Hours Of Extubation Research Articles

Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes

ObjectivesThe study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes. MethodsA prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs). ResultsIn 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0). ConclusionsTracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.

The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic.

Objectives:To determine if ICU reorganization due to the coronavirus disease 2019 pandemic affected outcomes in critically ill patients who were not infected with coronavirus disease 2019.Design:This was a Before-After study, with coronavirus disease 2019-induced ICU reorganization as the intervention. A retrospective chart review of adult patients admitted to a reorganized ICU during the coronavirus disease 2019 surge (from March 23, 2020, to May 06, 2020: intervention group) was compared with patients admitted to the ICU prior to coronavirus disease 2019 surge (from January 10, 2020, to February 23, 2020: before group).Setting:High-intensity cardiac, medical, and surgical ICUs of a community hospital in metropolitan Missouri.PATIENTS:All patients admitted to the ICU during the before and intervention period were included. Patients younger than 18 years old and those admitted after an elective procedure or surgery were excluded. Patients with coronavirus disease 2019 were excluded.Interventions:None.Measurements and Main Results:We identified a total of 524 eligible patients: 342 patients in the before group and 182 in the intervention group. The 28-day mortality was 25.1% (86/342) and 28.6% (52/182), respectively (p = 0.40). The ICU length of stay, ventilator length of stay, and ventilator-free days were similar in both groups. Rates of patient adverse events including falls, inadvertent endotracheal tube removal, reintubation within 48 hours of extubation, and hospital acquired pressure ulcers occurred more frequently in the study group (20 events, 11%) versus control group (12 events, 3.5%) (p = 0.001).Conclusions:Twenty-eight-day mortality, in patients who required ICU care and were not infected with coronavirus disease 2019, was not significantly affected by ICU reorganization during a pandemic.

Vocal Fold Mobility Impairment After Cardiovascular Surgery: Incidence, Risk Factors, and Sequela

We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes. This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed. Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05). Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes.

YOU HAD STRIDOR FOR HOW LONG? IT'S TIME WE DO SOMETHING ABOUT IT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post-extubation stridor is defined as inspiratory stridor occurring within 24 hours of extubation. It is associated with significant morbidity and mortality related to re-intubation, prolonged duration of mechanical ventilation, and longer length of ICU stay (3). The same complications are increased in those undergoing unplanned extubation (1). The rapid onset of stridor following extubation is usually caused by vocal cord edema and presents within hours of extubation (2). There are few published reports describing stridor secondary to tracheal stenosis. The objective of this report is to describe the unique etiology of post-extubation stridor related to tracheal stenosis. CASE PRESENTATION: In this case report, we describe a 70-year-old male with a past medical history of asthma, liver cirrhosis, CKD, COPD, obstructive sleep apnea, peripheral vascular disease, dyslipidemia, DM, HTN and GERD presenting with increasing shortness of breath and orthopnea for the past week. 3 months prior he was intubated for a severe COPD exacerbation. He then had to undergo unplanned extubation and re-intubation due to a mucous plug causing respiratory arrest and atrial fibrillation with a rapid ventricular response. During his current emergency department visit the patient was found to have significant respiratory distress and stridor on examination. The audible stridor was notably worse on inspiration but present on both phases of the respiratory cycle indicating a fixed intrathoracic obstruction. Objective data included: tachypnea (27 breaths/min) and hypotension (69/33) which resolved after placing patient on a nasal cannula at 2L/min and giving a fluid challenge. Labs revealed a leukocytosis (12.0 x10(3)/mcL Chest x-ray was unremarkable except for some hyperinflation of the lungs. Narrowing of the subglottic trachea to 5 mm along an 8 mm segment was visualized on CT of soft tissues of the neck. A balloon dilation via fiberoptic bronchoscopy was attempted but results were deemed unsuccessful. As a result, the patient was transferred to an accepting facility where he underwent an uncomplicated tracheal resection. DISCUSSION: Traumatic extubation is associated with significant mortality and morbidity in critically ill patients. Post-extubation stridor is also associated with poor outcomes. The patient, in this report, experienced a traumatic extubation and had an unusual presentation of stridor and respiratory distress that became critical 3 months following extubation. This presentation was unique in that the patient attributed his “mild symptoms” post-extubation to COPD. CONCLUSIONS: It is critical to establish proper follow-up with patient’s PCP following extubation to monitor for complications. Reference #1: Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161:1912. Reference #2: Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth. 1993;71:561–568. doi: 10.1093/bja/71.4.561 Reference #3: Schnell D, Planquette B, Berger A, et al. Cuff Leak Test for the Diagnosis of Post-Extubation Stridor. J Intensive Care Med 2017; :885066617700095. DISCLOSURES: No relevant relationships by Rafael Otero, source=Web Response No relevant relationships by Abaigeal Thompson, source=Web Response

PREEXISTING CHRONIC LIVER DISEASE AS AN INDEPENDENT RISK FACTOR REINTUBATION IN MECHANICALLY VENTILATED PATIENTS

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Hepatic functional status is not routinely considered a risk factor for ventilation liberation failure. We wanted to evaluate the impact of chronic liver disease (CLD) on the risk of reintubation after mechanical ventilation for ≥ 24 hours. METHODS: We queried the Medical Information Mart for Intensive Care database (MIMIC-III) for adult patients admitted to intensive care and mechanically ventilated for ≥ 24 hours. Data for 8,521 patient was analyzed, 623 had existing CLD and 7898 had no underlying liver abnormality. Only the first intubation for the hospital stay was included, and patient who underwent tracheotomy or terminal extubation were excluded. We identified underlying liver disease using International Classification of Diseases, 9th revision and clinical modification (ICD-9-CM) codes, we compared the means using unpaired t-test, and carried out logistic regression analysis after adjustment for Charlson Comorbidity Index. RESULTS: The mean age of patents receiving mechanical ventilation (MV) without underlying chronic liver disease was 72.1 years 95% CI [71, 73.2], the mean age of patients with CLD receiving MV was 57.1 years, 95% CI [55.5, 58.7], p < 0.001. 54.5% patient were men in the non-CLD sample and 66.1% were men in the CLD sample. The mean duration of ventilation was 7.12 days, 95% CI [6.94, 7.3] in the non-CLD sample vs 6.83 days, 95% CI [6.29, 7.37] in the CLD sample, p = 0.40. The mean length of ICU stay for non-CLD patient was 10.42 days, 95% CI [10.2, 10.6] in comparison for CLD patients was 10.2 days, 95% CI [9.52, 10.9] p = 0.59. 25.1% died during their hospital stay in the non-CLD cohort vs. 37.8% in the CLD cohort, adjusted OR 1.82, 95 % CI [1.53, 2.15]. Of the 7898 non-CLD patients undergoing mechanical ventilation 1488 were reintubated within 72 hours (18.8%), of the 623 CLD patients undergoing mechanical ventilation 144 (23.1%) were reintubated within 72 hours, adjusted OR 1.3 95 % CI [1.06, 1.57], p = 0.009. CONCLUSIONS: Patient having underlying chronic liver disease undergoing mechanical ventilation were younger in age, and had a higher in hospital mortality compared to general population receiving mechanical ventilation without underlying liver disease. Patient with chronic liver disease were 1.3 times more likely to get reintubated within 72 hours of extubation compared to patients without underlying liver abnormality. The mean duration of ventilation and mean ICU length of stay was not significantly different in the two samples. CLINICAL IMPLICATIONS: Underlying chronic liver disease should be accounted as an independent risk factor for reintuabtion in mechanically ventilated patients. DISCLOSURES: No relevant relationships by Muhammad Sameed, source=Web Response No relevant relationships by Muhammad Waleed, source=Web Response No relevant relationships by Jennie Zhang, source=Web Response

The Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory Failure Survivors.

To determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure. Prospective cohort study. ICUs at four academic tertiary care medical centers. Two hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled. Within 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians. For each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02). Larger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

Extubation Failure and Major Adverse Events Secondary to Extubation Failure Following Neonatal Cardiac Surgery.

To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. A single-center cohort study. A medical-surgical, 30-bed PICU in Victoria, Australia. One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. None. Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest (n = 10), chest reopening (n = 8), extracorporeal membrane oxygenation (n = 5), and death (n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction (n = 3), pulmonary overcirculation (n = 2), coronary ischemia (n = 2), cardiac tamponade (n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9; 95% CI: 1.1-32.2) and airway anomaly (odds ratio 6.0; 95% CI: 1.1-32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.

FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care

IntroductionEven though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive...

Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects.

In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center. Quality improvement project. High volume cardiac center, tertiary care children's hospital. Neonates undergoing Norwood operation. The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients. One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02). This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit.

IntroductionExtubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting.MethodsWe conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed.ResultsWe identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU.ConclusionSelect ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

510 Incidence of Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing` Factors

Abstract Introduction Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount to patient selection. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices used in critical care do not accurately predict extubation outcome in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of inhalation injury, as well as other factors, on extubation outcome. Methods Burn patients from a single center over the period 2009–2017 were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. Patients were excluded if they proceeded directly to tracheostomy, died prior to extubation, or experienced an unintentional extubation. From this cohort, a matched case-control analysis based on age, TBSA and gender was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours of extubation, to those who failed. Characteristics and clinical parameters were compared between these two groups to determine if any factor(s) could predict extubation failure. Results A 12.3% incidence of extubation failure was found in our cohort of 106 burn patients. In the matched case-control analysis of 48 extubation successes and 58 extubation failures, the presence of inhalation injury was surprisingly associated with extubation success as was a higher PaO2:FiO2 ratio immediately prior to extubation. Higher heart rate and lower serum pH was associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Conclusions Classic extubation criteria do not accurately predict extubation outcome in burn patients; analysis of other characteristics and clinical parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively. Applicability of Research to Practice Defining a constellation of parameters that can aid in identifying those at high risk of extubation failure could change practice.

Predictors of Success of Immediate Tracheal Extubation in Living Donor Liver Transplantation Recipients

Abstract Background Early tracheal extubation of recipients following liver transplantation (LT) has been promoted and gradually replacing standard postoperative prolonged mechanical ventilation, possibly contributing to better graft and patient survival and reduced costs. There are no universally accepted predictors of success of immediate extubation in LT recipients. We hypothesized a number of factors as predictors of successful immediate tracheal extubation in living donor liver transplantation (LDLT) recipients. Aim The aim of this study was to evaluate the validity of the following hypothesized factors: Model for end stage liver disease (MELD) score, duration of surgery, number of intraoperatively transfused packed red blood cells (RBCs) units and end of surgery (EOS) serum lactate, as predictors of success of immediate tracheal extubation in living donor liver transplantation (LDLT) recipients. Methods In this prospective clinical trial, perioperative data of adult LDLT recipients were recorded. “Immediate extubation” was defined as tracheal extubation immediately and up to 1 hour postransplant in the operating room. Patients were divided into; extubated group who were successfully extubated with no need for reintubation, and non-extubated group who failed to meet criteria of extubation or were re-intubated within 4 hours of extubation. Results Of 64 patients, 50 (76.9%) were extubated early after LDLT while 14 (23.07%) were transported to the intensive care unit (ICU) intubated. After data analysis, it was found that EOS serum lactate, duration of surgery and number of packed RBCs units transfused intraoperatively, were good predictors of success of immediate extubation, while MELD scores had no statistically significant impact on the results. In addition, other factors such as EOS urine output and pH were shown to have significantly affected the results. Conclusions EOS serum lactate, duration of surgery and number of packed RBCs units transfused were predictors of post-transplant early extubation.

Incidence, Predictors, and Adverse Outcomes of Extubation Failure in Young Children with Isolated Traumatic Brain Injury: A Prospective Observational Study

Abstract Background Mechanical ventilation is a life-saving mainstay of therapy in pediatric patients with isolated traumatic brain injury (iTBI). Because of the numerous complications and side effects associated with tracheal intubation, it is prudent to remove it as early as possible. Extubation failure and reintubation, however, are also associated with significant risks. Till date, there has been no comprehensive study on extubation failure in pediatric patients less than 5 years with iTBI. Materials and Methods A prospective observational study was conducted in the trauma intensive care unit (TICU) of a tertiary care center. All the children with iTBI, aged 0 to 5 years, on mechanical ventilation for more than 24 hours, admitted to the TICU were included. Extubation failure was defined as the need for reintubation occurring within 24 hours of extubation. Only the first attempt at extubation was included in the analysis. Results Pre-extubation paO2/FiO2 ratio &lt; 310 mm Hg is a predictor for extubation failure. Mean base deficit postextubation were found to be 2 ± 0.9 and –0.2 ± 1 (p = 0.00) between success and failure groups, respectively. Similarly, postextubation systolic blood pressure was also high in the failure group than in the success group (113.8 ± 10.4 vs. 100.5 ± 7.4; p = 0.00). Conclusions The incidence of first attempt extubation failure was 62.5%. Lower values of pre-extubation paO2/FiO2 ratio (ratio &lt; 310 mm Hg) are a predictor for extubation failure. Developing predictive tools and optimizing extubation decisions lead to timely identification of patients at elevated risk of extubation failure.

LUNG ULTRASOUND SCORE BEFORE AND AFTER EXTUBATION FOR PREDICTING WEANING OUTCOME

Background: Lung ultrasound (LUS) is an emerging, essential, safe and easily repeatable bed­side tool being used for the management of critically ill patients in ICUs. Weaning off the ventilator and decide to extubate require right decision and appropriate timing to avoid ex­tubation failure. The study aimed to perform LUS in planned extubation patients who passed SBT, for the assessment of lungs, before and after extubation.&#x0D; Methods: A single-centre, observational study at medical ICU of a tertiary level hospital in Nepal was conducted on invasive mechanically ventilated patients. LUS was performed be­fore extubation on those who were planned to extubate and repeat scan done after 24 hours of extubation. LUS scores were calculated at both times. p-value 0.05 was considered statisti­cally significant.&#x0D; Results: Twenty-eight patients were included after passing spontaneous breathing trial (SBT), one patient had extubation failure. Mean LUS score before and after extubation came to be 16.15 ± 7.00 and 13.15 ± 4.59 respectively with high degree of correlation (Pearson’s r = 0.896, P &lt;0.001). The mean difference in LUS scores before and after extubation was signifi­cant (Mean difference: 3.00 ± 3.54, t = 4.402, p &lt; 0.001).&#x0D; Conclusions: Lung ultrasound is very useful additive tool in predicting extubation failure eas­ily and timely. Its use after extubation also helps in early prediction of post-extubation failure by assessing aeration changes and other lung pathology.

Lung ultrasound score before and after extubation for predicting weaning outcome

Background: Lung ultrasound (LUS) is an emerging, essential, safe and easily repeatable bed­side tool being used for the management of critically ill patients in ICUs. Weaning off the ventilator and decide to extubate require right decision and appropriate timing to avoid ex­tubation failure. The study aimed to perform LUS in planned extubation patients who passed SBT, for the assessment of lungs, before and after extubation.&#x0D; Methods: A single-centre, observational study at medical ICU of a tertiary level hospital in Nepal was conducted on invasive mechanically ventilated patients. LUS was performed be­fore extubation on those who were planned to extubate and repeat scan done after 24 hours of extubation. LUS scores were calculated at both times. p-value 0.05 was considered statisti­cally significant.&#x0D; Results: Twenty-eight patients were included after passing spontaneous breathing trial (SBT), one patient had extubation failure. Mean LUS score before and after extubation came to be 16.15 ± 7.00 and 13.15 ± 4.59 respectively with high degree of correlation (Pearson’s r = 0.896, P &lt;0.001). The mean difference in LUS scores before and after extubation was signifi­cant (Mean difference: 3.00 ± 3.54, t = 4.402, p &lt; 0.001).&#x0D; Conclusions: Lung ultrasound is very useful additive tool in predicting extubation failure eas­ily and timely. Its use after extubation also helps in early prediction of post-extubation failure by assessing aeration changes and other lung pathology.

Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation

Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear. To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation. This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded. Invasive mechanical ventilation via an endotracheal tube. The incidence of UVFI as determined by flexible nasolaryngoscopy. One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI. Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.

Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery.

Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function. Prospective observational cohort study. Montreal Heart Institute, an academic cardiac surgery center in Canada. Adults undergoing nonemergency cardiac surgery. We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei-Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr). Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31-45%] vs 44% [interquartile range, 33-58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81-13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not. A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.

Negative Pressure Pulmonary Edema: A Case Report

Aim: Negative pressure pulmonary edema (NPPE) is a rare postoperative complication that arises due to upper airway obstruction and appears within an hour of extubation. Case: The patient was a 19 years-old male with no chronic diseases or complaints in his preoperative assessment. Forty-five minutes after extubation, the patient reported dyspnea, hemoptysis, chest pain and oxygen saturation was 60%. Computer Tomography (CT) scans revealed bilateral infiltration and consolidation, more prominent in the central and apical regions. His bedside echocardiogram was normal. NPPE was considered in the diagnosis; oxygen support, intravenous furosemide, nebulized salbutamol and budosenide were administered in addition to non-invasive mechanical ventilation. Two hours later, the symptoms abated. His repeat X-ray taken after 12 hours showed reduction in lung infiltrates and patient was discharged after five days. Conclusion: Abrupt decrease in oxygen saturation after extubation, dyspnea, chest pain and hemoptysis point to negative pressure pulmonary edema; the patient must immediately be moved to the intensive care unit and promptly treated.

Early decongestive therapy versus high-flow nasal cannula for the prevention of adverse clinical events in patients with acute cardiogenic pulmonary edema.

Few studies have investigated the role of decongestive therapy and high-flow nasal cannula (HFNC) in preventing reintubation and in-hospital mortality in patients with acute cardiogenic pulmonary edema (ACPE). Data from patients with ACPE who were weaned from mechanical ventilation in the cardiac intensive care unit between January 2013 and December 2017 were retrospectively evaluated. All patients were treated with HFNC or conventional oxygen therapy (COT), such as a nasal cannula or venturi mask, immediately after extubation. Decongestive therapy (intravenous furosemide infusion) was administered at the discretion of the attending physician. Of 212 patients treated during the study period, 47 were excluded due to recent open-heart surgery and two, due to insufficient clinical data. The remaining 163 patients had a mean age of 67.4±14.3 years, and 92 (56.4%) were male; 44 patients received HFNC, and 119 COT. Mean weight loss within 72 hours of extubation was -0.86±2.03 kg. A total of 38 patients (23.3%) required reintubation, 21 of whom (12.9%) required reintubation within 72 hours of extubation. In-hospital mortality occurred in 16 patients (9.8%). Multivariate analysis showed that weight increase within 72 hours of extubation was independent determinants of reintubation (OR =1.7; 95% CI: 1.2-2.2; P<0.001) and in-hospital mortality (OR =1.5; 95% CI: 1.1-2.1; P=0.005). The use of HFNC was not associated with reintubation or in-hospital mortality. Our findings indicate that early weight loss resulted in reduced reintubation and in-hospital mortality in patients with ACPE. However, HFNC and COT did not differ in the prevention of reintubation and in-hospital mortality. Therefore, aggressive decongestive therapy, rather than HFNC, should be considered early after extubation.

Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review.

BackgroundUse of a high-flow nasal cannula (HFNC) reduced postextubation respiratory failure (PERF) and reintubation rate compared to use of a low-flow oxygen system (LFOS) in low-risk patients. However, no obvious conclusion was reached for high-risk patients. Here, we sought to present the current status of HFNC use as adjunctive oxygen therapy in a clinical setting and to elucidate the nature of the protective effect following extubation.MethodsThe medical records of 855 patients who were admitted to the intensive care unit of single university hospital during a period of 5.5 years were analyzed retrospectively, with only 118 patients ultimately included in the present research. The baseline characteristics of these patients and the occurrence of PERF and reintubation along with physiologic changes were analyzed.ResultsEighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of high-risk features including old age, neurologic disease, moderate to severe chronic obstructive pulmonary disease, a long duration of mechanical ventilation, low baseline arterial partial pressure of oxygen to fraction of inspired oxygen ratio, and a high baseline alveolar–arterial oxygen difference. The reintubation rate at 72 hours after extubation was not different (9.5% vs. 8.8%; P=1.000). Hypoxic respiratory failure was slightly higher in the nonreintubation group than in the reintubation group (31.9% vs. 6.7%; P=0.058). Regarding physiologic effects, heart rate was only stabilized after 24 hours of extubation in the HFNC group.ConclusionsNo difference was found in the occurrence of PERF and reintubation between both groups. It is worth noting that similar PERF and reintubation ratios were shown in the HFNC group in those with certain exacerbating risk factors versus not. Caution is needed regarding delayed reintubation in the HFNC group.