Extubation Failure Rate Research Articles

Protocol-directed weaning versus conventional weaning from mechanical ventilation for neurocritical patients in an intensive care unit: a nonrandomized quasi-experimental study.

To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group.ClinicalTrials.gov Registry: NCT03128086.

Fitness checklist model for spontaneous breathing tests in pediatrics.

To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Modelo de checklist de aptidão para teste de respiração espontânea em pediatria

OBJECTIVE: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. METHODS: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. RESULTS: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. CONCLUSION: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Extubation failure and the use of noninvasive ventilation during the weaning process in critically ill COVID-19 patients.

To assess the outcome of extubation in COVID-19 patients and the use of noninvasive ventilation in the weaning process. This retrospective, observational, single-center study was conducted in COVID-19 patients aged 18 years or older who were admitted to an intensive care unit between April 2020 and December 2021, placed under mechanical ventilation for more than 48 hours and progressed to weaning. Early extubation was defined as extubation without a spontaneous breathing trial and immediate use of noninvasive ventilation after extubation. In patients who underwent a spontaneous breathing trial, noninvasive ventilation could be used as prophylactic ventilatory assistance when started immediately after extubation (prophylactic noninvasive ventilation) or as rescue therapy in cases of postextubation respiratory failure (therapeutic noninvasive ventilation). The primary outcome was extubation failure during the intensive care unit stay. Three hundred eighty-four extubated patients were included. Extubation failure was observed in 107 (27.9%) patients. Forty-seven (12.2%) patients received prophylactic noninvasive ventilation. In 26 (6.8%) patients, early extubation was performed with immediate use of noninvasive ventilation. Noninvasive ventilation for the management of postextubation respiratory failure was administered to 64 (16.7%) patients. We found that COVID-19 patients had a high rate of extubation failure. Despite the high risk of extubation failure, we observed low use of prophylactic noninvasive ventilation in these patients.

Descriptors of Failed Extubation in Norwood Patients Using Physiologic Data Streaming

The objective of this study is to evaluate the utility of high-frequency physiologic data during the extubation process and other clinical variables for describing the physiologic profile of extubation failure in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure. This is a single-center, retrospective analysis. Extubation events were collected from January 2016 until July 2021. Extubation failure was defined as the need for re-intubation within 48h of extubation. The data included streaming heart rate, respiratory rate, blood pressure, arterial oxygen saturation, and cerebral/renal near-infrared spectroscopy (NIRS). The most recent blood laboratory results before extubation were also included. These markers, demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations. The analysis included 311 extubations. The extubation failure rate was 10%. According to univariable analyses, failed extubations were preceded by higher respiratory rates (p = 0.029), lower end-tidal CO2 (p = 0.009), lower pH (p = 0.043), lower serum bicarbonate (p = 0.030), and lower partial pressure of O2 (p = 0.022). In the first 10min after extubation, the failed events were characterized by lower arterial (p = 0.028) and cerebral NIRS (p = 0.018) saturations. Failed events were associated with persistently lower values for cerebral NIRS 2h post-extubation (p = 0.027). In multivariable analysis, vocal cord anomaly, cerebral NIRS at 10min post-extubation, renal NIRS at pre-extubation and post-extubation, and end-tidal CO2 at pre-extubation remained as significant co-variables. Oximetric indices before, in the 10min immediately after, and 2h after extubation and vocal cords paralysis are associated with failed extubation events in patients with parallel circulation.

Comprehensive breathing variability indices enhance the prediction of extubation failure in patients on mechanical ventilation

Background and objectiveDespite the numerous studies on extubation readiness assessment for patients who are invasively ventilated in the intensive care unit, a 10–15% extubation failure rate persists. Although breathing variability has been proposed as a potential predictor of extubation failure, it is mainly assessed using simple statistical metrics applied to basic respiratory parameters. Therefore, the complex pattern of breathing variability conveyed by continuous ventilation waveforms may be underexplored. MethodsHere, we aimed to develop novel breathing variability indices to predict extubation failure among invasively ventilated patients. First, breath-to-breath basic and comprehensive respiratory parameters were computed from continuous ventilation waveforms 1 h before extubation. Subsequently, the basic and advanced variability methods were applied to the respiratory parameter sequences to derive comprehensive breathing variability indices, and their role in predicting extubation failure was assessed. Finally, after reducing the feature dimensionality using the forward search method, the combined effect of the indices was evaluated by inputting them into the machine learning models, including logistic regression, random forest, support vector machine, and eXtreme Gradient Boosting (XGBoost). ResultsThe coefficient of variation of the dynamic mechanical power per breath (CV-MPd[J/breath]) exhibited the highest area under the receiver operating characteristic curve (AUC) of 0.777 among the individual indices. Furthermore, the XGBoost model obtained the best AUC (0.902) by combining multiple selected variability indices. ConclusionsThese results suggest that the proposed novel breathing variability indices can improve extubation failure prediction in invasively ventilated patients.

886: EXTUBATION OUTCOMES: CALCULATED RISK OR LUCK OF THE DRAW?

Introduction: Prolonged mechanical ventilation is associated with longer hospitalization and higher mortality rates. Minimizing intubation duration is key in preventing such complications. Many factors have been assessed to predict the outcome of extubation, including Rapid Shallow Breathing Index (RSBI), Spontaneous Breathing Trial, and cough strength but 10-29% of patients who met these criteria still experience reintubation. Although there are no clear definitions of extubation failure, generally it is defined as required reintubation within 48 hours of a planned extubation. This study aims to address the extubation failure rate at Louisiana State University Health Shreveport hospital and provide insight on what patient characteristics were associated with failed extubation outcomes. Methods: A retrospective observational cohort study of intubated patients from 7/2020 – 4/2022 was conducted. Patient characteristics, hospitalization duration, reason for reintubation, oxygen requirements and disposition were recorded. Results: A total of 725 patients were intubated during the study. The most common indication for intubation was airway protection, surgical intervention and respiratory distress. Twenty-eight patients required reintubation in less than 48 hours and met our criteria for extubation failure. The reintubation rate was 3.8%. Approximately 54% of patients were male with average age of 62 years old. Average time to extubation failure was less than 24 hours. Average RSBI prior to extubation was reported as 59.75 with 8% of patients having a successful T-piece trial. The main cause of reintubation was airway protection. Out of the 28 subjects, 12 underwent tracheostomy after reintubation. The mortality rate in this study was 14% among patients who had extubation failure. Conclusions: Extubation failure is associated with an increase in the duration of mechanical ventilation, greater need for tracheostomy and higher mortality rate. Average reintubation rate or extubation failure rate is 10-20%. Lack of standardized practice for predicting extubation outcomes or standardized definitions of extubation failure puts patients at risk of intubation complications and death. Multicentered prospective studies are required for the development of standardized extubation practices to improve patient outcomes.

986: HOW ARE WE OVERSEDATING OUR MECHANICALLY VENTILATED PATIENTS IN THE MICU AT A TERTIARY CARE CENTER?

Introduction: Endotracheal intubation and invasive mechanical ventilation are distressing interventions in the Medical Intensive care Unit (MICU). Mechanically ventilated patients often receive analgesic and sedative medications to reduce agitation and pain. According to recommendations in the Society of Critical Care (SCC) PADIS guidelines, sedatives should be used only when pain and delirium have been addressed with specific pharmacologic and non-pharmacologic strategies. Despite this, we observe that many mechanically ventilated MICU patients are sedated on a routine basis without any clear indication. Methods: We performed a retrospective medical chart review of patients above 18 years of age who were intubated for more than 24 hours between January 2020 till October 2021. We analyzed indications for intubation and excluded patients requiring a deep level of sedation from the final study sample. We analyzed the type and number of sedatives initiated in the first 24 hours of intubation, associated RASS parameters set for sedation titration and its monitoring frequency by nurses, and the effect of our practices on intubation and hospitalization outcomes. Statistical analysis was performed using SPSS and SAS. Results: Of the 281 patients, 83% received fentanyl, 66% received propofol or dexmedetomidine, and 33% received midazolam in the first 24 hours. About 53% and 11% of patients were simultaneously started on a 2- and 3-agents sedative regimen in the first 24 hours, respectively. The most common upper and lower RASS limits for sedation titration were set at 0 and -3, respectively. The average frequency of nurses’ RASS documentation was once every 10 hours. There was a positive correlation between the number of sedative agents used in the first 24 hours and the associated length of intubation, hospitalization, and extubation failure. Furthermore, the use of benzodiazepine led to a higher rate of extubation failure, length of intubation, and hospitalization. Conclusions: In the absence of clear medical indication for deep sedation and appropriate sedation administration and titration parameter protocol, the indiscriminate use of sedatives leads to poor patient outcomes. There is a dire need to implement sedation protocols in institutions to standardize practices and improve sedation performance metric.

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

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

Pediatric Ventilation Liberation: Bundled Extubation Readiness and Analgosedation Pathways Decrease Mechanical Ventilation Duration and Benzodiazepine Exposure.

Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration. This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways. In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; P = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; P = .42). No difference in unplanned extubation (P > .99) or extubation failure rates (P = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; P = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; P < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; P = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; P = .14) was demonstrated. A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.

Ventilation Liberation Practices Among 380 International PICUs.

OBJECTIVES:1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes.DESIGN:International cross-sectional study.SUBJECTS:Nontrainee pediatric medical and cardiac critical care physicians.SETTING:Electronic survey.INTERVENTION:None.MEASUREMENTS AND MAIN RESULTS:Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3–10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%).CONCLUSIONS:Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.

Extubation Failure in Infants with Modified Blalock-Taussig Shunt: The Incidence, Predictors, and Outcomes

Infants with congenital heart diseases often require mechanical ventilation and a prolonged intensive care unit (ICU) stay due to complex cardiopulmonary complications. The primary objective of the study was to determine the incidence and predictors of tracheal extubation failure in infants undergoing modified Blalock-Taussig shunt (MBTS). The secondary objective was to evaluate if extubation failure was associated with increased mortality and longer ICU and hospital stays. Single-center, retrospective, cohort study. Tertiary center pediatric cardiac ICU. Infants who underwent MBTS between January 2010 and December 2019. None. The demographic data and details related to the preoperative, intraoperative, and pretracheal extubation clinical conditions in the ICU were compared between the 2 study arms. Statistically significant predictors were analyzed using multivariate analysis. The p value was based on the Student's -t test for continuous variables and the chi-square test for categorical variables. A total of 146 infants were recruited for the study. Extubation failure occurred in 27 infants (18.5%), resulting in longer ICU and hospital stays. Extubation failure was deemed to be positively associated with preoperative mechanical ventilation duration, the need for escalation of the inotropic score, diaphragmatic paralysis, and systolic blood pressure ≤50th percentile at the time of extubation. The incidence rate of extubation failure after placement of MBTS was 18.5%. Preoperative mechanical ventilation, diaphragmatic paralysis, the need for escalation of the inotropic score, and systolic blood pressure ≤50th percentile could be considered predictors of extubation failure in these infants.

Risk factors and outcomes of extubation failure in a South African tertiary paediatric intensive care unit.

Background Extubation failure contributes to poor outcome of mechanically ventilated children, yet the prevalence and risk factors have been poorly studied in South African (SA) children. Objectives To determine the prevalence, risk factors and outcomes of extubation failure in an SA paediatric intensive care unit (PICU). Methods This was a prospective, observational study of all mechanically ventilated children admitted to a tertiary PICU in Cape Town, SA. Extubation failure was defined as requiring re-intubation within 48 hours of planned extubation. Results There were 219 episodes of mechanical ventilation in 204 children (median (interquartile range (IQR)) age 8 (1.6 - 44.4) months). Twenty-one of 184 (11.4%) planned extubations (95% confidence interval (CI) 7.2% - 16.9%) failed. Emergency cardiac admissions (adjusted odds ratio (aOR) 7.58 (95% CI 1.90 - 30.29), dysmorphology (aOR 4.90; 95% CI 1.49 - 16.14), prematurity (aOR 4.39; 95% CI 1.24 - 15.57), and ventilation ≥48 hours (aOR 6.42 (95% CI 1.57 - 26.22) were associated with extubation failure. Children who failed extubation had longer durations of ventilation (231 hours (146.0 - 341.0) v. 53 hours (21.7 - 123.0); p<0.0001); longer duration of PICU (15 (9 - 20) days v. 5 (2 - 9) days; p<0.0001) and hospital length of stay (32 (21 - 53) days v. 15 (8 - 27) days; p=0.009); and higher 30-day mortality (28.6% v. 6.7%; p=0.001) than successfully extubated children. Conclusion Extubation failure was associated with significant morbidity and mortality in our setting. Risk factors for extubation failure identified in our context were similar to those reported in other settings. Contributions of the study This study provides novel data on the prevalence, risk factors and outcomes associated with extubation failure in a single-centre South African PICU. The results of this study may help identify high-risk groups for extubation failure within our local context, and forms a basis for practice improvement initiatives aimed at decreasing extubation failure rates and improving outcomes.

Respiratory Therapist-Driven Extubation Readiness Testing in a Single Pediatric ICU.

There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness. We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams. Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], P = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], P = .74) and duration of mechanical ventilation (2 [1-7] d vs 1 [1-3] d, P = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3-10] d vs 3 [1-6] d, P = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable. An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.

Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study.

Mechanical ventilation is often used in children after cardiac surgery but can impair hemodynamics and cause lung injury. Early extubation may improve ICU length of stay and survival. We aimed to describe trends in early extubation rates and evaluate if centers that more commonly practice early extubation have better severity-adjusted outcomes. Retrospective analysis was performed of admissions in the Virtual Pediatric Systems (VPS, LLC) database from 2009 to 2018. Early extubation was defined as patients extubated in the operating room or within 6 hours of PICU admission. PICUs participating in the VPS database. Children in the VPS database who underwent cardiac surgery. None. Among 69,739 subjects, 20% were neonates, 47% underwent early extubation, 5.3% failed extubation, and 2.5% died. Overall, early extubation rates did not change over the study period. Centers were placed in one of four groups based on their early extubation rate in lower complexity surgeries. Centers that most commonly used early extubation had more ICU-free time among all patients in univariable analysis (lowest early extubation group, 23.8 d [interquartile range, 18.2-25.9 d]; highest early extubation group, 24.7 d [20.0-26.2 d]; p < 0.001). After adjusting for center volume, sex, age, surgical complexity, and preoperative ICU admission, increasing center-level early extubation rates were not associated with more ICU-free days. Higher center-level early extubation rate was not associated with mortality in univariable or multivariable analysis but was associated with decreased extubation failure rate (lowest early extubation group, 6.4%; highest early extubation group, 3.6%; p < 0.001). In this large, multicenter database study, early extubation rates in postoperative cardiac patients did not significantly change between 2009 and 2018. Centers that performed early extubation more frequently did not have shorter ICU stays or difference in mortality rates but did have lower reintubation rates.

Predictive Factors of Extubation Failure in COVID-19 Mechanically Ventilated Patients.

Purpose: We investigated whether COVID-19 patients on mechanical ventilation (MV) had a different extubation outcome compared to non-COVID-19 patients while identifying predictive factors of extubation failure in the former. Methods: A retrospective, single-center, and observational study was done on 216 COVID-19 patients admitted to an intensive care unit (ICU) between March 2020 and March 2021, aged ≥ 18 years, in use of invasive MV for more than 24 h, which progressed to weaning. The primary outcome that was evaluated was extubation failure during ICU stay. A statistical analysis was performed to evaluate the association of patient characteristics with extubation outcome, and a Poisson regression model determined the predictive value. Results: Seventy-seven patients were extubated; the mean age was 57.2 years, 52.5% were male, and their mean APACHE II score at admission was 17.8. On average, MV duration until extubation was 8.7 ± 3.7 days, with 14.9 ± 10.1 days of ICU stay and 24.6 ± 14.0 days with COVID-19 symptoms. The rate of extubation failure (ie, the patient had to be reintubated during their ICU stay) was 22.1% (n = 17), while extubation was successful in 77.9% (n = 60) of cases. Failure was observed in only 7.8% of cases when evaluated 48 hours after extubation. The mean reintubation time was 4.28 days. After adjusting the analysis for age, sex, during of symptoms, days under MV, dialysis, and PaO2/FiO2 ratio, some parameters independently predicted extubation failure: age ≥ 66 years (APR = 5.12 [1.35-19.46]; p = 0.016), ≥ 31 days of symptoms (APR = 5.45 [0.48-62.19]; p = 0.016), and need for dialysis (APR = 5.10 [2.00-13.00]; p = 0.001), while a PaO2/FiO2 ratio >300 decreased the probability of extubation failure (APR = 0.14 [0.04-0.55]; p = 0.005). The presence of three predictors (ie, age ≥ 66 years, time of symptoms ≥ 31 days, need of dialysis, and PaO2/FiO2 ratio < 200) increased the risk of extubation failure by a factor of 23.0 (95% CI, 3.34-158.5). Conclusion: COVID-19 patients had an extubation failure risk that was almost three times higher than non-COVID-19 patients, with the extubation of the former being delayed compared to the latter. Furthermore, an age ≥ 66 years, time of symptoms ≥ 31 days, need of dialysis, and PaO2/FiO2 ratio > 200 were independent predictors for extubation failure, and the presence of three of these characteristics increased the risk of failure by a factor of 23.0.

Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial

BackgroundPost-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA. Materials and methodsWe enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups. ResultsThe prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation. ConclusionThe use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates.

Bi-level Positive Airway Pressure Versus Nasal CPAP for the Prevention of Extubation Failure in Infants After Cardiac Surgery.

Extubation early in the postoperative period is beneficial to the recovery and rehabilitation of patients. This study compared the postoperative extubation failure rates among infants who received postextubation respiratory support by either bi-level positive airway pressure (BPAP) or nasal CPAP following cardiac surgery. This was a single-center randomized controlled trial registered at the Chinese Clinical Trial Registry (number ChiCTR2000041453) and was conducted between January 2020 and March 2021. Ventilated infants who underwent cardiac surgery were randomized to either a BPAP or a nasal CPAP group for ventilatory support following extubation. The primary outcome measure was the extubation failure rate within 48 h. The analyses included 186 subjects. Treatment failure necessitating re-intubation was noted in 14 of the 93 infants (15%) in the BPAP group and in 11 of the 93 infants (12%) in the nasal CPAP group (P = .52). Moreover, there were no statistically significant differences between the 2 groups regarding the duration of noninvasive ventilation (P = .54), total enteral feeding time (P = .59), or complications (P = .85). We found that both the BPAP group and the nasal CPAP group showed significantly improved oxygenation and relief of respiratory distress after treatment. However, the PaCO2 level within 24 h was significantly lower in the BPAP group (P = .001) than in the CPAP group. Additionally, the PaO2 /FIO2 in the BPAP group was significantly higher than in the nasal CPAP group at 6 h, 12 h, and 24 h after treatment (P < .001). The introduction of BPAP for postextubation respiratory support was not inferior to nasal CPAP in infants after cardiac surgery. Moreover, BPAP was shown to be superior to nasal CPAP in improving oxygenation and carbon dioxide clearance.

A comparison of high-flow nasal cannula versus non-invasive positive pressure ventilation for respiratory support in infants following cardiac surgery.

Following cardiac surgery, infants often remain endotracheally intubated upon arrival to the cardiac ICU. High-flow nasal cannula and non-invasive positive pressure ventilation are used to support patients following extubation. There are limited data on the superiority of either mode to prevent extubation failure. We conducted a single-centre retrospective study for infants (<1 year) and/or <10 kg who underwent cardiac surgery between 3/2019-3/2020. Data included patient and clinical characteristics and operative variables. The study aimed to compare high-flow nasal cannula versus non-invasive positive pressure ventilation following extubation and their association with extubation failure. Secondarily, we examined risk factors associated with extubation failure. There were 424 patients who met inclusion criteria, 320 (75%) were extubated to high-flow nasal cannula, 104 (25%) to non-invasive positive pressure ventilation, and 64 patients (15%) failed extubation. The high-flow nasal cannula group had lower rates of extubation failure (11%, versus 29%, p = 0.001). Infants failing extubation were younger and had higher STAT score (p < 0.05). Compared to high-flow nasal cannula, non-invasive positive pressure ventilation patients were at 3.30 times higher odds of failing extubation after adjusting for patient factors (p < 0.0001). Extubation failure after cardiac surgery occurs in smaller, younger infants, and those with higher risk surgical procedures. Patients extubated to non-invasive positive pressure ventilation had 3.30 higher odds to fail extubation than patients extubated to high-flow nasal cannula. The optimal mode of respiratory support in this patient population is unknown.

Clinical Study on Early Extubation and Sequential Non-Invasive Respiratory Support for Children with Acute Respiratory Failure Receiving Invasive Mechanical Ventilation

To explore the treatment outcome of the strategy of early extubation and then switching to non-invasive mechanical ventilation in children with acute respiratory failure, and the safety and feasibility of using the strategy to replace traditional methods. A total of 102 children, aged between 1 month to 14 years old, who had acute respiratory failure and were admitted to the pediatric ICU of West China Second University Hospital, Sichuan University between January 2019 and December 2020 were enrolled and randomly assigned to treatment group 1 (n=55) and treatment group 2 (n=47). In addition, 53 children who had the same condition in the 12 month prior to the beginning of the study were included in the control group. In the two treatment groups, the patients were extubated first, and then weaned off the ventilator. In group 1, when the patient met the invasive-non-invasive switching criteria, the tracheal tube was pulled out and non-invasive bi-level positive airway pressure (BiPAP) ventilation was used for respiratory support. In group 2, high-flow nasal cannula (HFNC) oxygen therapy was used for respiratory support. The traditional progressive weaning method was adopted for the control group (extubing and weaning were performed at the same time). The incidence of ventilator-associated pneumonia (VAP) during the period of tracheal intubation was compared and the mortality of the two groups was evaluated from the point when the patients were recruited. At the time of extubation in the treatment groups and extubation plus weaning in the control group, the pressure support levels, or PC above PEEP, intubation time, sequential time (between 2 treatment groups only), weaning failure rate, and the incidence of laryngeal edema and nasal pressure ulcer were compared. The subjects of the study were predominantly infants (93 cases, 60%) and young children (31 cases, 20%). Among the 155 cases, 82 (53%) were male. There was no statistical difference in age distribution or gender among the groups. There was no significant difference in the clinical indicators among the three groups before tracheal intubation. At the time of extubation, the PC above PEEP in the two treatment groups was higher than that in the control group, and higher in group 1 than that of group 2, the difference being statistically significant (P<0.05). The intubation time of the two treatment groups was shorter than that of the control group, and shorter in group 1 than that of group 2 (P<0.05). The sequential time of group 2 was shorter than that of group 1 (P<0.05). The extubation failure rate and the incidence of VAP in the two treatment groups were lower than those in the control group, and there was no statistically significant difference between the two treatment groups. The incidence of nasal pressure ulcers in group 1 was higher than that in the other two groups (P<0.05). There was 1 death in treatment group 1, and no deaths in treatment group 2 or the control group. There was no significant difference in mortality or the incidence of laryngeal edema after extubation in the three groups. Early extubation and then switching to non-invasive mechanical ventilation can be well tolerated by the patients, and can be used in clinical practice as an effective weaning method for children with acute respiratory failure.