At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

Thille, Arnaud W.; Boissier, Florence

doi:10.1164/rccm.201601-0187le

Cited by 3 publications

(2 citation statements)

References 6 publications

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“…Up to 90% of adult patients who pass an SBT also tolerate extubation without the need for reintubation (10)(11)(12)(13)(14). Thus, although the final decision to extubate is often determined by various patient-specific factors, a successful SBT should generally nudge the clinician toward considering extubation (15). Not all patients are extubated after a successful SBT due to a perceived increased risk of extubation failure.…”

mentioning

confidence: 99%

Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial*

Taran¹,

Angriman

Pinto

et al. 2021

Critical Care Medicine

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OBJECTIVES: To identify whether factors associated with withholding extubation in the ICU also predict the risk of extubation failure. DESIGN: Retrospective cohort study. SETTING: Eight medical-surgical ICUs in Toronto. Patients: Adult patients receiving invasive mechanical ventilation, with a first successful spontaneous breathing trial within 28 days of initial ICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary end point had three mutually exclusive levels, including: 1) withholding extubation after a successful spontaneous breathing trial, 2) extubation failure within 48 hours, and 3) successful extubation. Among 9,910 patients, 38% of patients were not extubated within 24 hours of their first successful spontaneous breathing trial. A total of 12.9% of patients who were promptly extubated failed within the next 48 hours. Several discrepancies were evident in the association of factors with risk of withholding extubation and extubation failure. Specifically, both age and female sex were associated with withholding extubation (odds ratio, 1.07; 95% CI, 1.03–1.11; and odds ratio, 1.13; 95% CI, 1.02–1.26, respectively) but not a higher risk of failed extubation (odds ratio, 0.99; 95% CI, 0.93–1.05; and odds ratio, 0.93; 95% CI, 0.77–1.11, respectively). Conversely, both acute cardiovascular conditions and intubation for hypoxemic respiratory failure were associated with a higher risk of failed extubation (odds ratio, 1.32; 95% CI, 1.06–1.66; and odds ratio, 1.46; 95% CI, 1.16–1.82, respectively) but not a higher odds of a withheld extubation attempt (odds ratio, 0.79; 95% CI, 0.68–0.91; and odds ratio, 1.07; 95% CI, 0.93–1.23, respectively). CONCLUSIONS: Several factors showed discordance between the decision to withhold extubation and the risk of extubation failure. This discordance may lead to longer duration of mechanical ventilation or higher reintubation rates. Improving the decision-making behind extubation may help to reduce both exposure to invasive mechanical ventilation and extubation failure.

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confidence: 99%

Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial*

Taran¹,

Angriman

Pinto

et al. 2021

Critical Care Medicine

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“…[8,15,16] Although both are manifestations of increased work of breathing,[17,18] we selected distress because physicians rely on their observations of patients in determining the need for respiratory support and do so independent of patients’ ability to express dyspnea or its severity. [2,19] This choice was reasonable also because the rating of respiratory distress by physicians predicts the need for mechanical ventilation,[4] and because it is as reproducible as dyspnea. [8,20]…”

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confidence: 99%

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

Tulaimat

Trick

2017

PLoS ONE

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BackgroundThe assessment of the work of breathing in the definitions of respiratory failure is vague and variable.ObjectiveIdentify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients.MethodsWe examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis.ResultsWe performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress.ConclusionMost of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.

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Managing Extubation and the Post Extubation Period in the Intensive Care Unit

Glover¹,

Glossop²

2017

EMJ Respir

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The process of successfully weaning patients from invasive mechanical ventilation is a great challenge for all healthcare providers working in critical care. Despite several recent advances in the care of intensive care patients, failed extubation remains a significant problem that may result in poor patient outcomes. A lack of consensus in many areas regarding clinical approach to extubation and the peri-extubation period exists, and the numerous strategies described in this review add to the complexity of the decision faced by the clinicians involved. The process of weaning and timing of extubation may be improved by implementation of a consistent multidisciplinary approach to weaning, with a number of easily identifiable risk factors available to support clinical decision making. There are also many known risk factors that can be used to predict the likelihood of extubation failure; whilst these factors may not be easily modifiable, they do allow the identification of patients at a high risk of extubation failure who may require more detailed care and planning post extubation. Finally, a number of strategies, including non-invasive ventilation and high flow nasal oxygen therapy, are available to support carefully selected groups in the post extubation period. Evidence is emerging linking these adjuncts to a reduction in the risk of extubation failure. This article will discuss these risk factors and the evidence supporting their use in this challenging patient group.

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At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

Cited by 3 publications

References 6 publications

Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial*

Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial*

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

Managing Extubation and the Post Extubation Period in the Intensive Care Unit

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