Conventional Weaning Parameters Do Not Predict Extubation Outcome in Intubated Subjects Requiring Prolonged Mechanical Ventilation

Abstract

BACKGROUND: Approaches to respiratory care of patients needing prolonged mechanical ventilation (PMV) might be varied. In this study we assessed the predictive value of usual variables for extubation outcome in PMV patients. METHODS: From 2005 to 2007, intubated patients who were admitted to the intermediate respiratory care unit, had been on mechanical ventilation for > 21 days at the time of admission, and underwent extubation after successful spontaneous breathing trials were included. Comparisons between subjects with successful extubation and failed extubation in terms of weaning parameters and clinical predictors of extubation outcome were performed. Also, 1-year survival of subjects with regard to extubation outcome was analyzed. RESULTS: Twentyseven (23.7%) of 119 PMV subjects required reintubation within 7 days. Multivariate logistic regression analysis demonstrated that the only variable associated with extubation failure was ineffective cough (P < .001). Possessing 2 or more acceptable weaning parameters was not helpful in predicting extubation outcome. Subjects with failed extubation had worse 1-year survival (hazard ratio 0.49, 95% CI 0.28 -0.87, P ‫؍‬ .02) compared with those with successful extubation. CONCLUSIONS: In PMV subjects who tolerated spontaneous breathing trials and were ready to extubate, ineffective cough was the best predictor of extubation failure. Furthermore, extubation failure was associated with future mortality; thus, different management strategies need to be developed for improving patient outcome.

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

“…Finally, corroborating extensive evidence from the literature [8,15,40,45,] our study showed that EF is associated with worse global outcome. It is very likely that most of the observed associations in the patients in need for reintubation such as infectious complications, more frequent need for antibiotic treatment, longer sedation and ventilation times, and longer ICU-LOS may represent a chain of complications impacting that overall finding.…”

“…Coughing has been graded according to the clinically observed level of cough strength, usually qualitatively differentiating between 3 and 4 grades [39,40], by using a qualitative marker of cough efficiency like the ‘‘white card test,'' which evaluates the patients ability to cough secretions onto a card held in a short distance from the tube [41], or by adopting the technically more sophisticated quantitative measurement of cough peak flow with a pneumotachograph or a peak flow meter [32,35]. Irrespective of the method chosen, most studies have revealed that patients with a weak cough were at increased risk of EF [30,32,35,40,41,42]. More specifically, Thille et al [39] in their large prospective study suggested that reduced cough strength is associated with a 5-fold increased risk of reintubation, and that cough strength is even more important for extubation success than peripheral weakness.…”

Discontinuation of ventilatory support

“…An RCT including 181 patients has recently studied the effect of deflating the cuff on weaning and showed that deflating the tracheal cuff in tracheostomized patients shortened the weaning process compared with the inflated group (weaning time 8 days vs. 3 days, respectively; P < 0.01) and probably improved swallowing [46 && ]. In patients undergoing mechanical ventilation continuously for more than 21 days a multivariate logistic regression analysis showed that the only variable associated with extubation failure was ineffective cough and that weaning parameters were not helpful in predicting extubation outcome [47].…”

Ventilator Liberation for High-Risk-for-Failure Patients: Improving Value of the Spontaneous Breathing Trial

“…Although not discussed here, there may be other populations considered to be HRFF for whom our recommendations may be applicable, such as patients with neuromuscular weakness or prolonged mechanical ventilator dependence. [18][19][20] …”