Respiratory inductance plethysmography calibration for pediatric upper airway obstruction: an animal model

Khemani, Robinder G.; Flink, Rutger C.; Hotz, Justin; Ross, Patrick; Ghuman, Anoopindar; Newth, Christopher J L

doi:10.1038/pr.2014.144

Cited by 14 publications

(15 citation statements)

References 35 publications

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“…Moreover, nearly half of extubation failures are from post-extubation UAO [19,20,30], which may be difficult to predict during standard ERTs [31-33]. With < 5% of patients failing extubation from causes other than UAO, it is difficult to demonstrate that one mode of ERT results in lower reintubation rates.…”

Section: Discussionmentioning

confidence: 99%

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Pediatric extubation readiness tests should not use pressure support

et al. 2016

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Key Points: By performing direct measures of patient effort of breathing before and after extubation on over 400 mechanically ventilated children, we have found that patient effort of breathing on CPAP of 5cmH20 alone provides a good estimate of post-extubation effort. Regardless of the endotracheal tube size, pressure support should not be added to CPAP for extubation readiness testing because it results in significant under-estimation of postextubation effort of breathing.Social Network: Regardless of endotracheal tube size, PS during ERTs significantly underestimates post-extubation effort of breathing. ManuscriptClick here to download Manuscript BreathingThroughStraw_ICM_NoFigs.doc Click here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

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Section: Discussionmentioning

confidence: 99%

“…Prior to extubation, each child received an esophageal balloon catheter and had RIP bands calibrated under tidal breathing on CPAP of 5 cmH2O [20,21]. A self-calibrating pneumotachometer was used prior to extubation to measure peak inspiratory flow during tidal breathing.…”

Section: Study Protocolmentioning

confidence: 99%

Pediatric extubation readiness tests should not use pressure support

et al. 2016

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“…Using ePiMax as well as Pi, we computed Pi/ePiMax, and Tension Time Index (TTI) on each study condition (DSM Table 1). We calibrated RIP flow during airway occlusion, to assess for inspiratory flow limitation after extubation to characterize post-extubation upper airway UAO, as previously published (8, 31). For analysis, we labeled patients as having UAO when inspiratory flow limitation was new after extubation with an increase in Pressure Rate Product (PRP) of at least 50% over values before extubation on CPAP, and when they received a UAO specific intervention such as racemic epinephrine, heliox, or corticosteroids.…”

Section: Methodsmentioning

confidence: 99%

Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength*

Khemani

Sekayan²,

Hotz³

et al. 2017

Critical Care Medicine

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Objective Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength. Design Secondary analysis of prospectively collected data Setting Tertiary care pediatric ICU Patients 409 mechanically ventilated children Interventions Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made pre-extubation during airway occlusion and on CPAP of 5 and PS of 10/ above PEEP 5 cmH20, as well as 5 and 60 minutes post-extubation. Measurements and Main Results Thirty-four patients (8.3%) were re-intubated within 48 hours of extubation. Re-intubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax), longer length of ventilation, post-extubation upper airway obstruction (UAO), high respiratory effort post-extubation (Pressure Rate Product (PRP), Pressure Time Product, Tension Time Index) and high post-extubation Phase Angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cmH20) at the time of extubation, and were nearly three times more likely to be re-intubated than those with preserved strength (aPiMax >30 cmH20; 14% vs. 5.5%, p=0.006). Re-intubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (PRP > 500), while children with preserved aPiMax had re-intubation rates > 20% only when post-extubation effort was very high (PRP > 1000). When children developed post-extubation UAO, re-intubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p=0.02). Multivariable risk factors for re-intubation included acute neurologic disease, lower aPiMax, post-extubation UAO, higher pre-extubation PEEP, higher post-extubation PRP, and lower height. Conclusions Neuromuscular weakness at the time of extubation was common in children and was independently associated with re-intubation, particularly when post-extubation effort was high.

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“…Catheter position was verified by pressure deflections during ETT occlusions or by chest radiography (18). RIP flow was calibrated before extubation (see online supplement) (15,16,19). Mallinckrodt cuffless and Hi/Lo Intermediate cuffed Murphy eye endotracheal tubes (Medtronic, Minneapolis, MN) were predominantly used during the study period.…”

Section: Study Protocolmentioning

confidence: 99%

“…We have validated a minimally invasive objective tool to measure extrathoracic UAO in an animal model of pediatric UAO (15), used previously in adults (16). This tool uses calibrated respiratory inductance plethysmography (RIP) and esophageal manometry to identify inspiratory flow limitation.…”

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confidence: 99%

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Khemani

Hotz

Morzov

et al. 2016

Am J Respir Crit Care Med

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Rationale: Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors or prevention strategies. This may be due to subjective assessment of stridor or inability to differentiate supraglottic from subglottic disease.Objectives: Objective 1 was to assess the utility of calibrated respiratory inductance plethysmography (RIP) and esophageal manometry to identify clinically significant post-extubation upper airway obstruction (UAO) and differentiate subglottic from supraglottic UAO. Objective 2 was to identify risk factors for subglottic UAO, stratified by cuffed versus uncuffed endotracheal tubes (ETTs).Methods: We conducted a single-center prospective study of children receiving mechanical ventilation. UAO was defined by inspiratory flow limitation (measured by RIP and esophageal manometry) and classified as subglottic or supraglottic based on airway maneuver response. Clinicians performed simultaneous blinded clinical UAO assessment at the bedside. Measurements and Main Results:A total of 409 children were included, 98 of whom had post-extubation UAO and 49 (12%) of whom were subglottic. The reintubation rate was 34 (8.3%) of 409, with 14 (41%) of these 34 attributable to subglottic UAO. Five minutes after extubation, RIP and esophageal manometry better identified patients who subsequently received UAO treatment than clinical UAO assessment (P , 0.006). Risk factors independently associated with subglottic UAO included low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO (P , 0.04) for cuffed ETTs; and age (range, 1 mo to 5 yr) for uncuffed ETTs (P , 0.04). For uncuffed ETTs, the presence or absence of preextubation leak was not associated with subglottic UAO.Conclusions: RIP and esophageal manometry can objectively identify subglottic UAO after extubation. Using this technique, preextubation leak pressures or cuff leak volumes predict subglottic UAO in children, but only if the ETT is cuffed.

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Respiratory inductance plethysmography calibration for pediatric upper airway obstruction: an animal model

Cited by 14 publications

References 35 publications

Pediatric extubation readiness tests should not use pressure support

Pediatric extubation readiness tests should not use pressure support

Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength*

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

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