Investigating the risk of reintubation by cough force assessment using cough peak expiratory flow: a single-center observational pilot study.

BACKGROUND: No objective indicator exists for evaluating cough strength during extubation of tracheally intubated patients. This study aimed to determine whether cough peak expiratory flow (CPEF) can predict the risk of reintubation due to decreased cough strength. METHODS: This was a retrospective cohort study of patients who were admitted to our Emergency Intensive Care Unit between September 1, 2020 and August 31, 2021 and were under artificial ventilation management for ≥ 24 h. The patients were divided into two groups: successful extubation and reintubation groups, and the relationship between CPEF immediately before extubation and reintubation was investigated. RESULTS: Seventy-six patients were analyzed. In the univariate analysis, CPEF was significantly different between the successful extubation (90.7 ± 25.9 L/min) and reintubation (57.2 ± 6.4 L/min) groups (p < 0.001). In the multivariate analysis with age and duration of artificial ventilation as covariates, CPEF was significantly lower in the reintubation group (p < 0.01). The cutoff value of CPEF for reintubation according to the receiver operating characteristic curve was 60 L/min (area under the curve, 0.897; sensitivity, 78.5%; specificity, 90.9%; p < 0.01). CONCLUSION: CPEF in tracheally intubated patients may be a useful indicator for predicting the risk of reintubation associated with decreased cough strength. The cutoff CPEF value for reintubation due to decreased cough strength was 60 L/min.

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial.

BACKGROUND: Post-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general anesthesia occurs more frequently in nasal surgery than in other surgical procedures. This study aimed to assess the occurrence of emergence agitation in patients undergoing nasal surgery who were extubated under deep anesthesia or when fully awake. METHODS: A total of 202 patients (18-60 years, American Society of Anesthesiologists classification: I-II) undergoing nasal surgery under general anesthesia were randomized 1:1 into two groups: a deep extubation group (group D) and an awake extubation group (group A). The primary outcome was the incidence of emergence agitation. The secondary outcomes included number of emergence agitations, sedation score, vital signs, and incidence of adverse events. RESULTS: The incidence of emergence agitation was lower in group D than in group A (34.7% vs. 72.8%; p < 0.001). Compared to group A, patients in group D had lower Richmond Agitation-Sedation Scale scores, higher Ramsay sedation scores, fewer agitation episodes, and lower mean arterial pressure when extubated and 30 min after surgery, whereas these indicators did not differ 90 min after surgery. There was no difference in the incidence of adverse events between the two groups. CONCLUSIONS: Extubation under deep anesthesia can significantly reduce emergence agitation after nasal surgery under general anesthesia without increasing the incidence of adverse events. TRIAL REGISTRATION: Registered in Clinicaltrials.gov (NCT04844333) on 14/04/2021.

Assessing the reproducibility and predictive value of objective cough measurement for successful withdrawal of invasive ventilatory support in adult patients.

BACKGROUND: Utilizing clinical tests, such as objective cough measurement, can assist in predicting the success of the weaning process in critically ill patients. METHODS: A multicenter observational analytical study was conducted within a prospective cohort of patients recruited to participate in COBRE-US. We assessed the capability of objective cough measurement to predict the success of the spontaneous breathing trial (SBT) and extubation. Intra- and inter-observer reproducibility of the cough test and was evaluated using the intraclass correlation coefficient (ICC) and Cohen's weighted kappa. We used receiver operating characteristic curves (ROC-curve) to evaluate the predictive ability of objective cough measurement. RESULTS: We recruited 367 subjects who were receiving invasive mechanical ventilation. A total of 451 objective cough measurements and 456 SBTs were conducted. A significant association was found between objective cough measurement and successful SBT (OR: 1.68; 95% CI 1.48-1.90; p = 0.001). The predictive capability of the objective cough test for SBT success had a ROC-curve of 0.58 (95% CI: 0.56-0.61). Objective cough measurement to predict successful extubation had a ROC-curve of 0.61 (95% CI: 0.56-0.66). The intraobserver reproducibility exhibited an ICC of 0.94 (95% CI: 0.89-0.96; p < 0.001), while the interobserver reproducibility demonstrated an ICC of 0.72 (95% CI: 0.51-0.85; p < 0.001). The intraobserver agreement, assessed using Cohen's weighted kappa was 0.94 (95% CI: 0.93-0.99; p < 0.001), whereas the interobserver agreement was 0.84 (95% CI: 0.67 - 0.10; p < 0.001). CONCLUSIONS: The objective measurement of cough using the method employed in our study demonstrates nearly perfect intra-observer reproducibility and agreement. However, its ability to predict success or failure in the weaning process is limited.

Risk factors for delayed extubation after pediatric perineal anaplasty in patients less than 1 year of age: a retrospective study.

BACKGROUND: Anorectal malformation is a common congenital problem occurring in 1 in 5,000 births and has a spectrum of anatomical presentations, requiring individualized surgical treatments for normal growth. Delayed extubation or reintubation may result in a longer intensive care unit (ICU) stay and hospital stay, increased mortality, prolonged duration of mechanical ventilation, increased tracheostomy rate, and higher hospital costs. Extensive studies have focused on the role of risk factors in early extubation during major infant surgery such as Cardiac surgery, neurosurgery, and liver surgery. However, no study has mentioned the influencing factors of delayed extubation in neonates and infants undergoing angioplasty surgery. MATERIALS AND METHODS: We performed a retrospective study of neonates and infants who underwent anorectal malformation surgery between June 2018 and June 2022. The principal goal of this study was to observe the incidence of delayed extubation in pediatric anorectal malformation surgery. The secondary goals were to identify the factors associated with delayed extubation in these infants. RESULTS: We collected data describing 123 patients who had anorectal malformations from 2019 to 2022. It shows that 74(60.2%) in the normal intubation group and 49(39.8%) in the longer extubation. In the final model, anesthesia methods were independently associated with delayed extubation (P < 0.05). CONCLUSION: We found that the anesthesia method was independently associated with early extubation in neonates and infants who accepted pediatric anorectal malformation surgery.

Surfactant administration methods for premature newborns: LISA vs. INSURE comparative analysis.

INTRODUCTION: Respiratory Distress Syndrome (RDS) is the most common respiratory disorder among premature infants. The use of surfactant has significantly reduced respiratory complications and mortality. There are two conventional methods for administering surfactant: Intubate-Surfactant-Extubate (INSURE) and Less Invasive Surfactant Administration (LISA). This study aims to compare the effects of surfactant administration using these two methods on the treatment outcomes of premature newborns. MATERIALS AND METHODS: In this retrospective cohort study, we included 100 premature newborns with RDS and spontaneous breathing who were admitted to the Neonatal Intensive Care Unit of Besat Hospital in Sanandaj city in 2021. Exclusion criteria comprised congenital anomalies and the needing for intubation for resuscitation at birth. The outcomes of epmericaly trated with two methods were compared: the LISA (50 neonates) and the INSURE (50 neonates). Our interesting outcomes were needing for mechanical ventilation, duration of ventilation, pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia. Finally, we entered the data into STATA-14 statistical software and analyzed it using chi-square and t-tests. RESULTS: In this study, 69% of the neonates were boys. The LISA group exhibited significantly lower rates of need for mechanical ventilation (P = 0.003) and ventilation duration (P < 0.001) compared to the INSURE group. Conversely, there were no significant differences between the two groups (P > 0.05) in terms of pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia rates. CONCLUSION: The results of this study suggest that the LISA method is a safe and non-invasive approach for surfactant administration. Notably, it resulted in a reduced need for mechanical ventilation and decreased ventilation duration compared to the INSURE method.

Effect of Intravenous Dexmedetomidine Before Extubation on Emergence Delirium after Nasal Surgeries.

OBJECTIVE: To investigate the role of single dose of dexmedetomidine (0.5 mcg/kg) in reducing the incidence and severity of postoperative emergence delirium (EmD). STUDY DESIGN: A randomised controlled trial. Place and Duration of the Study: Department of Anaesthesia, Security Forces Hospital, Riyadh, Saudi Arabia, from 1st December 2022 to 30th March 2023. METHODOLOGY: Patients, aged between 18-65 years, with ASA 1-3 scheduled to undergo nasal surgeries under general anaesthesia, were inducted in the study. Exclusion criteria were patient refusal, later request for removal from the study, inability to give consent, known allergy to dexmedetomidine, body mass index (BMI) more than 35, history of obstructive sleep apnoea, history of psychiatric illness, pregnancy, and presence of liver and renal diseases. The primary outcome measure of the study was the incidence of emergence delirium in the postoperative period. RESULTS: The frequency of EmD after nasal surgery was 52.38% in the control group compared to 14.28% in the dexmedetomidine group (p = 0.01). Pain scores were not statistically different between the two groups. The duration of post anaesthesia care unit (PACU) stay was significantly lesser in dexmedetomidine group (p <0.001). The satisfaction score on the visual analogue scale (VAS) was also found to be higher in patients who received intravenous dexmedetomidine (p <0.001). CONCLUSION: The use of single dose dexmedetomidine before extubation in nasal surgeries reduces the EmD and improves patient satisfaction. KEY WORDS: Dexmedetomidine, Emergence delirium, Nasal surgery, Opioid consumption, Pain control.

Impact of Cluster Nursing Intervention on ICU Patients' Psychological Well-Being and Complications Associated with Tracheal Intubation and Extubation.

BACKGROUND Nurses in the Intensive Care Unit (ICU) play a critical role in recognizing patients who are at risk of deterioration by conducting continual assessments and taking suitable measures in response to changing health status. The validity of the cluster nursing intervention has been studied previously, but its use among ICU patients with tracheal intubation and extubation has not been examined. This study assessed the effectiveness of cluster nursing intervention in ICU patients with tracheal intubation and extubation. MATERIAL AND METHODS In this retrospective study, 80 patients on mechanical ventilation in the ICU ward were randomly assigned to control and intervention groups (40 patients each). The control group received the routine nursing mode, while the intervention group was given 5 sessions of cluster nursing intervention. Tracheal intubation and extubation-associated complications, blood gas analysis, patient nursing satisfaction, and changes in patients' negative emotions were compared before and after the intervention. RESULTS After the nursing intervention, the levels of PaO2 were higher, while PaCO2 levels were lower in the intervention group compared to the control group (P<0.05). Importantly, anxiety and depression scores in the intervention group were lower than in the control group (P<0.05). Moreover, the overall incidence of complications in the intervention group was lower than in the control group, whereas patient satisfaction with nursing services was higher (P<0.05). CONCLUSIONS Cluster nursing intervention can effectively reduce the incidence of complications and improve patients’ physiological and psychological conditions. Moreover, it enhances patient satisfaction with nursing services, thus improving patients' clinical symptoms.

A New Distal Pharyngeal Airway Device Associated with a Reduced Need for Chin-Lift and Jaw-Thrust Maneuvers in Sedated Patients.

Oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) sometimes require chin-lift or jaw-thrust (CLJT) maneuvers to relieve airway obstruction which creates the burden of continuous hands-on care by the anesthesia provider. A new distal pharyngeal airway device (DPA) was used on 63 successive ambulatory surgery patients to assess the frequency of patients requiring manual CLJT maneuvers to prevent airway obstruction. Results were then compared with a contemporaneous group of patients who had used OPA or NPA devices for similar procedures. Patients using the DPA had a 38.5% lower rate of CLJT maneuvers compared with the combined OPA/NPA groups (22.2% of 63 vs. 60.7% of 163, P ≤ .001). Moreover, the results for the DPA group were close to those of the natural airway group (22.2% of 62 vs. 24.8% of 233, P = .66) Results were similar for a sub-set of the above groups who required deep sedation or deep extubation. CLJT maneuvers were common in this ambulatory surgery setting. The new DPA device was associated with a reduced need for such manual maneuvers when compared with similar patients who received OPA or NPA devices and is comparable with the rate for natural airways.

Effect of intravenous and topical laryngeal lidocaine on sore throat after extubation: a prospective randomized controlled study.

OBJECTIVE: The present study aimed to compare the effect of topical laryngeal lidocaine with intravenous lidocaine before endotracheal intubation on the incidence and severity of postoperative sore throat, hoarseness, and cough. PATIENTS AND METHODS: This prospective randomized controlled study enrolled 144 patients undergoing laparoscopic cholecystectomy with endotracheal intubation. The patients were randomized to three groups and received 2% lidocaine by topical laryngeal spray (group T), intravenous 2% lidocaine (group I), and the equivalent volume of intravenous saline (group C) before intubation. The incidence and severity of sore throat, hoarseness, and cough reaction at 0.5, 1, 6, and 24 h after extubation were collected. RESULTS: The incidence of sore throat was significantly lower in group T than in groups I and C (6.4% vs. 37.2% and 86.7%, p < 0.001), respectively at 0.5 h after extubation, and it was significantly lower in group I than that in group C (37.2% vs. 86.7%, p < 0.001). Both the incidence of hoarseness and cough were significantly lower in group T than in group I and in group C (14.9% vs. 97.7% and 97.8%, p < 0.001, and 19.1% vs. 72.0% and 93.3%, p < 0.001), respectively. The severity of sore throat, hoarseness and cough in group T was significantly lower than that in group I and that in group C (p < 0.05), and it was significantly lower in group I than in group C (p < 0.05). CONCLUSIONS: Both topical laryngeal lidocaine and intravenous lidocaine before intubation have positive effects on preventing sore throat. Topical laryngeal route was superior to intravenous route. Chictr.org.cn ID: ChiCTR2100042442.

Air leak test in the Paediatric Intensive Care Unit (ALTIPICU): rationale and protocol for a prospective multicentre observational study.

INTRODUCTION: In children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has not been extensively studied in children. The objective of the ongoing study whose protocol is reported here is to investigate how well the qtCLT predicts UAO-related postextubation respiratory distress in paediatric intensive care unit (PICU) patients. METHODS AND ANALYSIS: Air Leak Test in the Paediatric Intensive Care Unit is a multicentre, prospective, observational study that will recruit 900 patients who are aged 2 days post-term to 17 years and ventilated through a cuffed endotracheal tube for at least 24 hours in any of 19 French PICUs. Within an hour of planned extubation, the qtCLT will be performed as a sequence of six measurements of the tidal volume with the cuff inflated then deflated. The primary outcome is the occurrence within 48 hours after extubation of severe UAO defined as combining a requirement for intravenous corticosteroid therapy and/or ventilator support by high-flow nasal cannula and/or by non-invasive ventilation or repeat invasive mechanical ventilation with a Westley score ≥4 with at least one point for stridor at each initiation. The results of the study are expected to identify risk factors for UAO-related postextubation respiratory distress and extubation failure, thereby identifying patient subgroups most likely to require preventive interventions. It will also determine whether qtCLT appears to be a reliable method to predict an increased risk for postextubation adverse events as severe UAO. ETHICS AND DISSEMINATION: The study was approved by the Robert Debré University Hospital institutional review board (IRB) on September 2021 (approval #2021578). The report of Robert Debré University Hospital IRB is valid for all sites, given the nature of the study with respect to the French law. The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05328206.

Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial.

BACKGROUND: Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required. METHODS: We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring. RESULTS: We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36. CONCLUSIONS: Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population. TRIAL REGISTRATION: Clinical trials registration (NCT04958668) was completed on 1 July 2021.

Factors Associated With Time to Decannulation in Patients With Tracheostomy Following Severe Traumatic Brain Injury.

BACKGROUND: Prolonged tracheal tube placement following severe traumatic brain injury (TBI) can cause serious complications. Safe removal requires sufficient ability for independent breathing and airway protection. Thus, identifying important factors for time to removal of the tracheal tube (decannulation) is essential for safe and efficient weaning. This study aimed to identify significant factors for time to decannulation in a Danish population of subjects with tracheostomy after TBI. METHODS: This was a retrospective register-based cohort study. Subjects with moderate and severe TBI and a tracheal tube were selected from the Danish Head Trauma Database between 2011-2021. Time to decannulation was calculated as time from injury to decannulation. Associations between selected explanatory variables representing demographic and clinical characteristics and time to decannulation were analyzed using linear regression models. RESULTS: A total 324 subjects were included with a median of 44 d to decannulation. Primary analysis found that an improvement in swallowing ability during the initial 4 weeks of rehabilitation was associated with an 8.2 d reduction in time to decannulation (95% CI -12.3 to -4.2, P < .001). Change in overall sensorimotor ability reduced time to decannulation by 0.94 (95% CI -0.78 to -0.10, P = .03) d. Change in cognitive abilities from rehab admission to 4-week follow-up did not significantly affect the number of days to decannulation (P = .66). Secondary analysis showed pneumonia was associated with the largest estimated increase of 24.4 (95% CI 15.9-32.9, P < .001) d and that increased cognitive functioning at rehabilitation admission was associated with a significant reduction in time to decannulation. CONCLUSIONS: This study found that a change in swallowing ability is a potentially significant factor for reducing time to decannulation. Identifying factors that could explain differences in time to decannulation is essential for patient outcomes, especially if these factors are modifiable and could be targeted in rehabilitation and treatment.

Association of Caffeine Daily Dose With Respiratory Outcomes in Preterm Neonates: A Retrospective Cohort Study.

Apnea and poor respiratory drive increase the risk of extubation failure (EF) and prolonged invasive mechanical ventilation (IMV) in preterm neonates (pre-nates) with respiratory distress. Caffeine citrate (CC) is often prescribed for pre-nates in doses of 5-10 mg/kg in 24 h. This study aimed to evaluate the most effective dosage regimen (5 mg/kg/day vs >5-10 mg/kg/day) to prevent apnea and EF with minimal caffeine-associated potential side effects (CC-APSEs) in pre-nates. This one-year retrospective cohort study included all the eligible neonates admitted to NICU and received CC-therapy till 28 days of life (DOL) or discharge. Based on CC-daily dose formed LD-caffeine-group (5 mg/kg/day) and HD-caffeine-group (>5-10 mg/kg/day). Antenatal, prenatal, and postnatal characteristics, CC-regimen, comorbidities, and CC-APSEs were compared between the groups. Predictors of apnea and EF were analyzed through logistic regression. There were 181 and 72 neonates in the LD and HD-caffeine-groups respectively. In HD-caffeine-group daily CC-dose was 7 to 7.5 mg/kg/day in 93% of neonates and >7.5 to 10 mg/kg/day in only 7%. Significantly fewer neonates experienced apnea and EF in the HD-caffeine-group till 28DOL or discharge. This difference was even greater in the subgroup of ≤28 weeks GA (15.6% vs 40.0%; P < .01). In HD-caffeine-group the incidence of severe/moderate-BPD was significantly lower and the frequency of CC-APSEs was higher. Multivariate analysis showed that; the smaller the GA higher the risk of apnea (AOR = 0.510, 95% CI 0.483-0.999) and EF (AOR = 0.787, 95% CI 0.411-0.997). The HD-caffeine was inversely associated with developing apnea (AOR = 0.244, 95% CI 0.053-0.291) and EF (AOR = 0.103, 95% CI 0.098-2.976). IMV-duration before extubation (AOR = 2.229, 95% CI 1.672-2.498) and severe/moderate-BPD (AOR = 2.410, 95%CI 1.104-2.952) had a high risk of EF. Initiating early HD-caffeine may prevent apnea and extubation failure in preterm neonates. Optimization of caffeine initiation time and dosages can be a safe and feasible approach to decrease the burden of neonatal respiratory morbidities.

Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes.

BACKGROUND: Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS: This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS: A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS: Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

Pressure Support Ventilation Versus T-piece as Spontaneous Breathing Trials for Extubation of Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Weaning patients with COPD from mechanical ventilation (MV) presents a challenge, as literature on this topic is limited. This study compares PSV and T-piece during spontaneous breathing trials (SBT) in this specific population. METHODS: A search of PubMed, EMBASE, and Cochrane in September 2023 yielded four randomized controlled trials (RCTs) encompassing 560 patients. Among these, 287 (51%) used T-piece during SBTs. RESULTS: The PSV group demonstrated a significant improvement in the successful extubation rate compared to the T-piece (risk ratio [RR] 1.14; 95% confidence interval [CI] 1.03-1.26; p = 0.02). Otherwise, there was no statistically significant difference in the reintubation (RR 1.07; 95% CI 0.79-1.45; p = 0.67) or the ICU mortality rates (RR 0.99; 95% CI 0.63-1.55; p = 0.95). CONCLUSION: Although PSV in SBTs exhibits superior extubation success, consistent weaning protocols warrant further exploration through additional studies.

Weaning from mechanical ventilation and assessment of extubation readiness.

Tremendous advancements in neonatal respiratory care have contributed to the improved survival of extremely preterm infants (gestational age ≤ 28 weeks). While mechanical ventilation is often considered one of the most important breakthroughs in neonatology, it is also associated with numerous short and long-term complications. For those reasons, clinical research has focused on strategies to avoid or reduce exposure to mechanical ventilation. Nonetheless, in the extreme preterm population, 70-100% of infants born 22-28 weeks of gestation are exposed to mechanical ventilation, with nearly 50% being ventilated for ≥ 3 weeks. As contemporary practices have shifted towards selectively reserving mechanical ventilation for those patients, mechanical ventilation weaning and extubation remain a priority yet offer a heightened challenge for clinicians. In this review, we will summarize the evidence for different strategies to expedite weaning and assess extubation readiness in preterm infants, with a particular focus on extremely preterm infants.

Respiratory Support After Extubation in Children With Pediatric ARDS.

BACKGROUND: Postextubation respiratory support in pediatric ARDS may be used to support the recovering respiratory system and promote timely, successful liberation from mechanical ventilation. This study's aims were to (1) describe the use of postextubation respiratory support in pediatric ARDS from the time of extubation to hospital discharge, (2) identify potential risk factors for postextubation respiratory support, and (3) provide preliminary data for future larger studies. METHODS: This pilot single-center prospective cohort study recruited subjects with pediatric ARDS. Subjects' respiratory status up to hospital discharge, the use of postextubation respiratory support, and how it changed over time were recorded. Analysis was performed comparing subjects who received postextubation respiratory support versus those who did not and compared its use among pediatric ARDS severity categories. Multivariable logistic regression was used to determine variables associated with the use of postextubation respiratory support and included oxygenation index (OI), ventilator duration, and weight. RESULTS: Seventy-three subjects with pediatric ARDS, with median age and OI of 4 (0.6-10.5) y and 7.3 (4.9-12.7), respectively, were analyzed. Postextubation respiratory support was provided to 54/73 (74%) subjects: 28/45 (62.2%), 19/21 (90.5%), and 7/7 (100%) for mild, moderate, and severe pediatric ARDS, respectively, (P = .01). OI and mechanical ventilation duration were higher in subjects who received postextubation respiratory support (8.7 [5.4-14] vs 4.6 [3.7-7], P < .001 and 10 [7-17] d vs 4 [2-7] d, P < .001) compared to those who did not. At hospital discharge, 12/67 (18.2%) survivors received home respiratory support (6 subjects died prior to hospital discharge). In the multivariable model, ventilator duration (adjusted odds ratio 1.3 [95% CI 1.0-1.7], P = .050) and weight (adjusted odds ratio 0.95 [95% CI 0.91-0.99], P = .02) were associated with the use of postextubation respiratory support. CONCLUSIONS: The majority of intubated subjects with pediatric ARDS received respiratory support postextubation, and a substantial proportion continued to require it up to hospital discharge.