Neurologic status, cough, secretions and extubation outcomes

Salam, Adil; Tilluckdharry, Lisa; Amoateng-Adjepong, Yaw; Manthous, Constantine A.

doi:10.1007/s00134-004-2231-7

Cited by 283 publications

(241 citation statements)

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“…Further, other investigators have reported that the absolute amount of tracheal secretions and inadequate cough response increases the risk of extubation failure in patients who no longer appear to need mechanical ventilation. 6,15,16 Consistent with a previous report, 11 another risk factor for extubation failure was the number of previously failed SBTs, which suggests that, despite a pattern of improvement over time, some patients with more difficult weaning may not have achieved complete resolution of acute respiratory failure and may be more likely to require reintubation. 17 Frutos-Vivar et al also reported that positive fluid balance in the previous 24 hours was a significant predictor of extubation failure.…”

Section: Discussionsupporting

confidence: 84%

“…22 Salam and colleagues reported that subjects unable to complete 4 task commands (open eyes, follow with eyes, grasp hand, and stick out tongue) prior to extubation were 4 times more likely to require reintubation. 6 However, the study by Coplin et al reported similar extubation failure among brain injured subjects regardless of their Glasgow coma score. 23 In addition, using the Full Outline of UnResponsiveness (FOUR) score, which combines assessment of eyes, brainstem, reflexes, and respiration, to assess mental status in 62 subjects with a primary neurologic injury, Ko and colleagues reported similar scores among those who were successfully extubated and those that failed.…”

Section: Discussionmentioning

confidence: 95%

“…[2][3][4] Nonetheless, even after passing an SBT, nearly one in 5 will require reintubation at some time during the hospital stay, with half of these patients requiring reintubation within the first 24 hours. 3,5 Salam et al 6 reported the ability to maintain a patent upper airway and clear secretions, indicated by a cough peak SEE THE RELATED EDITORIAL ON PAGE 301 flow Ͼ 60 L/min, tracheal secretions Ͻ 2.5 mL/min, and the ability to follow 4 simple tasks (ie, open eyes, track with eyes, grasp with hands, and stick out tongue) increased the odds of successful extubation. Mokhlesi and colleagues 7 reported on 122 patients who were followed after extubation to identify those who were reintubated within 48 hours.…”

Section: Introductionmentioning

confidence: 99%

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Predictors of Reintubation in Critically Ill Patients

et al. 2013

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BACKGROUND: Assessment of a patient's readiness for removal of the endotracheal tube in the ICU is based on respiratory, airway, and neurological measures. However, nearly 20% of patients require reintubation. We created a prediction model for the need for reintubation, which incorporates variables importantly contributing to extubation failure. METHODS: This was a cohort study of 2,007 endotracheally intubated subjects who required ICU admission at a tertiary care center. Data collection included demographic, hemodynamic, respiratory, and neurological variables preceding extubation. Data were compared between subjects extubated successfully and those who required reintubation, using bivariate logistic regression models, with the binary outcome reintubation and the baseline characteristics as predictors. Multivariable logistic regression analysis with robust variance was used to build the prediction model. RESULTS: Of the 2,007 subjects analyzed, 376 (19%) required reintubation. In the bivariate analysis, admission Simplified Acute Physiology Score II, minute ventilation, breathing frequency, oxygenation, number of prior SBTs, rapid shallow breathing index, airway-secretions suctioning frequency and quantity, heart rate, and diastolic blood pressure differed significantly between the extubation success and failure groups. In the multivariable analysis, higher Simplified Acute Physiology Score II and suctioning frequency were associated with failed extubation. The area under the receiver operating characteristic curve was 0.68 for failure at any time, and 0.71 for failure within 24 hours. However, prior failed SBT, minute ventilation, and diastolic blood pressure were additional independent predictors of failure at any time, whereas oxygenation predicted extubation failure within 24 hours. CONCLUSIONS: A small number of independent variables explains a substantial portion of the variability of extubation failure, and can help identify patients at high risk of needing reintubation. These characteristics should be incorporated in the decision-making process of ICU extubation.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 99%

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Predictors of Reintubation in Critically Ill Patients

et al. 2013

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“…5 The mortality of these SEE THE RELATED EDITORIAL ON PAGE 1050 patients is significantly higher than the mortality of patients who tolerate extubation, [5][6][7][8] so it is desirable to accurately identify patients who are at risk for re-intubation. [9][10][11][12][13][14] Some of the variability in the rate of extubation failure is probably due to differences in cohort characteristics, yet differences in physician practice may also explain some of this variation. 5 In particular, physicians may rely on different sets of variables, interpret variables with certain biases, or make different tradeoffs (in the case of extubation, between prolonged intubation and failed extubation).…”

Section: Introductionmentioning

confidence: 99%

Accuracy and Reliability of Extubation Decisions by Intensivists

Tulaimat

Mokhlesi

2011

Respir Care

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BACKGROUND: Mortality increases when extubations fail. Although predictors of extubation failure have been evaluated, physicians' reasoning to extubate a patient has received minimal attention. We hypothesized that the accuracy and reliability of physicians' extubation decisions are low. METHODS: We sent surveys to 55 physicians in the divisions of pulmonary and critical care medicine of 3 teaching hospitals in Chicago, Illinois. The survey comprised 32 clinical vignettes of real patients who were extubated after they tolerated a spontaneous breathing trial (16 failed extubations). Unaware of the outcomes of extubation, the physicians were asked if they would extubate each patient, and to give reasons if they opted not to. We quantified the agreement between and accuracy of the physicians' decisions, determined the patient characteristics that influence the extubation decision, and described the tradeoffs leading to that decision. RESULTS: Completed surveys were obtained from 45 physicians (82%). The physicians postponed extubation in 37% of the cases. Agreement between any 2 physicians was fair (mean ؎ SD phi 0.34 ؎ 0.15) and was highest between attending physicians from the same institution (0.37 ؎ 0.15). In deciding to extubate a patient, 33% of the physicians relied on the breathing pattern on pressure support ventilation, 49% relied on the acid-base status, 13% relied on the mental status, and 8% relied on the amount of secretions. The accuracy of the physicians' extubation decisions was low (area under the receiver operating characteristic curve 0.35). The sensitivity of the physicians identifying the patients who were successfully extubated was 57%, and the specificity was 31%. A model that comprises the same variables that influenced the physicians was more accurate in predicting extubation outcome (area under the receiver operating characteristic curve 0.88). CONCLUSIONS: For a decision made on an almost daily basis in intensive care units, physicians' extubation decisions are inaccurate and only fairly reliable.

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“…(Demling et al, 1988;Engoren et al, 1999;Rady et al, 1999). Outras pesquisas com populações mistas estimaram uma freqüência que variou de 12 a 20% (Capdevilla et al, 1995;Epstein et al, 1997;Vallverdú et al, 1998;Khamiees et al, 2001;Esteban et al, 2002;Martinez et al, 3003;Salam et al, 2004;Seymour et al, 2004). Os estudos de pacientes neurológicos apresentam taxas bem distintas (Coplin et al, 2000;Namen et al, 2001 Outro fator avaliado por Namen et al (2001) A falência do desmame também tem sido associada à maior duração da ventilação mecânica (Torres et al, 1995), maior duração de internação hospitalar e em UTI (Torres et al, 1995;Perren et al, 2002;de Lassence et al, 2002, Fernandez et al, 2004Seymour et al, 2004) e maior taxa de traqueostomia (Epstein, 2003 …”

Section: A Falência Do Desmameunclassified

"Falência do desmame: risco, fatores associados e prognóstico de pacientes sob ventilação mecânica prolongada"

Yamauchi¹

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Neurologic status, cough, secretions and extubation outcomes

Abstract: These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT.

Cited by 283 publications

References 8 publications

Predictors of Reintubation in Critically Ill Patients

Predictors of Reintubation in Critically Ill Patients

Accuracy and Reliability of Extubation Decisions by Intensivists

"Falência do desmame: risco, fatores associados e prognóstico de pacientes sob ventilação mecânica prolongada"

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