Failed Extubations Research Articles

Reducing Failed Extubations in Preterm Infants Via Standardization and Real-Time Decision Support.

Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR). A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation. We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator. Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns.

RYR1 myopathy complicated by RSV bronchiolitis requiring intubation leading to posthypoxic leukoencephalopathy in a 4 year-old.

Central core disease due to RYR1 mutations is a rare heterogeneous myopathy characterized by skeletal muscle weakness. In light of both the rarity of presentation as well as the relatively broad spectrum of clinical phenotypes, there is a need to report treatment strategies for common complications of this condition. In this case, we outline the ICU management of a 4 year-old girl with central core disease caused by RYR1 mutation who was hospitalized due to respiratory syncytial virus (RSV) bronchiolitis leading to respiratory failure. Her hospital stay was complicated by multiple failed extubations, hospital infections, and post-anoxic leukoencephalopathy.

An unusual case of multiple failed extubations in a neurosurgical patient

A 41 year old woman, ASA PS1, an operated case of Chiari type 1 malformation, syringomyelia and syringobulbia, was posted for right syringopleural shunt. After a routine on-table extubation, immediately postoperatively, she lost consciousness, became progressively hypoxaemic requiring emergent reintubation. Blood gases revealed severe respiratory acidosis. The patient was systematically evaluated for likely causes of respiratory failure considering the sites of surgery and her preoperative surgical condition, i.e., brainstem, chest and larynx. She failed three trials of extubation, at different stages of her evaluation. Suspecting an undiagnosed neurological condition, the neurologist’s evaluation discovered a three-month history of easy fatiguability, dysphagia and ptosis. Nerve conduction studies also pointed to the diagnosis of myasthaenia gravis. After initiating steroids and neostigmine, the patient made a steady recovery and was successfully weaned off the ventilator.

The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations

IntroductionThere is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations. ObjectiveTo determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings. MethodsA retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013–June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed. ResultsOf the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB. ConclusionsInfants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions.

The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. Retrospective case series. This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. 4 Laryngoscope, 130:1327-1332, 2020.

Risk factors for extubation failure in mechanically ventilated children in pediatric intensive care unit

Background: Mechanical ventilation is lifesaving in children with respiratory failure. However, its unnecessary prolongation once a child is capable of sustaining spontaneous effective ventilation is associated with significant complications. Objective: To identify the factors that lead to higher chance of extubation failure in mechanically ventilated children. Materials and Methods: A prospective, observational study was conducted over a period of 1 year. Children admitted to pediatric intensive care unit of a tertiary care hospital of Northern India aged 1 month–17 years, needing mechanical ventilation were included in the study. Predefined criteria were used to decide the timing of extubation. Relevant details were recorded to study various patient-related parameters and their association with extubation outcome. Results: Mean age of the study group was 50 months with a male:female ratio of 3:1. Extubation failure rate was 14.5%. Extubation failure was significantly higher in patients ventilated for &gt;7 days (p=0.01), those with the pediatric risk of mortality score &gt;10 at admission (p=0.009), in addition to peak inspiratory pressure &gt;16 cm H2O (p=0.009) and FiO2 ?0.35 (p=0.01) before extubation. Accidental extubation was also associated with higher extubation failure (p&lt;0.001). Conclusion: Our study demonstrates that even though sicker patients requiring ventilation for longer duration are more prone to failed extubations, protocol based, and planned extubations lead to better extubation success.

Predicting Extubation Outcomes—A Model Incorporating Heart Rate Characteristics Index

To test the hypothesis that in neonates on mechanical ventilation, heart rate characteristics index (HRCi) can be combined with a clinical model for predicting extubation outcomes in neonates. HRCi and clinical data for all intended intubation-extubation events (episodes) were retrospectively analyzed between June 2014 and January 2015. Each episode started 6 hours pre-extubation or at the time of primary intubation if ventilation duration was shorter than 6 hours (baseline). The episodes ended at 72 hours postextubation for successful extubations or at reintubation for failed extubations. Mean of 6 hourly epoch HRCi-scores (baseline) or fold-changes (postextubation) were analyzed. Results are expressed as medians (IQR) for continuous data and proportions for categorical data. Multivariable logistic regression mixed model was used for statistical analysis. Sixty-six infants contributed to 96 episodes (18 failed extubations, 78 successful extubations) in the study. Failed extubations had significantly longer duration of ventilation (65.3 hours, 19.94-158.2 vs 38.4, 16.5-71.3) and more culture positive sepsis (33.3% vs 3.8%) than successful extubations. Baseline HRCi scores (1.68, 1.29-2.45 vs 0.95, 0.54-1.86) and postextubation epoch-1 fold changes (1.25, 0.94-1.55 vs 0.94, 0.82-1.11) were higher in failed extubations compared with successful extubations. Multivariable linear mixed-effects regression was used to create prediction models for success of extubation, using relevant variables. The baseline and postextubation HRCi were significantly higher in neonates with extubation failure compared with those who succeeded. Models using HRCi and clinical variables to predict extubation success may add to the confidence of clinicians considering extubation.

Risk factors for extubation failure in the intensive care unit.

ObjectiveTo determine the risk factors for extubation failure in the intensive care unit.MethodsThe present case-control study was conducted in an intensive care unit. Failed extubations were used as cases, while successful extubations were used as controls. Extubation failure was defined as reintubation being required within the first 48 hours of extubation.ResultsOut of a total of 956 patients who were admitted to the intensive care unit, 826 were subjected to mechanical ventilation (86%). There were 30 failed extubations and 120 successful extubations. The proportion of failed extubations was 5.32%. The risk factors found for failed extubations were a prolonged length of mechanical ventilation of greater than 7 days (OR = 3.84, 95%CI = 1.01 - 14.56, p = 0.04), time in the intensive care unit (OR = 1.04, 95%CI = 1.00 - 1.09, p = 0.03) and the use of sedatives for longer than 5 days (OR = 4.81, 95%CI = 1.28 - 18.02; p = 0.02).ConclusionPediatric patients on mechanical ventilation were at greater risk of failed extubation if they spent more time in the intensive care unit and if they were subjected to prolonged mechanical ventilation (longer than 7 days) or greater amounts of sedative use.

Factors Associated with Reintubation in an Intensive Care Unit: A Prospective Observational Study.

Background and Aims:The objective of the study was to determine the incidence of failed extubations in our Intensive Care Unit (ICU) and identify associated clinical factors.Materials and Methods:A prospective observational study of mechanically ventilated patients who underwent extubation attempts in our (predominantly surgical) ICU was undertaken from July 2012 to August 2013. The primary endpoint was the need for nonelective reintubation within 72 h of extubation. Clinical data of the reintubated patients were compared with those who were successfully extubated to identify factors associated with reintubation.Results:Five hundred and eight extubation attempts were documented, 38 (7.5%) of which were unsuccessful. On multivariate analysis, the following clinical factors were found to be associated with an increased risk of failed extubation: unplanned extubations (adjusted odds ratio [OR] 5.8), the use of noninvasive ventilation (NIV) postextubation (adjusted OR 3.2), and sepsis (adjusted OR 2.9). Patient demographic factors, other premorbid and comorbid medical conditions, and differences of laboratory parameters did not appear to significantly influence reintubation rates in our study.Conclusions:Our study has demonstrated a relatively low reintubation rate, likely due to inclusion of elective admissions/intubations in our patient population. Unplanned extubations, the use of NIV postextubation, and sepsis were associated with increased reintubation risk, reinforcing the need for increased vigilance in this subgroup of patients after extubation.

Outcome of mechanically ventilated patients initially denied admission to an intensive care unit and subsequently admitted

The outcome of mechanically ventilated patients initially denied admission to an intensive care unit (ICU) and subsequently admitted is unclear. We compared outcomes of patients denied ICU admission and subsequently admitted, to those of patients admitted to the ICU and to patients refused ICU admission. The medical records of all the patients who were subjected to mechanical ventilation for at least 24h over a 4year period (2010–2014) were reviewed. Of 707 patients (757 admissions), 124 (18%) were initially denied ICU admission and subsequently admitted. Multivariate stepwise logistic regression analysis showed significant association with death of: age, length of stay, nursing home residency, duration of mechanical ventilation, previous admission with mechanical ventilation, cause for mechanical ventilation, rate of failed extubations, associated morbidity (previous cerebrovascular accident, dementia, chronic renal failure), and occurrence of nosocomial bacteremia. The odds for death among patients denied ICU admission and subsequently transferred to the ICU compared to patients admitted directly to the ICU was 3.6 (95% CI: 1.9–6.7) (P<0.0001). The odds for death among patients refused ICU admission compared to those who were initially denied and subsequently admitted were not statistically significant (OR=1.7, 95% CI: 0.8–3.8). In conclusion, patients denied ICU admission and subsequently admitted face a considerable risk of morbidity and mortality. Their odds of death are nearly three times those admitted directly to the ICU. Late admission to the ICU does not appear to provide benefit compared to patients who remain in general medicine wards.

Reintubation following planned extubation: incidence, mortality and risk factors

180 patients were initially included in the study, with 105 remaining once exclusion criteria had been applied. There were a total of 141 extubations with a failure rate of 38%. Those in thefailuregroup had a median length of ICU stay of 14.9 days vs. 8.2 days in thesuccessgroup. The ICU mortality in these groups being 10% vs 8% respectively. In relation to risk factors for extubation failure, there were no clinically significant differences between thefail- ureandsuccessgroups in terms of: age (58 vs 57 yrs); duration of IPPV (3.3 vs 4 days); fluid balance (+ve 2047 vs 2386 mls.); RSBI (50 vs 36) and APACHE II scores (15 vs 17) respectively. However, 90% of patients with a RSBI >100 immediately prior to extubation did subse- quently require reintubation. Emergency non-invasive ventilation was commenced in 10% of patients post extubation, with 70% subsequently requiring reintubation. The reasons for extubation failure were difficult to determine, but upper airway obstruction was documented as a contributing factor in 19% of failed extubations.

Predictors of need for mechanical ventilation at discharge after tracheostomy in the PICU.

The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay. This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients <18 years old admitted between 2009-2011 who required MV for at least 3 days and received a tracheostomy during their PICU stay were included. A total of 680 pediatric patients from 74 PICUs were included, of whom 347 (51%) remained on MV at the time of PICU discharge. Neonates (30/38, 79%) and infants (129/203, 64%) required MV at PICU discharge after tracheostomy more often than adolescents (66/141, 47%) and children (122/298, 41%). Time on MV pre-tracheostomy was longer among those who required MV at discharge (median 18.3 vs. 13.8 days, P < 0.0001); however, number of failed extubations was similar (median 1 for both groups, P = 0.97). On mixed-effects multivariable regression analysis, the age categories of neonate (OR 2.9, 95%CI 1.1-7.6, P = 0.03), and infant (OR 1.7, 95%CI 1.1-2.8, P = 0.03), and ventilator days prior to tracheostomy (OR 1.01, 95%CI 1.0-1.02, P = 0.01) were significantly associated with increased odds of MV upon PICU discharge, while being a trauma admission was associated with decreased odds (OR 0.45, 95%CI 0.28-0.73, P = 0.001). Younger patients and those with prolonged courses of MV prior to tracheostomy are more likely to continue to need MV upon PICU discharge.

An audit of characteristics and outcomes in adult intensive care patients following tracheostomy

Background:Tracheostomies are commonly performed on critically ill patients requiring prolonged mechanical ventilation. The purpose of this study was to review our experience with surgical and percutaneous tracheostomies and identify factors affecting outcome.Materials and Methods:Patients who underwent tracheostomy between January 1999 and June 2008 were identified on the basis of Diagnostic Related Group coding and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification procedural code. The primary endpoint was in-hospital mortality. Contingency tables were generated for clinical variables and a chi-squared test was used to determine significance.Results:One hundred and sixty-eight patients underwent tracheostomy between January 1999 and 30 June 2008. In-hospital mortality was 22.6%. The probability of death was found to be independent of timing of tracheostomy, technique used (percutaneous vs. surgical), number of failed extubations and obesity. On univariate analysis, the null hypothesis of independence was rejected for age on admission (P = 0.014), diagnosis of sepsis (P = 0.0008) or cardiac arrest (P = 0.0016), Acute Physiology and Chronic Health Evaluation II score (P = 0.0319) and the Australasian Outcomes Research Tool for Intensive Care calculated risk of death (P = 0.0432).Conclusion:Although a number of patient factors are associated with worse outcome, tracheostomy appears to be a relatively safe technique in the Intensive Care Unit population.

Incidence, Diagnosis, and Outcomes of Vocal Fold Immobility After Esophageal Atresia (EA) and/or Tracheoesophageal Fistula (TEF) Repair

The diagnosis of vocal fold paralysis in an infant is a devastating finding that may require a permanent tracheotomy. The incidence of congenital vocal fold paralysis is unknown, but it is thought to be more common in infants with anatomic anomalies in the aero-digestive system. Vocal fold paralysis after surgical repair of esophageal atresia and tracheoesophageal fistula is a rare finding often diagnosed after multiple failed extubations. Currently infants do not routinely undergo documentation of vocal fold motion prior to esophageal atresia repair. We report here on our experience with this rare complication. A retrospective review was done of patients with esophageal atresia and/or tracheoesophageal fistula from 1985 to 2009. Patient demographics, operative techniques, and outcomes were collected. 150 patients were identified. Mean age at surgical intervention was 12 ± 33 days. Otolaryngology service was consulted for 13% of patients with postoperative failure. Awake fiberoptic laryngoscopy identified 3% of patients with vocal fold paralysis. Bilateral vocal fold paralysis was found in 3 patients, and 2 patients had unilateral vocal fold paralysis. Patients with bilateral paralysis were treated with tracheotomy; unilateral paralysis was treated expectantly. In this study, 3% of patients were diagnosed with vocal fold paralysis after esophageal atresia repair. The etiology of vocal fold paralysis in this study is difficult to assess. Pre-operative fiberoptic laryngoscopy is recommended to identify children with congenital vocal fold paralysis prior to surgical intervention, especially in those requiring revision surgery.

Children with corrected or palliated congenital heart disease on home mechanical ventilation

Infants and children with surgically corrected or palliated congenital heart disease (CHD) are at risk for chronic respiratory failure, necessitating home mechanical ventilation (HMV) via tracheostomy. However, very little data exists on this population or their outcomes. We conducted a retrospective chart review of all children with CHD enrolled in the Childrens Hospital Los Angeles HMV program between 1994 and 2009. Data were collected on type of heart lesion, surgeries performed, number of failed extubations, timing of tracheostomy, mortality, length of time on HMV, weaning status, associated co-morbidities, and Risk Adjusted classification for Congenital Heart Surgery (RACHS-1) category. Thirty-five children were identified; six with single ventricle anatomy, who received palliative procedures. Twenty-three (66%) patients are alive; 8 (23%) living patients have been weaned off HMV. Twelve (34%) patients are deceased. The incidence of mortality for single ventricle patients was 50%, and only one of the surviving children has received final palliation and weaned off HMV. Eight of nine patients (89%) with a RACHS score > or =4 died, and none have been weaned off of HMV. The 5-year survival for all CHD HMV patients was 68%; 90% for patients with RACHS < or =3; and 12% for patients with score > or =4. Children with more complex lesions, as demonstrated by single ventricle physiology or greater RACHS scores, had higher mortality rates and less success weaning off HMV. This case series suggests that caregivers should give serious consideration to the type of heart defect as they advise families considering HMV in children with CHD.

The Role of Cytomegalovirus in Immune Thrombocytopenia Purpura.

Immune thrombocytopenia purpura(ITP) is one of the most common causes of acquired thrombocytopenia. Although ITP is believed to result from autoreactive antibodies that lead to platelet destruction, its exact pathogenesis is not known. Cytomegalovirus(CMV) has been implicated as a possible causative agent of ITP. Based on three case reports described here we believe that CMV may be a cause of refractory ITP in certain patients and that eradication of CMV with antiviral therapy will improve the ITP. A 72-year-old man experienced recurrent epistaxis and was found to be thrombocytopenic. He was diagnosed with ITP, and treated with IVIG and solumedrol, with platelets transiently rising to 45K/ul. He suffered a subdural hematoma and was placed on IVIG and prednisone daily and referred for splenectomy. Rituximab was ineffective. Testing for CMV revealed a positive PCR and ganciclovir IV qd, valganciclovir, and cytogam 2 times per week were initiated. With this regimen, the CMV PCR became undetectable and steroids and his anti-CMV medications were weaned off. He now maintains a normal count on no treatment. A 48-year-old male developed ITP which was refractory to treatment with steroids, IVIG, rituximab, danazol, vincristine, anti-thymocyte globulin, and IV anti-D; his platelet count was <20,000/ul and he had marked skin and oral bleeding. After being diagnosed with CMV, he was started on IV ganciclovir and cytogam for several months and was weaned after his PCR became undetectable. In retrospect, he had had mild transaminitis and atypical lymphocytes reported at presentation at another center. He experienced a reactivation of his CMV while being treated with 1 week of steroids for asthma, requiring a second 4 month course of ganciclovir. Currently he receives IVIG every 2-8 weeks. A 3-year-old female was well until 4 months of age, when she developed fevers, thrombocytopenia, elevated liver enzymes and a positive CMV PCR for which she was started on ganciclovir. She developed pancytopenia; bone marrow biopsy was consistent with ITP. She had poor responses to IVIG, IV anti-D and pulse steroids. She suffered from chronic CMV infection for which she received cytogam BIW and initially ganciclovir daily, until its discontinuation secondary to myelosuppression. Once her CMV PCR was negative and her platelets improved to near normal, cytogam was discontinued. Soon after discontinuation her platelet count dropped below 10,000K/ul. She was restarted on the ganciclovir and cytogam without effect. She experienced an intracranial hemorrhage, RSV bronchiolitis, gram positive bacteremia, and respiratory failure with multiple failed extubations and expired at 3 years of age. Toll like receptors 2, 7, and 9 were normal. Several reports have implicated CMV in the pathogenesis of rare cases of ITP. Our previous study suggested that it was at most rarely involved in ITP (Levy, A., 2002; BJH). We describe three cases of refractory ITP associated with CMV. The presentations include severe symptomatic treatment-refractory ITP, fever of unknown origin, and transaminitis. Treatment with immunosuppressive medication may have worsened the CMV-ITP. All cases showed dramatic improvement in platelet counts within 1-2 weeks when ganciclovir and cytogam were instituted. The relationship between CMV and ITP may be explained by immune-mediated destruction of infected platelets or by direct infection of megakaryoblasts by cytomegalovirus(Xiao,Y., 2006). Based on these case reports we believe that CMV infection needs to be considered in cases of refractory ITP and antiviral therapy instituted when infection is identified.

Failed extubation in the neonatal intensive care unit

To determine the causes of failed extubation in the Neonatal Intensive Care Unit (NICU) and the need for airway intervention. Retrospective chart review. Tertiary care children's hospital. We identified all premature infants (gestational age <37 weeks) admitted to the NICU of a tertiary care children's hospital from January 1998 until December 2006 who underwent direct laryngoscopy and bronchoscopy (DLB) in the operating room (OR) for failed extubation. Data was collected on weight, gestational age, co-morbid conditions, number of failed extubations, findings at DLB and whether or not a tracheostomy was performed. DLBs were performed on 63 patients to evaluate the cause of failed extubation. Group A comprised of 50 patients who underwent tracheostomy. They had an average gestational age of 30.0 weeks, birth weight of 1457g and number of failed extubations 2.68. Group B consisted of 13 patients who did not undergo tracheostomy. They had an average gestational age of 34.5 weeks, birth weight of 2309g and number of failed extubations 1.33. 56.0% of the tracheostomy group and 38.5% of the non-tracheostomy group had chronic lung disease (CLD). At endoscopy, 44% of Group A and 23.1% of Group B had some degree of subglottic stenosis. Abnormal laryngotracheal findings are common in neonates who fail extubation. When compared to their counterparts with similar co-morbidities, neonates with CLD, gestational age of 30 weeks or below and low birth weight are twice as likely to have subglottic edema and fail extubation. They are also likely to be candidates for a tracheostomy.

The Air-Leak Test Is Not a Good Predictor of Postextubation Adverse Events in Children Undergoing Cardiac Surgery

The air-leak test is recommended as a method of assessing the appropriate size of an uncuffed endotracheal tube (ETT) in children. The authors' primary objective was to determine whether the air-leak test would predict adverse events and reintubations after the removal of the ETT in children who have undergone cardiac surgery. Prospective, observational, clinical study. University tertiary care hospital. Ninety-four children <10 years of age undergoing elective cardiac surgery requiring cardiopulmonary bypass surgery. The attending anesthesiologist assessed air-leak pressure after intubation in the operating room (OR). In addition, the air-leak test was performed in 42 patients before extubation in the pediatric intensive care unit (PICU). The incidence of adverse events and the number of failed extubations were recorded after removal of the ETT. Eleven of the 94 patients were excluded from the study. Four (4.3%) of the patients died in the PICU before extubation, and 7 patients were excluded for other reasons. The median age of the 83 children was 0.9 years (range 0.01-9.6 years). The total incidences of postextubation adverse events and failed extubations were 30.1% and 8.4%, respectively. An audible air leak < or =25 cmH(2)O airway pressure during the OR phase or before removal of the ETT during the PICU recovery phase had no significant predictive value for the incidence of adverse events (p = 0.63) or reintubations (p = 1.0). The patients undergoing simple and complete operations compared with more complex and incomplete operations had significantly fewer postextubation adverse events (p = 0.03). Neonates did not have a higher risk for postextubation adverse events (p = 0.64) or reintubations (p = 0.26) than older children. The air-leak test did not predict an increased risk for postextubation adverse events and reintubations in children undergoing elective congenital heart surgery.

Tracheostomy in Preterm Infants

To study the indications for and outcomes of tracheostomy in a population of preterm infants. Retrospective analysis of case records. Two university-affiliated tertiary care children's hospitals. Patients We identified premature infants who required tracheostomies from January 1, 1997, through January 31, 2001. Information on weight, gestational age, comorbid conditions, indication for tracheostomy, and outcomes was collected. Infants were divided by birth weight into group 1 (<1000 g; n = 19 [very low birth weight]) and group 2 (> or =1000 g; n = 14). Comorbid conditions were scored and a total score was calculated for each patient. Group 1 had a higher incidence of patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity. The incidence of congenital or genetic defects was equal in groups 1 and 2 (11 infants [58%] and 8 infants [57%], respectively). Group 1 had a higher average number of failed extubations (5.17 vs 3.18) and a higher oxygen requirement (48.7% vs 30.3%) compared with group 2. Weight at tracheostomy was essentially equal in groups 1 and 2 (3.6 vs 3.7 kg). Subglottic stenosis and laryngotracheomalacia were equally common findings in groups 1 and 2. The average comorbidity score for group 1 was higher than that for group 2 (6.7 vs 2.8). The most common indication for tracheostomy was ventilatory dependence (n = 24 [73%]), compared with airway obstruction (n = 6 [18%]) and pulmonary toilet (n = 3 [9%]). Overall, 6 patients (18%) had a complication related to the tracheostomy. Severity of pulmonary disease was the most significant factor associated with the need for tracheostomy in preterm infants. A tracheostomy can safely be performed in these infants with minimal morbidity.

Reducing Failed Extubations in the Intensive Care Unit

Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital. Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline. Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000). The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.