Independent Risk Factors and Economic Burden Associated With Delayed Extubation Following Pediatric Liver Transplantation.

BACKGROUND: Successful early extubation (EE) after liver transplant (LT) has been shown to reduce intensive care unit (ICU) and hospital length of stay and infectious, vascular, and sedation-related complications in adults. EE may not always be feasible in children, and many may require prolonged mechanical ventilation. Limited data exists regarding the candidacy of EE, risk factors, consequences, and hospital costs of delayed extubation (DE) in pediatric LT. METHODS: We conducted a retrospective review to investigate predictive factors and associated costs of EE and DE in infants and children after orthotopic LT at our institution between 2011 and 2021. RESULTS: Of 338 LT (median age 39 months, 54% females), 246 (73%) had EE (within 24 h of LT), while 27% had DE. Age < 1 year (p = 0.0019), diagnosis of biliary atresia (0.02), abnormal pre-LT echocardiogram (0.02), and patients with ongoing hospital admission before LT (0.0001) were independently associated with DE. Hospital costs were significantly (∼3-fold) higher (p < 0.0001) in the DE group. In addition, factors associated with increased total hospital costs were age < 1 year and hospitalization before LT. CONCLUSION: EE post-LT is feasible and merits a trial. The prevalence of DE though modest is associated with increased resource utilization and hospital costs. Children who can be extubated early and those at risk for DE can be identified pre-operatively for optimal planning and allocation of resources.

Awake prone positioning in an infant following living donor liver transplantation.

BACKGROUND: Prone position has been proven to improve ventilation and oxygenation in infants. Currently, there are few reports of early prone position ventilation after pediatric liver transplantation. Here, we present our experience with prone position in an infant following living donor liver transplantation, in an attempt to improve oxygenation. CASE PRESENTATION: An 8-month-old boy, 7.5 kg, experienced two failed extubations that presented with Type II respiratory failure due to dyspnea, potentially caused by consolidation and airway secretions. To prevent the third failure of extubation, prone position ventilation was implemented after the third extubation on the 11th postoperative day. Oxygenation increased after each prone position session with no signs of transplant liver ischemia or other adverse outcomes. Following two days of continuous prone position, airway secretions decreased, and the infant was discharged from the ICU. The third extubation procedure was successful. CONCLUSIONS: Prone position ventilation may be effective in this infant without adverse events, indicating that early prone position is not absolutely contraindicated after pediatric liver transplantation. Therefore, more reasonable prone position strategies should be sought in infants undergoing liver transplantation.

Prevalence of unplanned extubation in a tertiary care neonatal intensive care unit.

Orotracheal intubation and mechanical ventilation (MV) have become routine practices in intensive care units. Unplanned extubation (UE) is one of the most important complications, particularly in premature infants and critically ill newborns. The objective of this study was to determine the prevalence of UE in a tertiary care neonatal intensive care unit (NICU). In this analytical cross-sectional retrospective study, all data, including perinatal data, indications for ventilatory support, days of MV at the time of UE, work shift, month of the event, reintubation, and postextubation complications, were obtained from the manual review of clinical charts. In total, 151 neonates, who received invasive MV, were included in this study. The prevalence of UE was 2.0/100 days of ventilation. The most affected were premature infants, with a gestational age of ≤ 32 weeks (54.7%) and a birth weight of ≤ 1500 g. The main cause for UE was deficient fixation of the endotracheal tube (ETT) (27.7%). Most UE events occurred during night shifts (48.1%). Reintubation was required in 83.3% of newborns. Immediate complications developed in 96.3% of the UE events, including desaturation (57.7%) and bradycardia (36.5%). The prevalence of UE was high, particularly in premature infants, with a high rate of reintubation and immediate complications. Standardized protocols for ETT care must be implemented to reduce these events.

Endotracheal Tube Cuff Deflation Methods Reduce Stress Response and Incidence of Postoperative Pharyngeal Complications in Patients Treated with Gynecological Laparoscopic Surgery.

AIM: This study aims to explore the impact of endotracheal tube cuff deflation methods on extubation stress responses and postoperative pharyngeal complications in patients treated with gynecological laparoscopic surgery. METHODS: In this study, retrospective clinical data of 94 patients treated with gynecological laparoscopic surgery under general anesthesia in Northwest Women's and Children's Hospital from June 2023 to June 2024 were collected and analyzed. Patients were assigned into two groups based on the cuff deflation methods used after anesthesia: Group A (45 patients) adopted a one-time deflation method, while Group B (49 patients) employed a gradual deflation method. Surgery-associated indicators were recorded, with heart rate (HR), mean arterial pressure (MAP), rate pressure product (RPP), epinephrine (E), norepinephrine (NE), and cortisol (Cor) levels monitored at selected time points: before cuff (T0), immediately after extubation (T1), 1 minute post-extubation (T2), 5 minutes post-extubation (T3), and 10 minutes post-extubation (T4). The incidence of pharyngeal complications was also compared between the two groups. RESULTS: Compared with Group A, Group B displayed smaller variations in HR, MAP, and RPP at T1, T2, and T3 (p < 0.05). Group B also showed smaller variations in E, NE, and Cor levels at T2, T3, and T4 in contrast with Group A (p < 0.05). The incidence of complications such as coughing, sore throat, and hoarseness was conspicuously attenuated in Group B compared to Group A (6.12% vs 22.22%, p < 0.05). CONCLUSIONS: Gradual deflation of the endotracheal tube cuff dramatically ameliorates extubation stress responses, stabilizes hemodynamics, and alleviates pharyngeal discomfort in patients treated with gynecological laparoscopic surgery.

High-flow nasal cannula oxygen therapy versus noninvasive ventilation for elderly chronic obstructive pulmonary disease patients after extubation: a noninferior randomized controlled trial protocol.

INTRODUCTION: Noninvasive ventilation (NIV) is widely used for sequential extubation in patients with chronic obstructive pulmonary disease (COPD). However, NIV may cause many adverse events such as claustrophobia, facial skin compression, air leakage, bloating, and even reflux aspiration, resulting in poor patient compliance/tolerance and high failure rate, especially for older adults who are at high risk of communication difficulties and consciousness disorder. High-flow nasal cannula (HFNC) oxygen therapy is a new alternative support to NIV, but whether it can effectively reduce the rate of re-intubation after extubation in elderly patients with COPD remains controversial. The purpose of this study is to explore the safety and efficacy of HFNC versus NIV for elderly COPD patients after extubation. METHODS AND ANALYSIS: This study is an investigator-initiated, single-center, prospective, non-inferior, randomized controlled trial. Elderly patients (age > 65 years) who have received invasive ventilation and was diagnosed with COPD will be randomly assigned to HFNC group or NIV group immediately after extubation with a planned enrollment of 168 patients. The primary outcomes will be reintubation rates at 72 h and 7 days after extubation. Secondary outcomes will include treatment failure, post-extubation vital signs and arterial blood gases, the scores of compliance and comfort of patients, duration of respiratory support after extubation, respiratory support related adverse events, sleep quality scores, usage of sedative and analgesic drugs after extubation, and the incidence of delirium. Additionally, clinical outcomes such as ventilator-free days at 28 days post-randomization, tracheotomy rate, duration of intensive care unit (ICU) and hospital stay, ICU and hospital mortality will be evaluated. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Committee of West China Hospital of Sichuan University (2023-2284). Informed consent is required. It is expected that a follow-up randomized controlled trial will be conducted. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION: The study was retrospectively registered at ClinicalTrials.gov (ChiCTR2400087312).

Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants.

BACKGROUND: Preterm infants who are extubated following a period of invasive ventilation via an endotracheal tube are at risk of developing respiratory failure, leading to reintubation. This may be due to apnoea, respiratory acidosis, or hypoxia. Historically, preterm infants were extubated to head box oxygen or low-flow nasal cannulae. Support with non-invasive pressure might help improve rates of successful extubation in preterm infants by stabilising the upper airway, improving lung function, and reducing apnoea. This is an update of a review first published in 1997 and last updated in 2003. OBJECTIVES: To determine whether nasal continuous positive airway pressure (NCPAP), applied immediately after extubation of preterm infants, reduces the incidence of extubation failure and the need for additional ventilatory support, without clinically important adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and trial registries on 22 September 2023 using a revised strategy. We searched conference abstracts and the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Eligible trials employed random or quasi-random allocation of preterm infants undergoing extubation. Eligible comparisons were NCPAP (delivered by any device and interface) versus head box oxygen, extubation to room air, or any other form of low-pressure supplemental oxygen. We grouped the comparators under the term no continuous positive airway pressure (no CPAP). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias and extracted data from the included studies. Where studies were sufficiently similar, we performed a meta-analysis, calculating risk ratios (RRs) with their 95% confidence intervals (CIs) for dichotomous data. For the primary outcomes that showed an effect, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to assess the certainty of the evidence for clinically important outcomes. MAIN RESULTS: We included nine trials (with 726 infants) in the quantitative synthesis of this updated review. Eight studies were conducted in high-income countries between 1982 and 2005. One study was conducted in Chile, which was classified as upper-middle income at the time of the study. All studies used head box oxygen in the control arm. Risk of bias was generally low. However, due to the inherent nature of the intervention, no studies incorporated blinding. Consequently, the neonatal intensive care unit staff were aware of the assigned group for each infant, and we judged all studies at high risk of performance bias. However, we assessed blinding of the outcome assessor (detection bias) as low risk for seven studies because they used objective criteria to define both primary outcomes. NCPAP compared with no CPAP may reduce the risk of extubation failure (RR 0.62, 95% CI 0.51 to 0.76; risk difference (RD) -0.17, 95% -0.23 to -0.10; NNTB 6, 95% CI 4 to 10; I2 = 55%; 9 studies, 726 infants; low-certainty evidence) and endotracheal reintubation (RR 0.79, 95% 0.64 to 0.98; RD -0.07, 95% CI -0.14 to -0.01; NNTB 15, 95% CI 8 to 100; I2 = 65%; 9 studies; 726 infants; very low-certainty evidence), though the evidence for endotracheal reintubation is very uncertain. NCPAP compared with no CPAP may have little or no effect on bronchopulmonary dysplasia, but the evidence is very uncertain (RR 0.89, 95% CI 0.47 to 1.68; RD -0.03, 95% CI -0.22 to 0.15; 1 study, 92 infants; very low-certainty evidence). No study reported neurodevelopmental outcomes. AUTHORS' CONCLUSIONS: NCPAP may be more effective than no CPAP in preventing extubation failure in preterm infants if applied immediately after extubation from invasive mechanical ventilation. We are uncertain whether it can reduce the risk of reintubation or bronchopulmonary dysplasia. We have no information on long-term neurodevelopmental outcomes. Although there is only low-certainty evidence for the effectiveness of NCPAP immediately after extubation in preterm infants, we consider there is no need for further research on this intervention, which has become standard practice.

Combined lung and diaphragm ultrasound predicts extubation outcomes in ARDS: a prospective study.

BACKGROUND: Extubation failure is a crucial issue for acute respiratory distress syndrome (ARDS). Ultrasound of the lung and diaphragm is individually valuable for predicting extubation outcomes. We aimed to determine whether combined lung and diaphragmatic ultrasound could improve the accuracy of predicting the extubation of ARDS patients. METHODS: This was a prospective cohort study of ARDS patients who were ready for extubation. The lung ultrasound score (LUS), diaphragmatic displacement (DD), diaphragm thickening fraction (DTF), and diaphragmatic-rapid shallow breathing index (D-RSBI) were measured at the end of the spontaneous breathing trial. The primary outcome was extubation success. Logistic regression was used to combine these indicators, and the predictive performance of the single and combined indicators was evaluated through receiver operating characteristic (ROC) curves, the Hosmer-Lemeshow C-test, and the Brier score. Multivariate logistic regression was used to determine the association between combined ultrasound indicators and extubation success. RESULTS: This study enrolled 132 eligible patients from January 2019 to December 2022. A total of 71% (94/132) of patients were successfully extubated from mechanical ventilation. The combination of LUS and D-RSBI had the largest area under the ROC curves, the lowest Brier score, and the greatest calibration. After formula transformation, LUS + 2.43 × D-RSBI ≤ 14.273 was significantly associated with extubation success in ARDS patients. CONCLUSIONS: In ARDS patients receiving mechanical ventilation, the combination of LUS and D-RSBI was more accurate than a single parameter alone in predicting extubation outcomes. This combined approach could help refine extubation protocols in critical care. Clinical trial registration This study is registered online with the Chinese Clinical Trial Registry (ChiCTR), http://www.chictr.org.cn , ChiCTR1800019340 (Registration time: 2018/11/06).

Minimally invasive technique facilitates early extubation after cardiac surgery: a single-center retrospective study.

BACKGROUND: Postoperative time to extubation plays a role in prognosis after heart valve surgery; however, its exact impact has not been clarified. This study compared the postoperative outcomes of minimally invasive surgery and conventional sternotomy, focusing on early extubation and factors influencing prolonged mechanical ventilation. METHODS: Data from 744 patients who underwent heart valve surgery at the Zhejiang Provincial People's Hospital between August 2019 and June 2022 were retrospectively analyzed. The outcomes in patients who underwent conventional median sternotomy (MS) and minimally invasive (MI) video-assisted thoracoscopic surgery were compared using inverse probability of treatment weighting (IPTW) and Kaplan-Meier curves. Clinical data, including surgical data, postoperative cardiac function, postoperative complications, and intensive care monitoring data, were analyzed. RESULTS: After propensity score matching and IPTW, 196 cases of conventional MS were compared with 196 cases of MI video-assisted thoracoscopic surgery. Compared to patients in the conventional MS group, those in the MI video-assisted thoracoscopic surgery group in the matched cohort had a higher early postoperative extubation rate (P < 0.01), reduced incidence of postoperative pleural effusion (P < 0.05), significantly shorter length of stay in the intensive care unit (P < 0.01), shorter overall length of hospital stay (P < 0.01), and lower total cost of hospitalization (P < 0.01). CONCLUSIONS: Successful early tracheal extubation is important for the intensive care management of patients after heart valve surgery. The advantages of MI video-assisted thoracoscopic surgery over conventional MS include significant reductions in the duration of use of mechanical ventilation support, reduced length of intensive care unit stay, reduced total length of hospitalization, and a favorable patient recovery rate.

Extubation-Related Complications.

Extubation represents an essential component of airway management. While being a common procedure in anesthesiology and critical care medicine, it is accompanied by a significant risk of morbidity and mortality. Safe extubation requires considerable skills, risk stratification and advanced planning. It is important to emphasize that intentional extubation is always an elective procedure, and as such should only be executed when conditions are optimal. The purpose of this review is to discuss the complications associated with planned extubation in the adult patient, including risk factors and management strategies, mainly focusing on the postoperative setting.

Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients.

INTRODUCTION: Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. MATERIALS AND METHODS: This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value. RESULTS: Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 µV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure. CONCLUSIONS: In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 µV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.

Situations and Risk Factors of Unplanned Extubation of Nasogastric Tubes in Inpatients: A Retrospective Study.

OBJECTIVE: The aim of the study is to understand whether the risk factors of the unplanned extubation (UE) of nasogastric (NG) tubes vary among different inpatient situations. METHODS: Inpatients who experienced UE between 2009 and 2022 at a medical center were selected, and electronic medical records were used to collect patient background data and their conditions during UE. A total of 302 patients were included in our analysis. RESULTS: Conscious patients were at greater risk of UE when coughing, scratching their nose, blowing their nose, or sneezing than those who were confused (odds ratio [OR] = 0.07, P < 0.001) and those who were drowsy or comatose (OR = 0.15, P = 0.026). During activity, repositioning, bathing, or changing incontinence pads, the risk of UE was higher in patients whose hands were not restrained at the time of UE than in those whose hands were restrained (OR = 0.05, P = 0.004), higher in those with companions than in those without companions (OR = 7.78, P = 0.002), and higher in those with longer NG tube placement time (OR = 1.05, P = 0.008). Accidental extubation (OR = 2.62, P = 0.007) occurred more frequently during activity, repositioning, bathing, or changing incontinence pads. CONCLUSIONS: There is an increased risk of UE in conscious patients during activity, repositioning, bathing, or changing incontinence pads. Patients inserted with an NG tube for a longer period of time were at greater risk of accidental extubation during activity, repositioning, bathing, or changing incontinence pads irrespective of whether a companion could aid them if their hands were or were not restrained.

Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Post-extubation dysphagia (PED) emerges as a frequent complication following endotracheal intubation within the intensive care unit (ICU). PED has been strongly linked to adverse outcomes, including aspiration, pneumonia, malnutrition, heightened mortality rates, and prolonged hospitalization, resulting in escalated healthcare expenditures. Nevertheless, the reported incidence of PED varies substantially across the existing body of literature. Therefore, the principal objective of this review was to provide a comprehensive estimate of PED incidence in ICU patients undergoing orotracheal intubation. METHODS: We searched Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science, Technology Journal Database (VIP), and SinoMed databases from inception to August 2023. Two reviewers independently screened studies and extracted data. Subsequently, a random-effects model was employed for meta-statistical analysis utilizing the "meta prop" command within Stata SE version 15.0 to ascertain the incidence of PED. In addition, we performed subgroup analyses and meta-regression to elucidate potential sources of heterogeneity among the included studies. RESULTS: Of 4144 studies, 30 studies were included in this review. The overall pooled incidence of PED was 36% (95% confidence interval [CI] 29-44%). Subgroup analyses unveiled that the pooled incidence of PED, stratified by assessment time (≤ 3 h, 4-6 h, ≤ 24 h, and ≤ 48 h), was as follows: 31.0% (95% CI 8.0-59.0%), 28% (95% CI 22.0-35.0%), 41% (95% CI 33.0-49.0%), and 49.0% (95% CI 34.0-63.0%), respectively. When sample size was 100 < N ≤ 300, the PED incidence was more close to the overall PED incidence. Meta-regression analysis highlighted that sample size, assessment time and mean intubation time constituted the source of heterogeneity among the included studies. CONCLUSION: The incidence of PED was high among ICU patients who underwent orotracheal intubation. ICU professionals should raise awareness about PED. In the meantime, it is important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED.

Predictive Value of Serial Rapid Shallow Breathing Index Measurements for Extubation Success in Intensive Care Unit Patients.

Background and Objectives: Extubation success in ICU patients is crucial for reducing ventilator-associated complications, morbidity, and mortality. The Rapid Shallow Breathing Index (RSBI) is a widely used predictor for weaning from mechanical ventilation. This study aims to determine the predictive value of serial RSBI measurements on extubation success in ICU patients on mechanical ventilation. Materials and Methods: This prospective observational study was conducted on 86 ICU patients at Hitit University between February 2024 and July 2024. Patients were divided into successful and unsuccessful extubation groups. RSBI values were compared between these groups. Results: This study included 86 patients (32 females, 54 males) with a mean age of 54.51 ± 12.1 years. Extubation was successful in 53 patients and unsuccessful in 33. There was no significant difference in age and intubation duration between the groups (p = 0.246, p = 0.210). Significant differences were found in RSBI-1a and RSBI-2 values (p = 0.013, p = 0.011). The median RSBI-2a was 80 in the successful group and 92 in the unsuccessful group (p = 0.001). The ΔRSBI was higher in the unsuccessful group (p = 0.022). ROC analysis identified optimal cut-off values: RSBI-2a ≤ 72 (AUC 0.715) and ΔRSBI ≤ -3 (AUC 0.648). RSBI-2a ≤ 72 increased the likelihood of successful extubation by 10.8 times, while ΔRSBI ≤ -3 increased it by 3.4 times. Using both criteria together increased the likelihood by 28.48 times. Conclusions: Serial RSBI measurement can be an effective tool for predicting extubation success in patients on IMV. These findings suggest that serially measured RSBI may serve as a potential indicator for extubation readiness.

Effect of Bilateral Erector Spinae Plane Block versus Fentanyl Infusion on Postoperative Recovery in Cardiac Surgeries via Median Sternotomy: A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of ultrasound-guided bilateral erector spinae plane block (ESPB) on the time to extubation in patients who had undergone cardiac surgery through a midline sternotomy. DESIGN: Randomized controlled trial. SETTING: Cairo University Hospital and National Heart Institute, Egypt. PARTICIPANTS: Patients aged 18 to 70 years who underwent a cardiac surgical procedure through a midline sternotomy. INTERVENTIONS: Recruited patients were randomized to receive either preoperative single-shot ultrasound-guided bilateral ESPB or fentanyl infusion. MEASUREMENTS: The primary outcome was the time to extubation. Other outcomes included total perioperative fentanyl consumption, pain score using the numerical rating score (NRS), length of intensive care unit (ICU) stay, and incidence of perioperative complications. MAIN RESULTS: Two hundred and nineteen patients were available for final analysis. The mean time to extubation was significantly shorter In the ESPB group compared to the control group (159.5 ± 109.5 minutes vs 303.2 ± 95.9 minutes; mean difference, -143.7 minutes; 95% confidence interval, -171.1 to -116.3 minutes; p = 0.0001). Ultra-fast track (immediate postoperative) extubation was achieved in 23 patients (21.1%) in the ESPB group compared to only 1 patient (0.9%) in the control group. The ICU stay was significantly reduced in the ESPB group compared to the control group (mean, 47.2 ± 13.3 hours vs 78.9 ± 25.2 hours; p = 0.0001). There was a more significant reduction in NRS in the ESPB group compared to the control group for up to 24 hours postoperatively (p = 0.001). CONCLUSIONS: Among adult patients undergoing cardiac surgery through a midline sternotomy, the extubation time was halved in patients who received single-shot bilateral ESPB compared to patients who received fentanyl infusion.

Prospective multi-center evaluation of the incidence of unplanned extubation and its outcomes in French intensive care units. The Safe-ICU study.

BACKGROUND: We aimed to determine the epidemiology and outcomes of unplanned extubation (UE), both accidental and self-extubation, in ICU. METHODS: A multicentre prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, and planned and unplanned extubation were recorded in each center over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes were compared based on the UE mechanism (accidental or self-extubation). Self-extubation outcomes were compared with planned extubation using a propensity-matched population. Finally, risk factors for extubation failure (re-intubation before day 7) were determined following self-extubation. RESULTS: During the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 605 UE, 88% were self-extubation and 12% were accidental-extubations. The latter had a worse prognosis than self-extubation (34% vs. 8% ICU-mortality, p < 0.001). Self-extubation did not increase mortality compared with planned extubation (8% vs. 11%, p = 0.075). Regardless of the type of extubation, planned or unplanned, extubation failure was independently associated with a poor outcome. Cancer, higher respiratory rate, lower PaO2/FiO2 at the time of extubation, weaning process not-ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation. CONCLUSION: Unplanned extubation, mostly represented by self-extubation, is common in ICU and accounts for 9% of all endotracheal extubations. While accidental extubations are a serious and infrequent adverse event, self-extubation does not increase mortality compared to planned extubation.

Decibel level of coughing as a predictor of extubation outcome in mechanically ventilated intensive care patients: A prospective, observational study.

AIM: This study aims to evaluate the feasibility and clinical utility of measuring cough decibel level as predictive markers for extubation outcomes in mechanically ventilated patients. DESIGN: A prospective observational study. SETTING: Three interdisciplinary medical-surgical intensive care units across China. MAIN OUTCOME MEASURES: The primary outcomes assessed were extubation results in patients. Secondary measures included the cough decibel level, semiquantitative cough intensity scores, and white card test results recorded prior to extubation. RESULTS: A total of 71 patients were included, 55 patients were in the extubation success group and 16 in the failure group. The mean age was 78(71,83) years, mainly male (73.2 %). Despite the baseline characteristics being mostly consistent across both groups, significant differences were noted in duration of mechanical ventilation, and intensive care units and hospital stay. Remarkably, the cough decibel was substantially lower in the extubation failure group compared to the other group (78.69 ± 8.23 vs 92.28 ± 7.01 dB). The Receiver Operating Characteristic curve analysis revealed that a cough decibel below 85.77 dB is the optimal threshold for predicting extubation failure, exhibiting an 80 % sensitivity and 91.67 % specificity. CONCLUSION: The study corroborates that the cough decibel level serves as a quantifiable metric in patients undergoing mechanical ventilation. It posits that the likelihood of extubation failure escalates when the cough decibel falls below 85.77 dB. IMPLICATIONS FOR CLINICAL PRACTICE: Quantification of coughing capacity in decibels may be a good predictor of extubation outcome, thus offering assistance to healthcare professionals in evaluating the readiness of patients for extubation.

Frequency of Airway Complications with Modified Recovery Position versus Conventional Recovery position for Extubation after General Anaesthesia.

OBJECTIVE: To compare the frequency of respiratory complications encountered in two different positions used for extubation i.e. conventional recovery position versus the modified recovery position (recovery position with 10-degree left tilt and head-down). STUDY DESIGN: Comparative study. Place and Duration of the Study: Department of Anaesthesia, Combine Military Hospital, Kohat, Pakistan, from April 2022 to March 2023. METHODOLOGY: Two hundred patients scheduled for elective nose and throat surgeries were equally divided into two groups (Group C and Group M). Patients with history of bronchial asthma, chronic obstructive pulmonary disease (COPD), recent respiratory infection, and gastro-oesophageal reflux disease (GERD) were excluded from this study. Patients with more than two intubation attempts were also excluded. Group C patients were extubated in a conventional left lateral recovery position, whereas Group M patients were extubated in a modified recovery position with patient in a left lateral position with 10-degree head-down and 10-degree left tilt. All patients were observed for persistent coughing (coughing that lasted for at least 2 minutes after extubation), breath holding for 20 seconds or more, desaturation (oxygen saturation less than 90%), laryngospasm, need for reintubation, vomiting, and regurgitation. RESULTS: Frequency of airway complications was significantly higher in Group C as compared to Group M. In Group C, 18 (18%) out of hundred patients had complications compared to 6 (6%) patients only in Group M (p = 0.009). CONCLUSION: Extubation in a modified recovery position is associated with reduced frequency of airway complications as compared to the conventional recovery position. KEY WORDS: Airway complications, Extubation, Cough, Laryngospasm, Recovery position.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in the neonatal intensive care unit (NICU): an Australian NICU experience.

BACKGROUND: Preterm infants often require non-invasive breathing support while their lungs and control of respiration are still developing. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is an emerging technology that allows infants to breathe spontaneously while receiving support breaths proportional to their effort. This study describes the first Australian Neonatal Intensive Care Unit (NICU) experience of NIV-NAVA. METHODS: Retrospective cohort study of infants admitted to a major tertiary NICU between October 2017 and April 2021 supported with NIV-NAVA. Infants were divided into three groups based on the indication to initiate NIV-NAVA (post-extubation; apnoea; escalation). Successful application of NIV-NAVA was based on the need for re-intubation within 48 h of application. RESULTS: There were 169 NIV-NAVA episodes in 122 infants (82 post-extubation; 21 apnoea; 66 escalation). The median (range) gestational age at birth was 25 + 5 weeks (23 + 1 to 43 + 3 weeks) and median (range) birthweight was 963 g (365-4320 g). At NIV-NAVA application, mean (SD) age was 17 days (18.2), and median (range) weight was 850 g (501-4310 g). Infants did not require intubation within 48 h in 145/169 (85.2%) episodes [72/82 (87.8%) extubation; 21/21 (100%) apnoea; 52/66 (78.8%) escalation). CONCLUSION: NIV-NAVA was successfully integrated for the three main indications (escalation; post-extubation; apnoea). Prospective clinical trials are still required to establish its effectiveness versus other modes of non-invasive support.

Well-Tempered Medical Prompt Engineering for Explainable Extubation.

This study investigated whether the large language model (LLM) utilizes sufficient domain knowledge to reason about critical medical events such as extubation. In detail, we tested whether the LLM accurately comprehends given tabular data and variable importance and whether it can be used in complement to existing ML models such as XGBoost.

Early extubation after elective surgical aortic valve replacement during the COVID-19 pandemic.

BACKGROUND: Surgical aortic valve replacement (SAVR) is an established therapy for severe calcific aortic stenosis. Enhanced recovery after cardiac surgery (ERACS) protocols have been shown to improve outcomes for elective cardiac procedures. The COVID-19 pandemic prompted early extubation post-elective surgeries to preserve critical care resources. AIM OF THIS STUDY: To investigate the effects of extubating patients within 6 h post-elective SAVR on hospital and ICU length of stay, mortality rates, ICU readmissions, and postoperative pneumonia. STUDY DESIGN AND METHODS: The retrospective analysis at the University Hospital Aachen, Germany, includes data from 2017 to 2022 and compares a total of 73 elective SAVR patients. Among these, 23 patients were extubated within 6 h (EXT group), while 50 patients remained intubated for over 6 h (INT group). RESULTS: The INT group experienced longer postoperative ventilation, needed more vasopressor support, had a higher incidence of postoperative pneumonia, and longer ICU length of stay. No significant differences were noted in overall hospital length of stay, mortality, or ICU readmission rates between the groups. CONCLUSION: This study demonstrates that early extubation in high-risk, multimorbid surgical aortic valve replacement patients is safe, and is associated with a reduction of pneumonia rates, and with shorter ICU and hospital length of stays, reinforcing the benefits of ERACS protocols, especially critical during the COVID-19 pandemic to optimize intensive care use.