Extubation outcome after a successful spontaneous breathing trial: A multicenter validation of a 3-factor prediction model

Abstract

Abstract. The aim of the present study was to validate, and if necessary update, a predictive model previously developed using a classification and regression tree (CART) algorithm for predicting successful extubation (ES) using a new cohort. This prospective cohort study enrolled adults admitted to 10 intensive care units, who had successfully passed a spontaneous breathing trial (SBT) and were considered ready for extubation. After extubation, the patients were followed up for 48 h. The primary outcome measure was ES, defined as the ability to maintain spontaneous unassisted breathing for >48 h after extubation. The 3-factor CART model was applied to patients in this cohort. The predicted probability of ES for each patient in this validation cohort was calculated based on the original CART model using the Laplace correction method. The performance was assessed by discrimination and calibration. A decision curve analysis was used assess the clinical net benefit (NB). Extubation failure (EF) occurred in 90/530 patients (17%). Among the 90 patients, 72 (13.6%) were reintubated, while 18 patients remained on rescue noninvasive ventilation within 48 h after extubation. The original CART model showed high discrimination but only moderate calibration with predicted probabilities that were systematically lower than expected. The original CART model was updated, and the updated model preserved excellent discrimination (area under the receiver operating characteristic curve, 0.91; 95% confidence interval, 0.87 to 0.93), but exhibited near-perfect calibration (calibration slope, 1; intercept, 0). Between threshold probabilities of 50 and 80%, the NB of using this updated model is significantly improved compared with the current strategy. The updated CART model may be used to estimate the predicted probability of ES after a successful SBT for individual patients. Applying this model appears to produce a substantial clinical consequence with regard to potential reduction in unexpected EFs.

Holistic Ultrasound to Predict Extubation Failure in Clinical Practice

“…However, even after a successful SBT, approximately 13-36% of patients are re-intubated. [2][3][4] To improve the predictive accuracy of breathing trials, studies have developed and evaluated additional tools such as P aO 2 =F IO 2 , the Rapid Shallow Breathing Index, and diaphragm thickening measured with ultrasound, with different levels of success. [5][6][7] These predictive parameters often evaluate a single organ system and fail to encompass the complex pathophysiology of extubation, which can be considered a stress test of the cardiorespiratory system because it increases oxygen demand and thus warrants a higher cardiac index and elevated breathing effort.…”

Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients

“…If the value was not available in the EMR, then we considered these erroneous values as missing in the final analysis. Probable predictor variables were chosen based on our clinical experience and information from other studies (11,20,(27)(28)(29)(30)(31)(32)(33)(34)(35)(36). Predictor variables that were significantly different between the success and failure groups (P ≤ 0.01) for which no more than 5% data were missing were included in multivariate analysis.…”

“…This study did not adequately characterize the respiratory variables proposed and was of relatively small sample size. Similarly, data from a cohort of mechanically ventilated elderly patients were prospectively analyzed and used to develop a predictive model using a classification and regressive tree (CART) algorithm, also known as a decision tree to predict extubation outcome in patients following a successful SBT ( 29 , 30 ). This CART model showed a good discrimination with an AUC of 0.94.…”

Upper limb muscle strength and exercise endurance as predictors of successful extubation in mechanically ventilated patients

“…Patients also had to respond to the qualitative question whether they were comfortable or not, before any test was commenced. Testing was discontinued immediately when a patient developed any sign of hemodynamic instability (any changes of 20% of the baseline heart rate, blood pressure, or oxygen saturation) [9,20] or if the heart rate, blood pressure, or oxygen saturation did not return to baseline after 5 min.…”