Patients’ prediction of extubation success

Abstract

Purpose: The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is the major diagnostic tool to determine if patients can be successfully extubated. However, little is known regarding the patient's subjective perception of autonomous breathing. Methods: We performed a prospective observational study in 211 mechanically ventilated adult patients successfully completing a SBT. Patients were randomly assigned to be interviewed during this trial regarding their prediction of extubation success. We compared post-extubation outcomes in three patient groups: patients confident (confidents; n = 115) or not (nonconfidents; n = 38) of their extubation success and patients not subjected to interview (control group; n = 58). Results: Extubation success was more frequent in confidents than in non-confidents (90 vs. 45%; p \ 0.001/positive likelihood ratio = 2.00) or in the control group (90 vs. 78%; p = 0.04). On the contrary, extubation failure was more common in non-confidents than in confidents (55 vs. 10%; p \ 0.001/ negative likelihood ratio = 0.19). Logistic regression analysis showed that extubation success was associated with patient's prediction [OR (95% CI): 9.2 (3.74-22.42) for confidents vs.non-confidents] as well as to age [0.72 (0.66-0.78) for age 75 vs. 65 and 1.31 (1.28-1.51) for age 55 vs. 65]. Conclusions: Our data suggest that at the end of a sustained SBT, extubation success might be correlated to the patients' subjective perception of autonomous breathing. The results of this study should be confirmed by a large multicenter trial.

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

“…However, Elsasser et al observed that the built-in commercial ATC may provide adequate inspiratory tube compensation with minimal overassistance (41). This conclusion is further supported by the observation that the reintubation rate in the present study (13.6%) is comparable with that reported from other trials assessing outcome after SBTs (4,6,8).…”

“…Adding factors of airway competence (such as cough strength and secretion volume) may have improved the performance of the model. However, in recent studies of extubation outcome (6,8,12,22,24,39), the authors reported that retained secretions and/or weak cough accounted for only 6.2% (range, 0 to 9.9%) of the EFs, which is consistent with the present results. The low frequency of abundant secretions in these studies suggests that a number of years after the increased risk of EF in the presence of copious secretions and weak cough was initially reported, physicians are proficient at extracting principles that emerge from research studies and incorporating them into everyday clinical practice.…”

“…However, decisions regarding reintubation in the ICUs were made by board-certified intensive care specialists using the standard policy in the institutions. Furthermore, the reintubation and EF rates (17%) in the present study are consistent with those observed in previous studies (4,6,8). Although never subjected to rigorous cost/benefit analyses, reintubation rates of 5 to 20% are generally considered reasonable, and are typical for the majority of effectively managed ICUs (3,40).…”

“…Currently, it is recommended that patients who successfully pass the SBT should be extubated if neurological status, excessive secretions, adequate cough and airway obstruction are not problematic (1,3). However, the rate Extubation outcome after a successful spontaneous breathing trial: A multicenter validation of a 3-factor prediction model of extubation failure is high (13.5 to 22%) in patients extubated on the basis of the current strategy (4)(5)(6). Delayed and premature discontinuation of mechanical ventilation (MV) have been associated with increased mortality (1,7,8).…”

Getting to the CORE of Weaning?

“…In a recent study, successful extubation was twice as frequent among patients who were confident of successful extubation than those who were not confident. 17 Given the many factors involved in respiratory failure, it is unlikely that the art and science of weaning from mechanical ventilation can be distilled to just one equation, or a confident nod. Nevertheless, we eagerly await confirmatory studies that examine the performance of the CORE index in predicting successful liberation of patients from ventilator and airway in a broad population of critically ill patients at multiple centers.…”