de falha da extubação em crianças no pós-operatório de cirurgia cardíaca submetidas à ventilação pulmonar mecânica

It is important to know the risk factors for extubation failure (EF) in children submitted to cardiac surgery in order to avoid inherent events due to reintubation (airways injury, usage of medications, cardiovascular changes) and because of prolonged ventilatory support (pneumonias, reduction of the ventilatory muscles strength). The objective of this study is to evaluate mechanical ventilation (MV) parameters, ventilatory mechanics [rapid shallow breathing index (RSBI), ventilatory muscles force [the maximum inspiratory pressure (MIP), the maximum expiratory pressure (MEP) and the load/force balance (LFB)] and blood gases before and after extubation in pediatric patients undergoing cardiac surgery. Prospective (March 2004 to March 2006) observational cross sectional study, enrolling children submitted to cardiac surgery admitted to an university PICU hospital and considered able to be extubated. With the tracheal tube in situ and maintaining the children spontaneously breathing we evaluate: expiratory minute volume (V E), MIP and MEP. We calculated the RSBI [(RR/VT)/Weight)], LFB [15x [(3xMAP)/MIP] + 0.03 x RSBI-5], the mean airway pressure (MAP) [MAP={(PIP-PEEP)x[Ti/(Te+Ti)]}+PEEP] and the oxygenation index (OI) [OI=(FiO2 x MAP/PaO2)x100]. Arterial blood gas was collected one hour before extubation. If after 48 hours there was no need to reintubate the patient the extubation was considered successful (SE). 59 children were included. EF was observed in 19% (11/59). Median (QI25%-75%) for age, weight, MAP, OI, duration of MV after cardiac surgery (DMV) were respectively, 36 (12-82) months, 12 (8-20) kg, 8 (6-9), 2 (2-5), 1 (1-3) days. Median (QI25-75%) of EF in relation to SE for OI, LFB and DMV were respectively 5(3-8) versus 2(2-4), p = 0.005; [8(6-11) versus 5(4-6), p =0.002 and 3(2-5) versus 1(1-2) days, p = 0.026. Mean ± SD of EF in relation to SE for V E, PaO2 and MIP were respectively 1.7 ± 0.82 versus 3 ± 2.7 mL/kg/min, p = 0.003); 64 ± 34 versus 111 ± 50 mmHg, p = 0.002 and 53 ± 18 versus 78 ± 28 cmH2O; p=0.002. Concerning the risk factors for EF: OI > 2 (area under the ROC 0.74, p = 0.017) and LFB > 4 (area under the ROC 0.80, p = 0.002), achieved a sensibility of 100% and specificity of 80%; MIP < -35 cmH2O (area under the ROC 0.23; p= 0.004) achieved a sensibility of 80% and specificity of 60%. EF in children submitted to cardiac surgery is related to OI > 2, LFB > 4, DMV > 3 days; V E < 1.7 mL/kg/min, PaO2 < 64 mmHg and MIP < - 53 cmH2O. The kind of cardiac defect, MAP, RSBI and arterial blood gas were not related to EF.