Successful Extubation Research Articles

Lung aeration estimated by chest electrical impedance tomography and lung ultrasound during extubation

BackgroundThis study hypothesized that patients with extubation failure exhibit a loss of lung aeration and heterogeneity in air distribution, which could be monitored by chest EIT and lung ultrasound. Patients at risk of extubation failure were included after a successful spontaneous breathing trial. Lung ultrasound [with calculation of lung ultrasound score (LUS)] and chest EIT [with calculation of the global inhomogeneity index, frontback center of ventilation (CoV), regional ventilation delay (RVD) and surface available for ventilation] were performed before extubation during pressure support ventilation (H0) and two hours after extubation during spontaneous breathing (H2). EIT was then repeated 6 h (H6) after extubation. EIT derived indices and LUS were compared between patients successfully extubated and patients with extubation failure.Results40 patients were included, of whom 12 (30%) failed extubation. Before extubation, when compared with patients with successful extubation, patients who failed extubation had a higher LUS (19 vs 10, p = 0.003) and a smaller surface available for ventilation (352 vs 406 pixels, p = 0.042). After extubation, GI index and LUS were higher in the extubation failure group, whereas the surface available for ventilation was lower. The RVD and the CoV were not different between groups.ConclusionBefore extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss of lung aeration persisted and was associated with regional lung ventilation heterogeneity.Trial registration Clinical trials, NCT04180410, Registered 27 November 2019—prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04180410.

Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial.

Daily evaluation of mechanically ventilated (MV) patients is essential for successful extubation. Proper withdrawal prevents complications and reduces the cost of hospitalization in the intensive care unit (ICU). Diaphragm ultrasonography (DUS) has emerged as a potential instrument for determining whether a patient is ready to be extubated. This study compared the efficacy rate of extubation using a standard withdrawal protocol and DUS in patients with MV. A randomized, parallel, single-blind, controlled study was conducted on ICU patients undergoing MV. Patients were randomly assigned to either the control (conventional weaning protocol) group or intervention (DUS-guided weaning) group in a 1 : 1 ratio. The primary outcome measure was the rate of reintubation and hospital mortality. Forty patients were randomized to the trial. The mean age of the sample was 70 years, representing an older population. The extubation success rate was 90% in both groups. There was no reintubation in the first 48 hours and only two reintubations in both groups between the second and seventh days. The hospital mortality risk in patients with acute kidney injury was positively correlated with age and the need for hemodialysis. Discussion. This study demonstrates the usefulness of DUS measurement protocols for withdrawing MV. The rate of reintubation was low for both cessation methods. As a parameter, the diaphragm thickness fraction comprehensively evaluates the diaphragm function. The results demonstrate that DUS has the potential to serve as a noninvasive tool for guiding extubation decisions. In conclusion, using DUS in patients with respiratory failure revealed no difference in reintubation rates or mortality compared with the conventional method. Future research should concentrate on larger, multicentered, randomized trials employing a multimodal strategy that combines diaphragmatic parameters with traditional clinical withdrawal indices.

Predictive factors for extubation success in very low and extremely low birth weight preterm infants.

Although invasive mechanical ventilation (IMV) has contributed to the survival of preterm infants with extremely low birth weight (ELBW), it is also associated with unsatisfactory clinical outcomes when used for prolonged periods. This study aimed to identify factors that may be decisive for extubation success in very low birth weight (VLBW) and extremely low birth weight (ELBW) preterm infants. The cohort study included preterm infants with gestational age (GA) <36 weeks, birth weight (BW) <1500 grams who underwent IMV, born between 2015 and 2018. The infants were allocated into two groups: extubation success (SG) or failure (FG). A stepwise logistic regression model was created to determine variables associated with successful extubation. Eighty-three preterm infants were included. GA and post-extubation arterial partial pressure of carbon dioxide (PaCO2) were predictive of extubation success. Infants from FG had lower GA and BW, while those from SG had higher weight at extubation and lower post-extubation PaCO2. Although we found post-extubation PaCO2 as an extubation success predictor, which is a variable representative of the moment after the primary outcome, this does not diminish its clinical relevance since extubation does not implicate in ET removal only; it also involves all the aspects that take place within a specified period (72 hours) after the planned event. GA and post-extubation PaCO2 were predictors for extubation success in VLBW and ELBW preterm infants. Infants who experienced extubation failure had lower birth weight and higher FiO2 prior to extubation.

Predictive Score for Early Successful Tracheal Extubation After Liver Transplant: A Case-Control Study.

Prolonged tracheal intubation and mechanical ventilation after liver transplant increase postoperative complications. Hence, timely extubation should be considered; however, a standard clinical criteria set or scoring system to select patients has not been established for early extubation after livertransplant.We investigated the factors that affect early extubation to design a predictive scoring system for early extubation. This study is a case-control study of adult liver transplant patients. Preoperative, intraoperative, and postoperative clinical data were collected. Early extubation was defined as tracheal extubation immediately or up to 6 hours posttransplant. The variables were compared between the early extubation group and the delayed extubation (>6 hours) group. Our study enrolled 237 patients; among them, 57 patients (24%) were in the early extubation group, and 180 (76%) were in the delayed extubation group. Multiple logistic regression analysis showed that postoperative base excess level at admission to the intensive care unit, number of units of packed red blood cells transfused during surgery, urine volume, and excess base level 6 hours after surgery were the main predictors of successful early extubation. The initial base excess level at the entrance to the intensive care unit(postsurgery) and 6 hours after surgery, packed red blood cell volume transfused during surgery, and urine volume 6 hours after surgery are the main predictors for a successful early tracheal extubation.These factors are considered for the Shiraz Extubation Predictor formula.

Ultrasonographic Evaluation of Diaphragmatic Thickness versus Excursion as a Predictor of Weaning in Mechanically Ventilated Patients

Abstract Background Best predictor of successful extubation after mechanical ventilation is a matter of debate. Objective The aim of this study was to assess the efficiency of diaphragm thickness and/or diaphragm excursion as measured by means of ultrasound as a predictor of extubation in mechanically ventilated patients in ICU. Methods We performed a prospective study on fifty patients who successfully passed spontaneous breathing trial (SBT). During T-tube spontaneous breathing trial (SBT) we evaluated the right hemidiaphragm excursion by using the M mode and diaphragmatic thickness fraction (DTF%) using B mode, and they were classified in to the successful extubation group and the failure group. Primary outcome: defined as weaning failure and requirement of either noninvasive ventilation or mechanical ventilation. Secondary outcome: To investigate possible factors related to weaning failure Results Of the 50 patients in the study, 35 patients were successfully weaned and 15 failed weaning. The mean diaphragmatic thickness fraction with respect to cut-off value was higher in the failure group during SBT whereas the diaphragmatic excursion with respect to cut off value was less in the failure group during SBT while there was increase in both DTF and diaphragmatic excursion with respect to cut off value in the success group. The diaphragmatic excursion cut-off value predictive of weaning was 10 mm with a specificity 78% and sensitivity 82% respectively and the diaphragmatic thickness cut-off value predictive of weaning was 21.5% with a specificity of 71% and sensitivity of 76% respectively. There was negative correlation between diaphragmatic function and duration of mechanical ventilation. Conclusion The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

Impact of peripheral muscle strength on extubation success after cardiac surgery

Impact of peripheral muscle strength on extubation success after cardiac surgery

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

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

Diaphragm dysfunction predicts weaning outcome after bilateral lung transplant.

Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (TFdi; the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuro-ventilatory efficiency (NVE; the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. We hypothesized that: i) diaphragm dysfunction, as defined by a TFdi<29%, is more likely to occur in difficult weaning; ii) TFdi and NVE predict weaning outcome; iii) and duration of mechanical ventilation before the first spontaneous breathing trial (SBT) is associated with diaphragm dysfunction. Adult bilateral-lung transplant patients admitted to our ICU were screened at the time of the first SBT (pressure-support of 5cmH2O and zero positive end-expiratory pressure). At the fifth minute, TFdi and NVE were measured over three respiratory cycles. Weaning was classified as simple, difficult or prolonged (successful extubation at the first SBT, within three or after three SBTs, respectively). Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%); all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both TFdi (24[20-29] vs 39[35-45]%) and NVE (34[26-45] vs 55[43-62]ml/µV) were lower in difficult weaning (both p<0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 [95%CI 0.73-0.99] for TFdi, and 0.85 [95%CI 0.71-0.95] for NVE. Duration of ventilation demonstrated a linear inverse correlation with both TFdi and NVE. Diaphragm dysfunction is common following bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for TFdi and NVE were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation.

Analysis of the efficacy of a single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy

BackgroundRadical cystectomy and urinary diversion are the standard surgical treatments for patients with muscle-invasive or high-risk, or recurrent non-muscle-invasive bladder cancer. Although this approach significantly prolongs patient survival, it can lead to postoperative complications. This study aims to compare the efficacy and complications of bilateral cutaneous ureterostomy with a single subumbilical stoma to those of cutaneous ureterostomy with two stomas and an ileal conduit as a means of urinary diversion after radical cystectomy. The findings of this study will provide valuable information for healthcare providers in selecting the appropriate urinary diversion method for their patients.MethodsThe clinical data for 108 patients who received bilateral cutaneous ureterostomy with a single subumbilical stoma (ureterostomy with a single stoma group), cutaneous ureterostomy with two stomas (ureterostomy with two stomas group), or an ileal conduit (ileal conduit group) after radical cystectomy were retrospectively analysed. The operative time, pathological stage, survival status, perioperative complication rate, rate of successful first extubation, rehospitalization rate at 6 months after surgery,ostomy-related medical costs,and postoperative quality of life were compared between the three groups of patients.ResultsA significant difference in the operative time was found between the three groups (P = 0.001). No significant differences in pathological stage, survival status, perioperative complication rate, rehospitalization rate at 6 months after surgery, or bladder cancer index (BCI) score were identified among the three groups. The difference in the successful first extubation rate between the three groups of patients was significant (P = 0.001). Significant differences in ostomy-related medical costs were observed among the three groups of patients (P = 0.006).ConclusionA single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy may result in shorter surgery time, increased success rates for initial catheter removal, and lower medical expenses. However, to confirm these findings, further prospective randomized clinical trials are necessary.

Effect of high-flow nasal cannula versus non-invasive ventilation after extubation on successful extubation in obese patients: a retrospective analysis of the MIMIC-IV database

BackgroundThe pathophysiological characteristics of the respiratory system of obese patients differ from those of non-obese patients. Few studies have evaluated the effects of high-flow nasal cannula (HFNC) and non-invasive ventilation...

Commentary on "Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit".

How to cite this article: Chowdhury SR, Kundu R. Commentary on "Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit." Indian J Crit Care Med 2023;27(8):596.

Author Reply "Comment on Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care".

How to cite this article: Rajbanshi LK. Author Reply "Comment on Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care". Indian J Crit Care Med 2023;27(8):597-598.

Long-term sedation with remimazolam besylate versus propofol in critically ill patients during invasive mechanical ventilation: a study protocol for a multicenter randomized non-inferior trial.

Background: Remimazolam besylate is a novel ultra-short-acting benzodiazepine that can potentially be a safe and effective sedative in intensive care units. This study aims to assess whether remimazolam besylate is not inferior to propofol in maintaining mild-to-moderate sedation in critically ill patients receiving long-term mechanical ventilation. Methods and analysis: This is a multicenter, randomized, single-blind, propofol-controlled, non-inferiority study. Eligible patients are randomly assigned to receive remimazolam besylate or propofol in a 1:1 ratio to maintain a Richmond Agitation-Sedation Scale score between -3 and 0. When patients are under-sedated, rescue sedation of dexmedetomidine is added. The primary outcome is the percentage of time in the target sedation range. The secondary outcomes are hours free from the invasive ventilator in 7days, successful extubation in 7days, and weaning time, the length of intensive care unit stay, the length of hospital stay, and mortality in 28days. Modified intention-to-treat and safety analysis is performed. Clinical trial registration number: https://clinicaltrials.gov/ct2/show/NCT05555667.

Mechanical insufflation-exsufflation to promote extubation success in critically ill adults on intensive care: protocol for a randomised controlled feasibility trial

BackgroundExtubation failure, defined as reintubation within 48 h, is associated with increased intensive care unit (ICU) length of stay and higher mortality risk. One cause of extubation failure is secretion retention, resulting from an inability to cough effectively. Mechanical insufflation-exsufflation (MI-E) simulates a cough aiding secretion clearance. However, MI-E is not routinely used in the ICU for invasively ventilated patients. This study aims to determine feasibility and acceptability of a randomised controlled trial (RCT) examining MI-E use to promote extubation success in intubated, ventilated adults.MethodsIt is a single-centre, feasibility RCT with semi-structured interviews, economic scoping, and exploratory physiology study.The feasibility RCT (n = 50) will compare standard care to a MI-E protocol including a minimum of two MI-E sessions via the endotracheal tube prior to extubation. Post-extubation, MI-E will be delivered via facemask or mouthpiece up to two times/day for 48 h. MI-E settings will be individualised. All patients will receive standard care (no MI-E) in relation to mechanical ventilation, weaning, rehabilitation, physiotherapy techniques such as positioning, manual airway clearance techniques, manual/ventilator hyperinflation, endotracheal suctioning, and nebulisation. Clinical data collection will occur before, on completion, and 5-min post-physiotherapy sessions (intervention/control arms). Resource use will be calculated for each 24-h period. Analyses will be descriptive and address feasibility outcomes including participant recruitment and attrition, proportion of MI-E treatment sessions completed, dataset completeness, and frequency of adverse events and acceptability.Semi-structured online interviews informed by the Theoretical Framework of Acceptability (TFA) with patients, clinicians, and family members will explore the acceptability of the MI-E intervention and study processes.Interview data will be analysed using reflexive thematic analysis based on TFA domains through first-level coding.The embedded physiology study will use electrical impedance tomography and lung ultrasound to explore lung recruitment and de-recruitment during MI-E in a subset of 5–10 patients.DiscussionThis study will examine feasibility and acceptability of a RCT protocol of MI-E to promote extubation success. Study findings will inform design modification and conduct of a future adequately powered trial. Furthermore, the study will contribute and advance the understanding of MI-E use in critically ill intubated adults.Trial registrationISRCTN 24603037; IRAS 303674

Use of ketamine for severe asthma exacerbation in a pregnant patient with persistent bronchospasm: a case report

Abstract Background Estimated 4%–8% of pregnancies are complicated by asthma. Adequate management in this population is critical to minimize complications. Patients presenting with asthma exacerbation are typically managed with standard bronchodilators and systemic corticosteroids. However, additional agents may be used in patients with refractory asthma exacerbation. Ketamine has been used in refractory bronchospasm, although its efficacy in published literature is heterogeneous. Case Presentation We present a case of a pregnant patient with severe asthma exacerbation refractory to standard and salvage treatment who achieved termination of bronchospasm with ketamine infusion. Conclusion After receiving ketamine infusion for several days, the patient had improved air flow and achieved successful extubation, without experiencing rebound bronchospasm. Although this individual clinical case alone cannot change guidelines or directives to use in refractory asthma exacerbations, it offers a possible treatment option to patients and providers in unusually severe cases with extenuating risk factors.

Association between microcirculation in spontaneous breathing trial and extubation success.

This study assessed the association between changes in sublingual microcirculation after a spontaneous breathing trial (SBT) and successful extubation. Sublingual microcirculation was assessed using an incident dark-field video microscope before and after each SBT and before extubation. Microcirculatory parameters before the SBT, at the end of the SBT, and before extubation were compared between the successful and failed extubation groups. Forty-seven patients were enrolled and analysed in this study (34 patients in the successful extubation group and 13 patients in the failed extubation group). At the end of the SBT, the weaning parameters did not differ between the two groups. However, the total small vessel density (21.2 [20.4-23.7] versus 24.9 [22.6-26.5] mm/mm2), perfused small vessel density (20.6 [18.5-21.8] versus 23.1 [20.9-25] mm/mm2), proportion of perfused small vessels (91 [87-96] versus 95 [93-98] %), and microvascular flow index (2.8 [2.7-2.9] versus 2.9 [2.9-3]) were significantly lower in the failed extubation group than in the successful extubation group. The weaning and microcirculatory parameters did not differ significantly between the two groups before the SBT. More patients are required to investigate the difference between baseline microcirculation before a successful SBT and the change in microcirculation at the end of the SBT between the successful and failed extubation groups. Better sublingual microcirculatory parameters at the end of SBT and before extubation are associated with successful extubation.

Which spontaneous breathing trial to predict effort to breathe after extubation according to five critical illnesses: the cross-over GLOBAL WEAN study protocol

IntroductionReadiness to be freed from ventilatory support can be evaluated by spontaneous breathing trial (SBT) assessing the patient’s ability to sustain respiratory effort after extubation. Current SBT practices are heterogenous...

Does lung ultrasound help in determining the need of surfactant administration?

Background. Fetal lung immaturity can lead to neonatal respiratory distress syndrome (RDS), a significant cause of respiratory failure and neonatal mortality in premature infants due to lack of pulmonary surfactant. Lung ultrasound may aid in deciding when to administer surfactant. Case report. The patient was diagnosed with respiratory distress syndrome (RDS) and received timely surfactant therapy based on their FiO2 and Lung Ultrasound Score. This led to an improved clinical status and successful extubation within 48 hours. After being discharged at 30 days, the patient showed normal development during a 7-month follow-up period. Conclusions. A favorable outcome results from prompt and targeted lung ultrasound (LUS) interventions, specifically highlighting the efficacy of timely surfactant intervention and collaborative healthcare management in addressing RDS in neonates.

Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit.

Spontaneous breathing trial (SBT) is always successful in mechanically ventilated patients. This study was conducted to assess the prediction of successful SBT and extubation of trachea by bedside lung ultrasound in mechanically ventilated patients. This was a prospective observational study for 1 year conducted at a tertiary teaching hospital ICU on 102 patients with age more than 18 years and who were mechanically ventilated for more than 24 hours. Bedside lung ultrasound was used to assess the lung ultrasound score (LUS) and lung profiles in patients who clinically met the criteria for SBT. The LUS at the beginning of SBT and 30 minutes after SBT were used to predict the successful SBT and tracheal extubation. Spontaneous breathing trial and tracheal extubation were successful in 73 (71.6%) and 57 (55.8%) of the patients. The AUC for lung ultrasound in predicting successful SBT at the beginning and 30 minutes of SBT were 0.781 (CI 95% 0.674-0.888, p < 0.001) and 0.841 (CI 95% 0.742-0.941, p < 0.001) with a cut-off value of 17.5 and 19.5, respectively. Similarly, AUC for LUS in relation to tracheal extubation was 0.786 (CI 95% 0.694-0.879, p < 0.001) and 0.841(CI 95% 0.756-0.925, p < 0.001) at 0 and 30 minutes. About 57.5% of the patients with A profiles tolerated successful SBT while 48.3% of the patients having C profile had failed SBT (p < 0.001). COPD, lung ultrasound, higher SOFA score, and longer duration of mechanical ventilation had a statistically significant negative correlation with successful SBT. Lower LUS and A profiles lung ultrasound are associated with more successful weaning and tracheal extubation in mechanically ventilated patients. Rajbanshi LK, Bajracharya A, Devkota D. Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit. Indian J Crit Care Med 2023;27(7):482-487.

Effect of Clinical Decision-Making Based on Interactive Training on Successful Extubations in Intensive Care Unit Patients

Background: The proper decision-making on weaning patients from the ventilator, removing the endotracheal tube, reducing complications, and the way of cooperating between doctor and nurse is always one of the concerns of intensive care unit (ICU) nurses. Objectives: This study aimed to determine the effect of clinical decision-making based on interactive education on the successful extubations of patients in the ICU. Methods: This quasi-experimental study was conducted on 50 nurses in the ICU of Ganjavian Hospital in Dezful, Iran, within August-December 2021. The nurses were selected based on inclusion criteria and randomly assigned into intervention and control groups. Clinical decision-making training regarding extubation was provided interactively for one month in five sessions in the experimental group. The data were obtained using a demographic information questionnaire, the Clinical Decision-Making Questionnaire by Lauri et al., and extubation checklist and analyzed using SPSS software (version 24) using descriptive and inferential statistics (i.e., chi-square test, covariance, independent t-test, and paired t-test). Results: No difference was observed between the two groups in terms of demographic information (P &lt; 0.05). After the intervention, the mean score of nurses’ clinical decisions and the number of successful extubations in the experimental group were higher than in the control group, with a statistically significant difference (P = 0.014). Conclusions: Interactive training effectively improves decision-making skills concerning successful extubations. Therefore, it is suggested to use this method in educational programs to improve the clinical decision-making of nurses, students, and nursing managers.