A spontaneous breathing trial with pressure support overestimates readiness for extubation in children

Ferguson, Lee P.; Walsh, Brian K; Munhall, Daphne; Arnold, John H.

doi:10.1097/pcc.0b013e3182231220

Cited by 52 publications

(39 citation statements)

References 23 publications

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“…Our findings mirror those of Kurachek et al (6) who showed that the rate of extubation failure goes up markedly after 48 hours (8.2%) and 10 days (17.5%) of ventilation in a general PICU cohort. Several previous investigations demonstrate the limitations of spontaneous breathing trials in critically ill children (13, 14) to predict successful transition from mechanical ventilation. Patients ventilated for prolonged periods in the CICU are more likely to suffer from clinically significant cardiovascular dysfunction compared with the general PICU population, which may also limit successful unassisted respiration.…”

Section: Discussionmentioning

confidence: 99%

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU

Gaies¹,

Tabbutt

Schwartz

et al. 2015

Pediatric Critical Care Medicine

104

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Objective To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. Design Retrospective cohort study using prospectively collected clinical registry data. Setting Pediatric Cardiac Critical Care Consortium registry. Patients All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. Interventions None. Measurements and Main Results Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). Conclusions Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.

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Section: Discussionmentioning

confidence: 99%

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU

Gaies¹,

Tabbutt

Schwartz

et al. 2015

Pediatric Critical Care Medicine

104

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“…12 However, performing the SBT with the pressure support set at a higher level for a smaller endotracheal tube can overestimate readiness for extubation in children. 19 The responses to our survey reflect the uncertainty regarding the performance of SBTs. In adults an elevated RSBI predicts failure, 15,16 whereas in children the performance and outcomes of RSBI are under debate.…”

Section: Discussionmentioning

confidence: 99%

The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

et al. 2013

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BACKGROUND:The pediatric literature addressing extubation readiness parameters and strategies to wean from mechanical ventilation is limited. METHODS: We designed a survey to assess the use of extubation readiness parameters among pediatric critical care physicians at academic centers in the United States. RESULTS: The overall response rate was 44.1% (417/945). The majority of respondents check for air leak and the amount of tracheal secretions. Fewer respondents use sedation score, the rapid shallow breathing index, or the airway-occlusion pressure 0.1 s after the start of inspiratory flow prior to extubation. The majority perform a spontaneous breathing trial with pressure support. The majority consider 30 cm H 2 O as the upper limit of an air leak test, and the need for endotracheal suctioning once every 2-4 hours as acceptable for extubation. In preparation for termination of mechanical ventilation the majority daily wean the ventilator rate and/or the pressure support instead of conducting a spontaneous breathing trial. CONCLUSIONS: Most pediatric critical care physicians reported assessing extubation readiness by checking air leak and suctioning need, and less often consider or perform sedation score or the rapid shallow breathing index.

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“…The determination of readiness for extubation from mechanical ventilation in critically-ill infants and children in general continues to be challenging for pediatric intensive care providers [6]. In the adult population, measures of pulmonary function and weaning indices have been developed and standardized to increase the likelihood of extubation success, but the results from applying similar weaning indices in pediatric patients have been inconsistent [7][8] and have not been readily implemented by current pediatric critical care physicians [9].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

Laudato

Gupta

Walters

et al. 2015

Pediatric Critical Care Medicine

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Objective: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, though data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. Design: Retrospective chart reviewSetting: Urban tertiary care free-standing children's hospital Interventions: Extubation failure was defined as re-intubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. Measurements & Main Conclusions:Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.3

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A spontaneous breathing trial with pressure support overestimates readiness for extubation in children

Cited by 52 publications

References 23 publications

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU

The Use of Extubation Readiness Parameters: A Survey of Pediatric Critical Care Physicians

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

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