Physiotherapist prediction of extubation outcome in the adult intensive care unit

Abstract

ObjectiveMost patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator‐associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre‐extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU.MethodsA single‐centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists—which included risk stratification of extubation failure as “high,” “moderate,” or “low”—was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre‐extubation factors were predictive of extubation outcome.ResultsDuring the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as “high risk” (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and “inappropriate” neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre‐extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists.ConclusionPatients classified as “high risk” of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.

Factors associated with extubation failure in an intensive care unit: a case-control study

“…However, extubation should not be delayed in patients with adequate cough, despite presenting with peripheral weakness 12 . Related to muscle strength after successful SBT, the most important parameter for successful extubation is the cough efficiency for the management of bronchial secretion, as an effective cough is essential to clear secretions from the more proximal airways 9 , 15 , 18 - 19 , 26 , with an extubation failure rate of about 33-41% in patients with ineffective cough, compared to 5-8% in those with effective cough strength 12 , 39 .…”

“…Regarding the amount of pulmonary secretion, this was verified in the physical therapists’ notes of the last 24 hours before extubation, being defined as a large amount of secretion when the airway aspiration procedure was performed according to the patient’s need in a period of less than two hours between aspirations 22 . The patient was evaluated for cough effectiveness by the physical therapist by observing the contraction of the abdominal muscles associated with the ability to mobilize secretion by the OTT 26 .…”

Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle

“…Em relação à quantidade de secreção pulmonar, esta foi verificada nas anotações dos fisioterapeutas das últimas 24 horas antes de extubar, sendo definida como grande quantidade de secreção quando o procedimento de aspiração de vias aéreas era realizado de acordo com a necessidade do paciente em um período inferior a duas horas entre as aspirações (22) . O paciente era avaliado quanto à eficácia da tosse pelo fisioterapeuta por meio da observação da contração da musculatura abdominal associada à capacidade de mobilizar secreção pelo TOT (26) .…”

“…No entanto, a extubação não deve ser atrasada em pacientes com tosse adequada, apesar de se apresentarem com fraqueza periférica (12) . Relacionado à força muscular após o sucesso no TRE, o parâmetro mais importante para o sucesso na extubação é a eficiência da tosse para o manejo da secreção brônquica, pois uma tosse eficaz é essencial para limpar as secreções das vias aéreas mais proximais (9,15,(18)(19)26) , sendo em torno de 33-41% a taxa de falha de extubação em pacientes com tosse ineficaz, comparado a 5-8% naqueles com força de tosse efetiva (12,39) .…”

Conhecimento Dos Estudantes De Medicina Sobre a Atuação Da Fisioterapia No Ambiente Hospitalar

“…No atendimento multidisciplinar oferecido aos pacientes em UTI, a fisioterapia se faz presente em várias etapas do tratamento intensivo e envolve os cuidados dos pacientes com e sem necessidade de suporte ventilatório; assistência após cirurgias com o objetivo de evitar complicações respiratórias e motoras; mobilização precoce [4][5][6] , entre outras. No suporte ventilatório, o fisioterapeuta tem ativa participação, auxiliando na condução da Ventilação Mecânica (VM), desde o preparo e ajuste do ventilador até a intubação, evolução do paciente durante a VM, interrupção e desmame ventilatório e extubação 7,8 .…”