Background Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate-oxygenation (ROX) index on the outcomes of COVID-19 pneumonia. Methods: This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88). Results: A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 57±14 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group. Conclusions: Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.
Background In 3%–19% of patients, reintubation is needed 48–72 hours following extubation, which increases intensive care unit (ICU) morbidity, mortality, and expenses. Extubation failure is frequently caused by diaphragm dysfunction. Ultrasonography can be used to determine the mobility and thickness of the diaphragm. This study looked at the role of diaphragm excursion (DE) and thickening fraction in predicting successful extubation from mechanical ventilation.
Methods Thirty-one patients were extubated with the advice of an ICU consultant using the ICU weaning regimen and diaphragm ultrasonography was performed. Ultrasound DE and thickening fraction were measured three times: at the commencement of the t-piece experiment, at 10 minutes, and immediately before extubation. All patients' parameters were monitored for 48 hours after extubation. Rapid shallow breathing index (RSBI) was also measured at the same time.
Results Successful extubation was significantly correlated with DE (P=0.01). Receiver curve analysis for DE to predict successful extubation revealed good properties (area under the curve [AUC], 0.83; P<0.001); sensitivity, 77.8%; specificity, 84.6%, positive predictive value (PPV), 87.5%; negative predictive value (NPV), 73.3% while cut-off value, 11.43 mm. Diaphragm thickening fraction (DTF) also revealed moderate curve properties (AUC, 0.69; P=0.06); sensitivity, 61.1%; specificity, 84.6%; PPV, 87.5%; NPV, 61.1% with cut-off value 22.33% although former one was slightly better. RSBI could not reach good receiver operating characteristic value at cut-off points 100 b/min/L (AUC, 0.58; P=0.47); sensitivity, 66.7%; specificity, 53.8%; PPV, 66.7%; NPV, 53.8%).
Conclusions To decrease the rate of reintubation, DE and DTF are better indicators of successful extubation. DE outperforms DTF.
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Background Identifying when intubated patients are ready to be extubated remains challenging. The negative inspiratory force (NIF) is a recommended predictor of weaning success. However, little is known about the role of NIF in the weaning process for the Asian surgical intensive population, especially for the Vietnamese population. Here, we aimed to investigate the cutoff threshold and predictive value of the NIF index for predicting the success of ventilator weaning in Vietnamese surgical intensive care patients.
Methods A cross-sectional study was conducted at the Surgical Intensive Care Unit of Viet Duc Hospital from October 2016 to August 2017. A total of 64 patients aged 16–70 years undergoing ventilatory support through an orotracheal tube satisfied the criteria for readiness to begin weaning. The correlation between the NIF index with outcomes of the weaning process was analyzed. Specificity (Sp), sensitivity (Se), positive predictive value (PPV), negative predictive value (NPV), receiver operating characteristic (ROC) curve, and area under the curve (AUC) were calculated.
Results The success rate of the entire weaning process was 67.2% (43/64). The median NIF values were –26.0 cm H2O (interquartile range [IQR], –28.0 to –25.0) in the successful weaning group and –24.0 cm H2O (IQR, –25.0 to –23.0) in the weaning failure group (P<0.001). According to ROC analysis, an NIF value ≤–25 cm H2O predicted weaning success (AUC, 0.836) with 91% Se, 62% Sp, 83% PPV, and 77% NPV.
Conclusions An NIF cutoff threshold ≤–25 cm H2O can be used as predictor of weaning success in Vietnamese surgical intensive care patients.
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Background Before the main trial in which respiratory polygraphy will be used to evaluate postextubation sleep apnea in critically ill patients, we performed a prospective pilot study to ensure that any issues with the conduct of the trial would be identified.
Methods In the present study, 13 adult patients who had received mechanical ventilation for ≥24 hours were prospectively recruited. Among the patients, 10 successfully completed respiratory polygraphy on the first or second night after extubation. Data regarding the types and doses of corticosteroids, analgesics, sedatives, and muscle relaxants as well as the methods of oxygen delivery were recorded.
Results During the night of respiratory polygraphy, all 10 patients received supplemental oxygen (low-flow oxygen, n=5; high-flow oxygen, n=5), and seven patients received intravenous corticosteroids. Three of the 10 patients had a respiratory event index (REI) ≥5/hr. All respiratory events were obstructive episodes. None of the patients receiving high-flow oxygen therapy had an REI ≥5/hr. Two of the seven patients who received corticosteroids and one of the other three patients who did not receive this medication had an REI ≥5/hr. Although low- or high-flow oxygen therapy was provided, all patients had episodes of oxygen saturation (SpO2) <90%. Two of the three patients with an REI ≥5/hr underwent in-laboratory polysomnography. The patients’ Apnea-Hypopnea Index and REI obtained via polysomnography and respiratory polygraphy, respectively, were similar.
Conclusions In a future trial to evaluate postextubation sleep apnea in critically ill patients, pre-stratification based on the use of corticosteroids and high-flow oxygen therapy should be considered.
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Background Use 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.
Methods The 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.
Results Eighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of highrisk 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.
Conclusions No 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.
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extubation: A multicentre observational study Amit Kansal, Shekhar Dhanvijay, Andrew Li, Jason Phua, Matthew Edward Cove, Wei Jun Dan Ong, Ser Hon Puah, Vicky Ng, Qiao Li Tan, Julipie Sumampong Manalansan, Michael Sharey Nocon Zamora, Michael Camba Vidanes, Juliet Tolentino Sahagun, Juvel Taculod, Ad Annals of the Academy of Medicine, Singapore.2021; 50(6): 467. CrossRef
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Background Unplanned extubation (UE) of patients requiring mechanical ventilation in an intensive care unit (ICU) is associated with poor outcomes for patients and organizations. This study was conducted to assess the clinical features of patients who experienced UE and to determine the risk factors affecting reintubation after UE in an ICU.
Methods Among all adult patients admitted to the ICU in our institution who required mechanical ventilation between January 2011 and December 2013, those in whom UE was noted were included in the study. Data were categorized according to noninvasive or invasive management after UE.
Results The rate of UE was 0.78% (the number of UEs per 100 days of mechanical ventilation). The incidence of self-extubation was 97.2%, while extubation was accidental in the remaining patients. Two cases of cardiac arrest combined with respiratory arrest after UE were noted. Of the 214 incidents, 54.7% required invasive management after UE. Long duration of mechanical ventilation (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.32-1.75; p = 0.000) and high ICU mortality (OR 4.39; 95% CI 1.33-14.50; p = 0.015) showed the most significant association with invasive management after UE. In multivariate analysis, younger age (OR 0.96; 95% CI 0.93-0.99; p = 0.005), medical patients (OR 4.36; 95% CI 1.95-9.75; p = 0.000), use of sedative medication (OR 4.95; 95% CI 1.97-12.41; p = 0.001), large amount of secretion (OR 2.66; 95% CI 1.01-7.02; p = 0.049), and low PaO2/FiO2 ratio (OR 0.99; 95% CI 0.98-0.99; p = 0.000) were independent risk factors of invasive management after UE.
Conclusions To prevent unfavorable clinical outcomes, close attention and proper ventilatory support are required for patients with risk factors who require invasive management after UE.
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Negative pressure pulmonary edema (NPPE) is a rare complication of acute airway obstruction which develops after endotracheal extubation. The proposed mechanism is generation of very low negative pressure during laryngospasm by inspiratory efforts, which leads to alveolar exudation and hemorrhage. The diagnosis of NPPE is confirmed by clinical findings of tachypnea, pink prothy sputum in the endotracheal tube, hypoxemia on arterial blood gas analysis, and distinctive radiologic findings. NPPE is usually self-limited within 48 hours when diagnosed early and treated appropriately. We report three patients who recovered from NPPE without complications.
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Negative pressure pulmonary edema after endotracheal tube extubation during recovery of general anesthesia in a pediatric patient with cerebral palsy Hyun Jung Kim, Sun Kyung Park Allergy, Asthma & Respiratory Disease.2022; 10(4): 229. CrossRef
BACKGROUND Unplanned endotracheal extubation is a potentially serious complication, as some patients may need reintubation while in very critical conditions that may increase the morbidity and mortality rates. We conducted a study to evaluate the predictors for reintubation after unplanned extubation. METHODS: Patients who presented unplanned extubation over a 35-month period in two multidisciplinary intensive care units of university affiliated hospital were included. Any replacement of an endotracheal tube within 48 hours after unplanned extubation was considered as reintubation. RESULTS: There were 62 episodes of unplanned endotracheal extubation in 56 patients (incidence rate 2.8%). Fifty seven episodes (91.9%) were deliberate self-extubation, while 5 episodes (8.1%) were accidental extubation. Reintubation was required in 42 episodes (67.7%). Only 44.4% (12/27) of the patients who presented unplanned extubation required reintubation during weaning period, while reintubation was mandatory in 85.7% (30/35) of the patients who presented unplanned extubation during full ventilatory support (P<0.001). The multiple logistic regression analysis was made to obtain a model to predict the need for reintubation as a dependent variable: ventilatory support mode (odds ratio: 12.0) was significantly associated with the need for reintubation. The model correctly classified the need of reintubation in 72.6% (45/62) of the patients. CONCLUSIONS: Reintubation in unplanned extubation strongly depended on the type of the mechanical ventilatory support. The probability of requiring reintubation after unplanned extubation was higher during full ventilatory support than during weaning period.
Postoperative hypertension occurs often in hypertensive patients due to pain, hypercapnia, hypoxemia, or excessive intravascular fluid volume. In addition, tracheal extubation exacerbates hypertension and tachycardia, which leads to left ventricular failure, myocardial infarction, or cerebral hemorrhage. We experienced a case of recurrent intracerebral hemorrhage after extubation in the postanesthetic care unit.
The patient was 50-year old female who underwent total abdominal hysterectomy. Three months ago, she suffered a hypertensive cerebral hemorrhage with conservative treatment. Anesthesia induction and intraoperative course were relatively uneventful. In the postanesthetic care unit, she had voluntary movement of all limbs to command and fully awake consciousness. Immediately after tracheal extubation, the blood pressure was increased sharply to 200/110 mmHg.
After then, the patient's mental status was deteriorated and the motor weakness of left extremities was developed. Brain CT showed a hypertensive hemorrhage at the right putamen and emergency stereotaxic aspiration was performed. After rehabilitative treatment, the patient was discharged with alert mental status and moderate improvement of motor weakness.