Role of ICU-acquired weakness on extubation outcome among patients at high risk of reintubation

Abstract

Background: Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. Methods: A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-notreintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semiquantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. Results: Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. Conclusion: ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.

Extubation Failure in Critically Ill COVID-19 Patients: Risk Factors and Impact on In-Hospital Mortality

“…Greater disease severity, frequent need for suctioning post-extubation and ICU-acquired weakness were identified as predictors of extubation failure in non-COVID patients. 11 , 12 Clinical markers to predict extubation success or failure are currently unknown in the critically ill COVID-19 population. In our cohort, reintubated patients were significantly older (on average by 8 years) compared to those whose extubation was successful; the comorbidity burden and the mortality risk assessed by the SOFA score on intubation day were similar.…”

Role of sleep on respiratory failure after extubation in the ICU

“…Although patients with altered sleep had lower central respiratory drive (as indicated by lower P 0.1 ), their risk of post-extubation respiratory failure or reintubation was not significantly increased as compared to those with normal sleep. Once a trial is successful and the patient able to breathe spontaneously, sleep quality may no longer be a determinant for extubation failure, which may be more likely be due to multiple factors including underlying cardiac or respiratory disease, cough strength, ICU-acquired weakness and respiratory muscle dysfunction [ 17 , 28 , 34 ]. However, we cannot rule out the possibility that the sleep times observed in our study after extubation were so short in the overall population that the potential impact on prognosis of altered sleep cannot be accurately assessed.…”

“…We hypothesized that patients with poor sleep quality (with atypical sleep or no REM sleep) may have reintubation rates reaching 40%, i.e., close to the reintubation rates reported in the most severe patients with severe cardiac heart failure, severe limb weakness or ineffective cough [ 17 , 27 , 28 ], versus only 10% in patients with good sleep quality, i.e., as patients at low-risk of reintubation [ 29 ]. Enrollment of 64 patients with adequate polysomnography was determined to provide a power of 80% and to show an absolute difference of 30% in rate of reintubation between patients with poor sleep quality and those with good sleep quality.…”

Risk Factors of ICU-Acquired Weakness in Critical Ill Patients with ECMO Support: A Retrospective Study

“…With the advancements in modern intensive care medicine, mortality of critical ill patients has decreased, however, at the cost of a growing incidence of ICU-AW [10]. ICU-AW is known to have detrimental effects on both short-term and long-term clinical outcomes, identifying those who at high risk of developing ICU-AW is important [8,11].In our research, we show in a population of critical ill patients that the use of adrenaline and occurrence of infection are closely associated with the development of ICU-AW when discharged. We showed in a population of critical ill patients with ECMO support, there was higher proportion of adrenaline use in ICU-AW group, the use of adrenaline significantly increased the risk of developing ICU-AW.…”