Effect of Reintubation Within 48 Hours on Mortality in Critically Ill Patients After Planned Extubation.

BACKGROUND: Re-intubation is necessary in 2% to 30% of cases of patients receiving a planned extubation. This procedure is associated with prolonged mechanical ventilation, a greater need for tracheostomy, a higher incidence of ventilator-associated pneumonia, and higher mortality. The aim of this study was to evaluate the effect of re-intubation within 48 h on mortality after planned extubation by using a randomized controlled trial database. METHODS: Secondary analysis of a multi-center randomized trial, which evaluated the effect of reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial, followed by extubation. The study included adult subjects who received invasive mechanical ventilation for > 12 h. The subjects were divided into an extubation failure group and an extubation success group. The outcome was in-hospital mortality. Two multivariate logistic regression models were constructed to identify independent factors associated with mortality. RESULTS: Among the 336 subjects studied, extubation failed in 52 (15.4%) and they were re-intubated within 48 h. Most re-intubations occurred between 12 and 24 h after planned extubation (median [interquartile range] 16 [6-36] h). Mortality of the extubation failure group was higher both in the ICU (32.6% vs 6.6%; odds ratio [OR] 6.77, 95% CI 3.22-14.24; P < .001) and in-hospital (42.3% vs 14.0%; OR 4.47, 95% CI 2.34-8.51; P < .001) versus the extubation success group. Multivariate logistic regression analyses showed that re-intubation within 48 h was independently associated with both ICU mortality (OR 6.10, 95% CI 2.84-13.07; P < .001) and in-hospital mortality (OR 3.36, 95% CI 1.67-6.73; P = .001). In-hospital mortality was also associated with rescue noninvasive ventilation after extubation (OR 2.44, 95% CI 1.25-4.75; P = .009). CONCLUSIONS: Re-intubation within 48 h after planned extubation was associated with mortality in subjects who were critically ill.

Physiological effects of high-flow nasal cannula oxygen therapy after extubation: a randomized crossover study.

BACKGROUND: Prophylactic high-flow nasal cannula (HFNC) oxygen therapy can decrease the risk of extubation failure. It is frequently used in the postextubation phase alone or in combination with noninvasive ventilation. However, its physiological effects in this setting have not been thoroughly investigated. The aim of this study was to determine comprehensively the effects of HFNC applied after extubation on respiratory effort, diaphragm activity, gas exchange, ventilation distribution, and cardiovascular biomarkers. METHODS: This was a prospective randomized crossover physiological study in critically ill patients comparing 1 h of HFNC versus 1 h of standard oxygen after extubation. The main inclusion criteria were mechanical ventilation for at least 48 h due to acute respiratory failure, and extubation after a successful spontaneous breathing trial (SBT). We measured respiratory effort through esophageal/transdiaphragmatic pressures, and diaphragm electrical activity (ΔEAdi). Lung volumes and ventilation distribution were estimated by electrical impedance tomography. Arterial and central venous blood gases were analyzed, as well as cardiac stress biomarkers. RESULTS: We enrolled 22 patients (age 59 ± 17 years; 9 women) who had been intubated for 8 ± 6 days before extubation. Respiratory effort was significantly lower with HFNC than with standard oxygen therapy, as evidenced by esophageal pressure swings (5.3 [4.2-7.1] vs. 7.2 [5.6-10.3] cmH2O; p < 0.001), pressure-time product (85 [67-140] vs. 156 [114-238] cmH2O*s/min; p < 0.001) and ΔEAdi (10 [7-13] vs. 14 [9-16] µV; p = 0.022). In addition, HFNC induced increases in end-expiratory lung volume and PaO2/FiO2 ratio, decreases in respiratory rate and ventilatory ratio, while no changes were observed in systemic hemodynamics, Troponin T, or in amino-terminal pro-B-type natriuretic peptide. CONCLUSIONS: Prophylactic application of HFNC after extubation provides substantial respiratory support and unloads respiratory muscles. Trial registration January 15, 2021. NCT04711759.

The Effect of Reconnection to Mechanical Ventilation for 1 Hour After Spontaneous Breathing Trial on Reintubation Among Patients Ventilated for More Than 12 Hours: A Randomized Clinical Trial.

BACKGROUND: The resting of the respiratory musculature after undergoing the spontaneous breathing trial (SBT) to prevent extubation failures in critically ill patients needs to be studied further. RESEARCH QUESTION: Is the reconnection to mechanical ventilation (MV) for 1 h after a successful SBT able to reduce the risk of reintubation? STUDY DESIGN AND METHODS: Randomized clinical trial conducted in four ICUs between August 2018 and July 2019. Candidates for tracheal extubation who met all screening criteria for weaning were included. After achieving success in the SBT using a T-tube, the patients were randomized to the following groups: direct extubation (DE) or extubation after reconnection to MV for 1 h (R1h). The primary outcome was reintubation within 48 h. RESULTS: Among the 336 patients studied (women, 41.1%; median age, 59 years [interquartile range, 45-70 years]), 12.9% (22/171) in the R1h group required reintubation within 48 h vs 18.2% (30/165) in the DE group (risk difference, 5.3 [95% CI, -2.49 to 13.12]; P = .18). No differences were found in mortality, length of ICU or hospital stay, causes of reintubation, or signs of extubation failure. A prespecified exploratory analysis showed that among the 233 patients (69.3%) who were ventilated for more than 72 h, the incidence of reintubation was 12.7% (15/118) in the R1h group compared with 22.6% (26/115) observed in the DE group (P = .04). INTERPRETATION: Reconnection to MV after a successful SBT, compared with DE, did not result in a statistically significant reduction in the risk of reintubation in mechanically ventilated patients. Subgroup exploratory findings suggest that the strategy may benefit patients who were ventilated for more than 72 h, which should be confirmed in further studies. TRIAL REGISTRY: Brazilian Clinical Trials Registry; No.: RBR-3x8nxn; URL: www.ensaiosclinicos.gov.br.

Uso de ventilación no invasiva luego de la discontinuación de la ventilación mecánica invasiva en pacientes adultos / Use of noninvasive ventilation after discontinuation of invasive mechanical ventilation in adult patients

Introducción: la discontinuación de la ventilación mecánica invasiva en las Unidades de Cuidados Intensivos es un objetivo fundamental y primario, en pos de evitar las complicaciones asociadas a ella. El uso de ventilación no invasiva en este contexto resulta de utilidad en tres escenarios específicos: a) como prevención de fallo de extubación, b) como cambio de interface, c) en fallo instalado. No existe evidencia suficiente sobre el tiempo de uso habitual de la VNI en esta subpoblación, las variables que se utilizan para elegirla, las causas de fallo de la VNI y la mortalidad asociada en estos pacientes. Objetivos: describir epidemiológicamente a los pacientes adultos con uso de VNI posextubación y su evolución hasta el alta hospitalaria. Describir la indicación de VNI, el tiempo de uso, las tasas de reintubación y mortalidad intrahospitalaria. Materiales y métodos: cohorte retrospectiva de pacientes internados en la UCI de adultos del Hospital Italiano de San Justo que utilizaron VNI posextubación. A partir de la historia clínica electrónica se registraron variables epidemiológicas previas al ingreso en la UCI y datos evolutivos durante la internación. El período analizado abarca desde el 17 de diciembre de 2016 hasta el 01 de agosto de 2018. Resultados: se incluyeron 48 pacientes en el presente estudio. La mediana de edad fue de 76 años (RIQ 62,75-83,25). El 58,33% eran hombres. El índice de comorbilidad de Charlson tuvo un valor de mediana de 5 (RIQ 3-6). Del total de pacientes reclutados, 33 utilizaron VNI como prevención de fallo de extubación (68,75%), 13 como cambio de interface (27,08%) y solo 2 como fallo instalado (4,16%). La mediana de días de uso de VNI fue 1 (RIQ 0-5) en prevención de fallo, 1 (RIQ 1-2) en cambio de interface y en fallo instalado 13,5 días (RIQ 8,75-18,25). Ocho pacientes fueron reintubados (16,66%). La mortalidad fue del 9,1% en el grupo de prevención de fallo y 7,7% en el grupo de cambio de interface, respectivamente. En cuanto al grupo que la usó a partir del fallo instalado, la tasa de mortalidad fue del 50% (total de dos pacientes). Conclusiones: la VNI como método de discontinuación de la VMI se utiliza principalmente tanto para la prevención de fallo como para cambio de interfaz. El tiempo de uso de VNI posextubación es, en general, limitado. Se necesitan futuros trabajos que identifiquen las horas requeridas de uso de VNI posextubación. (AU)

Introduction: the discontinuation of invasive mechanical ventilation in the intensive care unit is a fundamental and primary objective, both of which aim to avoid the complications associated with it. The use of non-invasive ventilation in this context may follow three specific scenarios: a) as prevention of extubation failure, b) as interface change, c) in overt failure. There is not enough evidence on the time of use of NIV in this subpopulation, the variables used to guide its use, the causes of NIV failure and the associated mortality in these patients. Objectives: to describe the use of NIV after extubation in adult critically ill patients. Further, we aim to describe the time of NIV use, the mortality and reintubation rate of each subgroup. Materials and methods: retrospective cohort study including adult patients admitted to the ICU at Hospital Italiano de San Justo, who received NIV post-extubation. Using the electronic health database, epidemiological variables were recorded prior to admission to the ICU and follow-up data during the hospitalization. The period analyzed was from December 17, 2016 to August 1, 2018. Results: 48 patients were included in the present analysis. Median age was 76 years (RIQ 62.75-83.25) and 58.33% were men. The Charlson comorbidity index had a median value of 5 (RIQ 3-6). Of the total number of patients recruited, 33 used NIV as prevention of extubation failure (68.75%), 13 as interface change (27.08%). ) and only 2 as overt extubation failure (4.16%).The median number of days of NIV use was 1 (RIQ 0-5) in failure prevention and 1 (RIQ 1-2) in the change of interface group. 8 patients were reintubated (16.66%). 9.1% and 7.7% of patients died in the groups that used NIV as prevention of extubation failure and change of interface respectively. Conclusions: NIV is frequently used in adult patients following extubation in our centre. Further studies are warranted to depict the necessary time of use to better allocate resources within the intensive care unit. (AU)

Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit.

AIM: We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru. METHODS: This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis. RESULTS: High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions. CONCLUSION: High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.

Factors Associated With Unplanned Extubation in Children: A Case-Control Study.

PURPOSE: Although several studies assess unplanned extubation (UE) in children, few have addressed determinants of UE and factors associated with reintubation in a case-controlled manner. We aimed to identify the risk factors and outcomes associated with UE in a pediatric intensive care unit. METHODS: Cases of UE were randomly matched with control patients at a ratio of 1:4 for age, severity of illness, and admission diagnosis. For cases and controls, we also collected data associated with UE events, reintubation, and outcomes. RESULTS: We analyzed 94 UE patients (0.75 UE per 100 intubation days) and found no differences in demographics between the 2 groups. Logistic regression revealed that patient agitation (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.28-4.65), continuous sedation infusion (OR: 3.27; 95% CI: 1.70-6.29), night shifts (OR: 9.16; 95% CI: 4.25-19.72), in-charge nurse experience <2 years (OR: 2.38; 95% CI: 1.13-4.99), and oxygenation index (OI) >5 (OR: 76.9; 95% CI: 16.79-352.47) were associated with UE. Risk factors for reintubation after UE included prior level of sedation (COMFORT score < 27; OR: 7.93; 95% CI: 2.30-27.29), copious secretion (OR: 11.88; 95% CI: 2.20-64.05), and OI > 5 (OR: 9.32; 95% CI: 2.45-35.48). CONCLUSIONS: This case-control study showed that both patient- and nurse-associated risk factors were related to UE. Risk factors associated with reintubation included lower levels of consciousness, copious secretions, and higher OI. Further evidence-based studies, including a larger sample size, are warranted to identify predisposing factors in UEs.

Predicting Reintubation After Unplanned Extubations in Children: Art or Science?

PURPOSE: Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs. METHODS: All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected. RESULTS: Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations. CONCLUSION: The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.

Falla de extubación en la Terapia Intensiva de un Hospital Universitario. Estudio retrospectivo / Failure of extubation in the Intensive therapy of a University Hospital. study retrospective

Introducción: Aproximadamente un 40% del tiempo que un paciente está en ventilación mecánica corresponde al proceso de destete. La tasa de falla de extubación planeada es del 2-25%. La reintubación y su demora se asocian a complicaciones que incrementan la tasa de mortalidad y de la estancia en las Unidades cerrada y hospitalaria. Objetivo: Conocer la tasa de falla de extubación y analizar las características de estos pacientes en la Terapia Intensiva de un Hospital universitario. Pacientes y Métodos: Se incluyeron pacientes >18 años que ingresaron en la Terapia Intensiva del Hospital de Clínicas "José de San Martín" entre junio de 2013 y mayo de 2014, que fueron extubados de forma planeada y recibieron ventilación mecánica invasiva, por lo menos, 12 horas. Resultados: Se analizaron 139 pacientes. La tasa de falla de extubación fue del 14,4%. El grupo que falló presentó una media de tiempo hasta la reintubación de 18,2 h (DE ± 13.4). La neumonía asociada a la ventilación mecánica fue mayor en el grupo de falla (p = 0,001), al igual que los días de ventilación mecánica (p = 0,05), la estancia en terapia intensiva (p = 0,05), la mortalidad en terapia intensiva (p = 0,008) y hospitalaria (p = 0,003). Conclusiones: La tasa de falla de extubación coincide con lo reportado en la bibliografía. Los pacientes que fallaron tuvieron tasas mayores de neumonía asociada a la ventilación mecánica, de días de ventilación mecánica, de estancia en terapia intensiva, y de mortalidad en terapia intensiva y hospitalaria (AU)

Introduction: Approximately 40% of the time that a patient is mechanically ventilated is dedicated to the weaning process. The failure rate of planned extubation is 2-25%. Reintubation delay and extubation failure are associated with poor clinical outcomes, including an increase in the mortality rate and prolonged hospital and Intensive Care Unit stay. Objective: To analyze the extubation failure rate and determine the impact of extubation failure on patient outcomes in a University Hospital. Patients and Methods: Patients >18 years old admitted to Hospital de Clínicas "José de San Martín", between June 2013 and May 2014, who have receive mechanic ventilation for more than 12 hours, and with planned extubation. Results: A total of 139 patients were studied. Extubation failure rate was 14.4%. The mean time to reintubation of the group that failed was 18.2 hours (SD ± 13.4). Mechanical ventilation-associated pneumonia was greater in the failure group (p = 0.001), as well as days with the mechanical ventilation (p = 0.05), the Intensive Care Unit stay (p = 0.05), the Intensive Care Unit mortality rate (p = 0.008) and the hospital mortality rate (p = 0.003). Conclusions: The extubation failure rate coincides with that reported in the literature. Patients who failed had greater rates of mechanical ventilation-associated pneumonia, mechanical ventilated days, intensive care unit stay, and Intensive Care Unit and hospital mortality (AU)

Factores pronósticos en la neumonía asociada a la ventilación mecánica / Prognosis factors in the pneumonia associated with the mechanical ventilation

Se llevó a cabo una investigación analítica de casos y controles, de 172 pacientes expuestos a ventilación mecánica, atendidos en la Unidad de Cuidados Intensivos del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, desde mayo del 2013 hasta igual periodo del 2014, con vistas a identificar los factores pronósticos que inciden en la aparición de la neumonía asociada a la ventilación mecánica. El grupo de estudio estuvo conformado por 72 afectados, y el control por 100. Entre los factores que mostraron importancia pronóstica significativa figuraron: tiempo de intubación superior a 7 días, sedación, reintubación y administración previa de antibióticos.

An analytic investigation of cases and controls, of 172 patients exposed to mechanical ventilation, assisted in the Intensive Care Unit from "Saturnino Lora Torres" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba was carried out from May, 2013 to the same period of 2014, with the objective of identifying the prognosis factors influencing on the emergence of pneumonia associated with the mechanical ventilation. The study group was formed by 72 affected, and the control group by 100. Among the factors showing significant importance for prognosis there were: intubation time longer than 7 days, sedation, reintubation and previous administration of antibiotics.

Factores de Riesgo de extubación no planificada y reintubación en pacientes pediátricos / Risk factors for unplanned extubation and reintubation in pediatric patients

Extubación no planificada (ENP) y reintubación son eventos adversos inherentes a la atención médica que acarrean complicaciones en el paciente, pudiesen prevenirse y se consideran indicadores de calidad de atención en cuidados críticos. Determinar la frecuencia, factores de riesgo y resultados de la ENP y la reintubación en niños hospitalizados en el Instituto Autónomo Hospital Universitario de Los Andes entre Julio 2010-Julio 2011. Estudio observacional, clínico, prospectivo concurrente en niños quefueron extubados. De estos se obtuvieron las características demográficas-clínicas y evolución. El análisis estadístico se realizó con elSPSS-12.0. Se incluyeron 76 pacientes, edad promedio 6,43 ± 6,04 años (1 mes a 15 años). Los diagnósticos etiológicospredominantes fueron infecciones y traumatismos. El 37,2% se intubó por insuficiencia respiratoria. El 27,3% de las extubaciones fueron no planificadas (accidentales 19,7%, autoextubaciones 7,98%). La mayoría de los pacientes se encontraba en ventilación mecánica (VM) modalidad asistida controlada antes de la extubación. La ENP fue más frecuente en niños pequeños con el uso de tubos sin balón, administración de sedantes y relajantes previos a la extubación, agitación y Glasgow menor de 9 puntos. La reintubación se asociósignificativamente a ENP, uso de sedantes y relajantes previos, no utilizar esteroides ni broncodilatadores, falta de deshabituación, agitación y Glasgow menor de 9 puntos. Las ENP y reintubaciones incrementaron el tiempo de VM. Puede reconocerse elpaciente con factores de riesgo para ENP y reintubación, por lo cual es necesario implementar medidas que disminuyan la frecuencia de eventos adversos en estos pacientes.

Unplanned extubation (UEX) and reintubation are adverse events related with medical care, which can produce complications, could be prevented and are considered health quality indicators in critical care. To determine the frequency, risk factors and results ofUEX and reintubation in hospitalized children in the Instituto Autónomo Hospital Universitario de Los Andes from July 2010-July 2011. This was an observational, clinical, prospective and concurrent study in children who were extubated. Demographic and clinical features were analyzed and their evolution was followed. Statistical analysis was performed with SPSS-12.0. 76 patientswere included, average age was 6, 43 years (1 month to 15 years, SD ± 6,04). The main diagnoses were infections and trauma. 37,2% of the patients were intubated because of respiratory insufficiency. 27, 3% of the extubations were unplanned (accidental 19,7%,autoextubation 7,98%). Most of the patients were on assisted ventilation (AV), controlled ventilator mode before the extubation. The UEX was more frequent in younger children, with uncuffed tubes, administration of neuromuscular blockers and sedative therapy, agitation and Glasgow below 9 points. Reintubation was associated with UEX, sedative drugs and neuromuscular blockers, no steroids or bronchodilators, no weaning, agitation and Glasgow below 9 points. The UEX and reintubations prolonged the AV time. There are risk factors which can be recognized in patients with UEX and reintubations, for which reason it is important to develop strategies to prevent these adverse events.