Ventilator variables predicting extubation readiness in extremely premature infants with prolonged mechanical ventilation: A retrospective observational study.

BACKGROUND: The current generation of neonatal ventilators enables periodic storage of set, measured, and calculated ventilatory parameters. DESIGN: Retrospective observational study. OBJECTIVES: To evaluate and identify the ventilatory, demographic, and clinical pre-extubation variables that are significant for estimating extubation readiness. METHODS: Eligible subjects included premature infants <33 weeks of gestation weaned from mechanical ventilation (MV) lasting >24 h. A total of 16 relevant ventilator variables, each calculated from 288 data points over 24 h, together with eight demographic and three clinical pre-extubation variables, were used to create the generalized linear model (GLM) for a binary outcome and the Cox proportional hazards model for time-to-event analysis. The achievement of a 120-h period without reintubation was defined as a successful extubation attempt (EA) within the binary outcome. RESULTS: We evaluated 149 EAs in 81 infants with a median (interquartile range) gestational age of 25+2 (24+3-26+1) weeks. Of this, 90 EAs (60%) were successful while 59 (40%) failed. GLM identified dynamic compliance per kilogram, percentage of spontaneous minute ventilation, and postmenstrual age as significant independent positive variables. Conversely, dynamic compliance variability emerged as a significant independent negative variable for extubation success. This model enabled the creation of a probability estimator for extubation success with a good proportion of sensitivity and specificity (80% and 73% for a cut-off of 60%, respectively). CONCLUSIONS: Ventilator variables reflecting lung mechanical properties and the ability to spontaneously breathe during MV contribute to better prediction of extubation readiness in extremely premature infants with chronic lung disease.

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.

Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A Delphi study.

OBJECTIVE: The objective of this study was to develop an extubation practice protocol for adult intensive care unit (ICU) patients who underwent endotracheal intubation, providing theoretical guidance for clinical extubation procedures in the ICU. METHODS: A research team was established consisting of medical, nursing, anaesthesia, and respiratory therapy professionals; the multidisciplinary team systematically searched domestic and foreign literature, summarised the best evidence, and combined it with clinical practice experience to preliminarily develop an extubation protocol for adult ICU patients who underwent endotracheal intubation. Seventeen experts in critical care medicine, intensive care nursing, clinical anaesthesia, and respiratory therapy were invited to participate in a Delphi expert consultation to screen and modify the draft protocol. RESULTS: The response rates of the two Delphi expert enquiries were 100% and 94.1%, with expert authority coefficients of 0.94 and 0.93, respectively, and Kendall's concordance coefficients were 0.152 and 0.198, respectively, indicating statistically significant differences (p < 0.001). The final protocol included three level I indicators, 14 level II indicators, and 34 level III indicators, covering extubation evaluation, implementation, and postextubation management. CONCLUSION: The extubation protocol for adult tracheal intubation patients in the ICU constructed in this study is scientific, practical, and reliable. This study can provide theoretical guidance for extubation in ICU patients who have undergone endotracheal intubation.

Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study.

PURPOSE: A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital. METHODS: In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia). RESULTS: We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2 years, standard deviation [SD] 25.2 years) and 8,091 in the normal pressure extubation group (mean age 47.8 years, SD 25.8 years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94). CONCLUSIONS: These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique. CLINICAL TRIAL NUMBER: Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

Impact of Inspiratory Muscle Training and Positive Expiratory Pressure on Lung Function and Extubation Success of ICU Patients: a Randomized Controlled Trial.

Introduction: Preparing patients for extubation from mechanical ventilation (MV) necessitates focused respiratory muscle strengthening. This study aimed to evaluate the effect of threshold inspiratory muscle training (IMT) and positive expiratory pressure (PEP) exercises on outcomes of patients who underwent MV in intensive care unit (ICU). Methods: This randomized controlled trial was conducted in 2023 at the ICUs of Imam Reza Hospital, Mashhad, Iran. Participants were allocated to either intervention or control group (each comprising 35 patients) through block randomization. The intervention group received standard daily chest physiotherapy as well as targeted inspiratory and expiratory muscle strengthening exercises using the threshold IMT/PEP device, administered twice daily over one week. The control group received standard daily chest physiotherapy alone. Finally, the outcomes (lung compliance, duration of intubation, extubation success rate, and diaphragmatic metrics) of the two groups were compared. Results: 70 patients with the mean age of 56.10 ± 14.15 (range: 28.00-85.00) years were randomly divided into two groups (50% male). Significant improvements were observed in the intervention group regarding pulmonary compliance values (35.62 ± 4.43 vs. 30.85 ± 6.93; p= 0.001), peak expiratory flow (PEF) (55.20 ± 10.23 vs. 47.80 ± 11.26; p = 0.002), and maximum inspiratory pressure (MIP) (33.40 ± 4.25 vs. 30.08 ± 6.08; p = 0.01) compared to the control group. Diaphragm inspiratory thickness (0.29 ± 0.03 vs. 0.26 ± 0.04; p = 0.001), diaphragm expiratory thickness (0.22 ± 0.03 vs. 0.20 ± 0.04; p = 0.006) and motion (1.61 ± .29 vs. 1.48 ± .21; p = 0.04) also exhibited significant differences between the two groups. Extubation success rate was higher in the intervention group (68.60% vs. 40%; p = 0.01). The duration of mechanical ventilation was 15.14±7.07 days in the intervention group and 17.34±7.87 days in the control group (p = 0.20). The mean extubation time was 7.00 ± 1.88 days for the intervention group and 9.00 ± 2.00 days for the control (p < 0.001). Conclusion: Threshold IMT/PEP device exercises effectively enhance respiratory muscle strength, diaphragm thickness, and reduce ventilator dependency. These findings support their potential for inclusion in rehabilitation programs for ICU patients.

Analyzing Risk Factors for Delayed Extubation Following Posterior Approach Surgery for Congenital Scoliosis: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Investigate the risk factors for delayed extubation after posterior approach orthopedic surgery in patients with congenital scoliosis. METHODS: The clinical data of patients who received surgery for congenital scoliosis at the First Affiliated Hospital of Xinjiang Medical University between January 2021 and July 2023 have been gathered. Patients are categorized into the usual and the delayed extubation groups, depending on the duration of tracheal intubation after surgery. The study employs univariate and multivariate logistic regression models to examine the clinical characteristics of the two cohorts and discover potential risk factors linked to delayed extubation. In addition, a prediction model is created to visually depict the significance of each risk factor in terms of weight according to the nomogram. RESULTS: A total of 119 patients (74.8% females), with a median age of 15 years, are included. A total of 32 patients, accounting for 26.9% of the sample, encountered delayed extubation. Additionally, 13 patients (10.9%) suffered perioperative complications, with pneumonia being the most prevalent. The multivariate regression analysis revealed that the number of osteotomy segments, postoperative hematocrit, postoperative Interleukin-6 levels, and weight are predictive risk factors for delayed extubation. CONCLUSIONS: Postoperative hematocrit and Interleukin-6 level, weight, and number of osteotomy segments can serve as independent risk factors for predicting delayed extubation, with combined value to assist clinicians in evaluating the risk of delayed extubation of postoperative congenital scoliosis patients, improving the success rate of extubation, and reducing postoperative treatment time in the intensive care unit.

Extravascular lung water assessment by lung ultrasound in infants following pediatric cardiac surgery.

BACKGROUND: Lung edema is a significant factor in prolonged mechanical ventilation and extubation failure after cardiac surgery. This study assessed the predictive capability of point-of-care Lung Ultrasound (LUS) for the duration of mechanical ventilation and extubation failure in infants following cardiac procedures. METHODS: We conducted a prospective observational trial on infants under 1 year, excluding those with pre-existing conditions or requiring extracorporeal membrane oxygenation. LUS was performed upon intensive care unit (ICU) admission and prior to extubation attempts. B-line density was scored by two independent observers. The primary outcomes included the duration of mechanical ventilation and extubation failure, the latter defined as the need for reintubation or non-invasive ventilation within 48 h post-extubation. RESULTS: The study included 42 infants, with findings indicating no correlation between initial LUS scores and extubation timing. Extubation failure occurred in 21% of the patients, with higher LUS scores observed in these cases (p = 0.046). However, interobserver variability was high, impacting the reliability of LUS scores to predict extubation readiness. CONCLUSIONS: LUS was ineffective in determining the length of postoperative ventilation and extubation readiness, highlighting the need for further research and enhanced training in LUS interpretation.

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.

Development of Extubation Success Prediction Model for Mechanically Ventilated Patients with Spontaneous Cerebellar Hemorrhage.

Spontaneous cerebellar hemorrhage (SCH) patients have a low success rate in extubation, but there are currently no guidelines establishing specifically for SCH patients extubation. The study included 68 SCH patients who received mechanical ventilation for more than 24 h, with 39 cases (57.3%) resulting in successful extubation. The multivariate analysis identified four factors significantly associated with extubation success: patient age under 66 years, an Intracerebral Hemorrhage (ICH) score less than 4 points, the presence of tissue shift, and a Glasgow Coma Scale (GCS) score (excluding language) above 6 points at extubation. By simplifying the prediction model, we obtained the Spontaneous Cerebellar Hemorrhage Extubation Success scoring system (SCHES-SCORE). Within the scoring system, 2 points were allocated for a GCS score (excluding language) above 6 at extubation, 1 point each for age under 66 years and an ICH score below 4, while tissue shift was assigned a negative point. A score of Grade A (SCHES-SCORE = 3-4) was found to correlate with a 92.9% success rate for extubation. The area under the receiver operating characteristic curve was 0.923 (95% CI, 0.863 to 0.983). Notably, successful extubation was significantly linked to reduced durations of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay. In conclusion, the scoring system developed for assessing extubation outcomes in SCH patients has the potential to enhance the rate of successful extubation and overall patient outcomes.

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.

High Flow Nasal Cannula Versus Conventional Oxygen Therapy and Incidence of Post-Extubation Airway Obstruction in PICU: An Open-Label Randomized Controlled Trial (HiFloCOT-PICU Trial).

OBJECTIVES: To study the impact of high flow nasal cannula (HFNC) vs. conventional oxygen therapy (COT) (by simple nasal cannula) as respiratory support after extubation on the rates of post-extubation airway obstruction (PEAO) among mechanically ventilated critically ill children. METHODS: This open-label randomized controlled trial was conducted in pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India over a period of 7 mo (11 August 2021 to 10 March 2022). Children aged 3 mo to 12 y who required invasive mechanical ventilation for > 72 h and had passed spontaneous breathing trial (ready for extubation) were enrolled and randomized by computer generated block randomization to receive HFNC or COT after extubation. Primary outcome was rate of PEAO (assessed by modified Westley croup score, mWCS) within 48 h of extubation; and secondary outcomes were rate and number of adrenaline nebulization, treatment failure (requiring escalation of respiratory support), extubation failure, adverse events, and length of PICU stay in two groups. RESULTS: During the study period, 116 children were enrolled (58 each in HFNC and COT groups). There was no difference in rate of PEAO (55% vs. 51.7%, respectively), need of adrenaline nebulization, extubation failure, adverse events, and duration of PICU stay in two groups. However, the HFNC group had significantly lower rates of treatment failure (27.6% vs. 48.3%, p = 0.02). CONCLUSIONS: The rate of PEAO was similar in HFNC and COT groups. However, HFNC group had significantly lower rate of treatment failure requiring escalation of respiratory support.

Dexamethasone Use to Reduce Mechanical Ventilation and Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit.

Background: Ventilator-dependent neonates are at risk of bronchopulmonary dysplasia (BPD), a chronic lung disease. Dexamethasone may be used to facilitate extubation and reduce the incidence of BPD. Objectives: To determine the efficacy of dexamethasone in reducing the incidence of established BPD at 36 weeks postmenstrual age (PMA); to establish the rate of extubation success; to determine the factors affecting extubation success; and to describe complications associated with dexamethasone therapy. Methods: A chart review was conducted at Surrey Memorial Hospital, in Surrey, British Columbia, for neonates who received dexamethasone to reduce the development of BPD between July 1, 2016, and June 30, 2022. Results: A total of 47 neonates met the inclusion criteria. Of the 45 neonates still alive at 36 weeks PMA, all (100%) had BPD. Use of dexamethasone led to extubation success for 21 (47%) of these 45 neonates. The mean PMA at dexamethasone initiation was 30.7 weeks for neonates with extubation success, compared with 28.6 weeks for those with extubation failure (p = 0.001). Complications occurred in 43 (91%) of the 47 neonates. Conclusions: BPD occurred in all of the neonates, despite a 47% extubation success rate. The timing of dexamethasone initiation was associated with extubation success. Further research is required to determine the dose and timing of dexamethasone needed to reduce the incidence of BPD.

Contexte: Les nouveau-nés qui dépendent d'un ventilateur sont exposés à un risque de dysplasie broncho-pulmonaire (DBP), une maladie pulmonaire chronique. La dexaméthasone peut être utilisée pour faciliter l'extubation et réduire l'incidence de cette maladie. Objectifs: Déterminer l'efficacité de la dexaméthasone pour réduire l'incidence de la DBP établie à 36 semaines d'âge postmenstruel (APM); établir la réussite de l'extubation; déterminer les facteurs ayant une incidence sur cette dernière; et décrire les complications associées au traitement par la dexaméthasone. Méthodologie: Un examen des dossiers a été effectué à l'hôpital Surrey Memorial, à Surrey (Colombie-Britannique) pour les nouveau-nés ayant reçu de la dexaméthasone entre le 1er juillet 2016 et le 30 juin 2022 afin de réduire le risque de DBP. Résultats: Au total, 47 nouveau-nés répondaient aux critères d'inclusion. Sur les 45 nouveau-nés encore en vie à 36 semaines d'APM, tous (100 %) souffraient de DBP. L'utilisation de dexaméthasone a permis de réussir l'extubation chez 21 (47 %) de ces 45 nouveau-nés. L'APM moyen au début de l'administration de la dexaméthasone était de 30,7 semaines pour les nouveau-nés dont l'extubation avait été réussie, contre 28,6 semaines pour ceux chez qui ce n'était pas le cas (p = 0,001). Des complications sont survenues chez 43 (91 %) des 47 nouveau-nés. Conclusions: La DBP est survenue chez tous les nouveau-nés, malgré un taux de réussite d'extubation de 47 %. Le moment du début de l'administration de la dexaméthasone était associé à la réussite de l'extubation réussie. Des recherches supplémentaires sont nécessaires pour déterminer la dose de dexaméthasone requise et le moment opportun de l'administration pour réduire l'incidence de la BPD.

Compassionate Ventilator Release in Patients With Neuromuscular Disease: A Two-Case Comparison.

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease.

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.

Incidence, risk factors and long-term outcomes for extubation failure in intensive care unit in patients with obesity A retrospective analysis of a multicenter prospective observational study.

BACKGROUND: No large observational study has compared the incidence and risk factors for extubation failure within 48 hours and during intensive care unit (ICU) stay in the same cohort of unselected critically ill patients with and without obesity. RESEARCH QUESTION: Which are the incidence and risk factors of extubation failure in patients with and without obesity? STUDY DESIGN AND METHODS: In this prospective multicenter observational FREE-REA study in 26 intensive care units, the primary objective was to compare the incidence of extubation failure within 48 hours in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis. RESULTS: Of 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1082 (79%) in patients without obesity. The incidence of extubation failure within 48 hours among patients with or without presence of obesity was 23/288 (8.0%) versus 118/1082 (11%) respectively; unadjusted odds ratio (OR) 0.71 95% confidence interval (CI, 0.45-1.13), P=0.15); alongside patients with obesity receiving significantly more noninvasive ventilation (87/288, 30% versus 233/1082, 22%, P=0.002) and physiotherapy (165/288, 57% versus 527/1082, 49%, P=0.02) than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female gender [adjusted (a)OR 4.88 95%CI(1.61-13.9), P=0.002] and agitation before extubation [aOR 6.39 95%CI (1.91-19.8), P=0.001] in patients with obesity; absence of strong cough before extubation [aOR 2.38 95%CI (1.53-3.84), P=0.0002] and duration of invasive mechanical ventilation before extubation [aOR 1.03 per day 95%CI (1.01-1.06), P=0.01] in patients without obesity. The decision tree analysis found similar risk factors. INTERPRETATION: Our findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rate of extubation failure among patients with and without obesity. CLINICAL TRIAL REGISTRATION: NCT XXX.

Mobility Levels of Critically Ill Adult Patients and Extubation Success: A Cohort Study.

Background: The reduced mobility in critically ill patients is still a reality in many intensive care units. This study aims to investigate if mobility level is associated with extubation outcome in adult patients.Methods: Prospective cohort study which comprised adults who had undergone initial invasive mechanical ventilation for more than 24 hours and were independently mobile before hospitalization. Patient progress was monitored from ICU admission to discharge. Data were collected daily from medical records and multidisciplinary teams, considering variables such as age, sex, BMI, SAPS III score, type of ICU admission, comorbidities, sedation, usage of vasoactive drugs, neuromuscular blockers, duration of mechanical ventilation, and ICU mobility scale (IMS). The primary outcome was the success of extubation.Results: IMS values did not directly associate with extubation outcome. Older patients demonstrated a reduced tendency for high IMS values, as did those on prolonged usage of vasoactive drugs or mechanical ventilation. Patients with higher IMS values achieved successful extubation earlier, suggesting a link between mobility and faster extubation success.Conclusion: The level of mobility assessed 24 hours after extubation was not associated with extubation success. The following characteristics were associated with a lower propensity to present high IMS: older age, greater number of days of use of vasoactive drugs and mechanical ventilation. Patients with higher levels of mobility had a successful extubation event earlier in the ICU. Studies that assess mobility on a continuous basis would be more precise in identifying this association.

The Complex Interplay of Variables in Extubation Decision-Making Following Pediatric Cardiac Surgery: A Narrative Review.

Pediatric cardiac surgery poses significant challenges in developing countries, where a considerable number of children require intervention for congenital heart disease (CHD). The utilization of endotracheal intubation and anesthesia is pivotal in conducting surgical or angiography procedures on patients with CHD exhibiting diverse anatomical and hemodynamic characteristics. The decision to extubate pediatric patients following cardiac surgery remains a crucial element of postoperative care. This article explores the complexities surrounding extubation decision-making in this population, emphasizing the critical role of surgical, physiological, and postoperative factors. Various preoperative and intraoperative factors influence the timing of extubation. Early extubation is increasingly prevalent, offering benefits like reduced length of stay and minimized drug exposure. Multidisciplinary collaboration and protocol-driven strategies contribute to improved extubation outcomes, emphasizing the need for a comprehensive approach in pediatric cardiac surgery. Future research can focus on the implementation and efficacy of standardized extubation procedures involving collaboration among healthcare experts.

Feasibility of deescalating postoperative care in enhanced recovery after cardiac surgery.

Introduction: Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring. Methods: 358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU). Results: Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery (n = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement (n = 79) and aortic surgery (n = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU. Conclusions: If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.

Inhalational Agent Dosing Behaviors of Anesthesia Practitioners Cause Variability in End-Tidal Concentrations at the End of Surgery and Prolonged Times to Tracheal Extubation.

INTRODUCTION: Prolonged times to tracheal extubation are intervals from the end of surgery to extubation ≥15 minutes. We examined why there are associations with the end-tidal inhalational agent concentration as a proportion of the age­adjusted minimum alveolar concentration (MAC fraction) at the end of surgery. METHODS: The retrospective cohort study used 11.7 years of data from one hospital. All p­values were adjusted for multiple comparisons. RESULTS: There was a greater odds of prolonged time to extubation if the anesthesia practitioner was a trainee (odds ratio 1.68) or had finished fewer than five cases with the surgeon during the preceding three years (odds ratio 1.12) (both P<0.0001). There was a greater risk of prolonged time to extubation if the MAC fraction was >0.4 at the end of surgery (odds ratio 2.66, P<0.0001). Anesthesia practitioners who were trainees and all practitioners who had finished fewer than five cases with the surgeon had greater mean MAC fractions at the end of surgery and had greater relative risks of the MAC fraction >0.4 at the end of surgery (all P<0.0001). The source for greater MAC fractions at the end of surgery was not greater MAC fractions throughout the anesthetic because the means during the case did not differ among groups. Rather, there was substantial variability of MAC fractions at the end of surgery among cases of the same anesthesia practitioner, with the mean (standard deviation) among practitioners of each practitioner's standard deviation being 0.35 (0.05) and the coefficient of variation being 71% (13%). CONCLUSION: More prolonged extubations were associated with greater MAC fractions at the end of surgery. The cause of the large MAC fractions was the substantial variability of MAC fractions among cases of each practitioner at the end of surgery. That variability matches what was expected from earlier studies, both from variability among practitioners in their goals for the MAC fraction given at the start of surgical closure and from inadequate dynamic forecasting of the timing of when surgery would end. Future studies should examine how best to reduce prolonged extubations by using anesthesia machines' display of MAC fraction and feedback control of end-tidal agent concentration.

Ultrasound evaluation of cardiac and diaphragmatic function at different positions during a spontaneous breathing trial predicting extubation outcomes: a retrospective cohort study.

BACKGROUND: The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed to predict extubation outcomes. However, few studies focused on the predicting value of E/Ea and DE at different positions during a spontaneous breathing trial (SBT), as well as the effects of △E/Ea and △DE (changes in E/Ea and DE during a SBT). METHODS: This study was a reanalysis of the data of 60 difficult-to-wean patients in a previous study published in 2017. All eligible participants were organized into respiratory failure (RF) group and extubation success (ES) group within 48 h after extubation, or re-intubation (RI) group and non-intubation (NI) group within 1 week after extubation. The risk factors for respiratory failure and re-intubation including E/Ea and △E/Ea, DE and △DE at different positions were analyzed by multivariate logistic regression, respectively. The receiver operating characteristic (ROC) curves of E/Ea (septal, lateral, average) and DE (right, left, average) were compared with each other, respectively. RESULTS: Of the 60 patients, 29 cases developed respiratory failure within 48 h, and 14 of those cases required re-intubation within 1 week. Multivariate logistic regression showed that E/Ea were all associated with respiratory failure, while only DE (right) and DE (average) after SBT were related to re-intubation. There were no statistic differences among the ROC curves of E/Ea at different positions, nor between the ROC curves of DE. No statistical differences were shown in △E/Ea between RF and ES groups, while △DE (average) was remarkably higher in NI group than that in RI group. However, multivariate logistic regression analysis showed that △DE (average) was not associated with re-intubation. CONCLUSIONS: E/Ea at different positions during a SBT could predict postextubation respiratory failure with no statistical differences among them. Likewise, only DE (right) and DE (average) after SBT might predict re-intubation with no statistical differences between each other.