Tag Archives: Airway Extubation

Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial.

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Hernández G, et al. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA. 2016 Mar 15. [Epub ahead of print]

IMPORTANCE: Studies of mechanically ventilated critically ill patients that combine populations that are at high and low risk for reintubation suggest that conditioned high-flow nasal cannula oxygen therapy after extubation improves oxygenation compared with conventional oxygen therapy. However, conclusive data about reintubation are lacking.

OBJECTIVE: To determine whether high-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy for preventing reintubation in mechanically ventilated patients at low risk for reintubation.

DESIGN, SETTING, AND PARTICIPANTS: Multicenter randomized clinical trial conducted between September 2012 and October 2014 in 7 intensive care units (ICUs) in Spain. Participants were 527 adult critical patients at low risk for reintubation who fulfilled criteria for planned extubation. Low risk for reintubation was defined as younger than 65 years; Acute Physiology and Chronic Health Evaluation II score less than 12 on day of extubation; body mass index less than 30; adequate secretions management; simple weaning; 0 or 1 comorbidity; and absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, and prolonged mechanical ventilation.

INTERVENTIONS: Patients were randomized to undergo either high-flow or conventional oxygen therapy for 24 hours after extubation.

MAIN OUTCOMES AND MEASURES: The primary outcome was reintubation within 72 hours, compared with the Cochran-Mantel-Haenszel χ2 test. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis and multiorgan failure, ICU and hospital length of stay and mortality, adverse events, and time to reintubation.

RESULTS: Of 527 patients (mean age, 51 years [range, 18-64]; 62% men), 264 received high-flow therapy and 263 conventional oxygen therapy. Reintubation within 72 hours was less common in the high-flow group (13 patients [4.9%] vs 32 [12.2%] in the conventional group; absolute difference, 7.2% [95% CI, 2.5% to 12.2%]; P = .004). Postextubation respiratory failure was less common in the high-flow group (22/264 patients [8.3%] vs 38/263 [14.4%] in the conventional group; absolute difference, 6.1% [95% CI, 0.7% to 11.6%]; P = .03). Time to reintubation was not significantly different between groups (19 hours [interquartile range, 12-28] in the high-flow group vs 15 hours [interquartile range, 9-31] in the conventional group; absolute difference, -4 [95% CI, -54 to 46]; P = .66]. No adverse effects were reported.

CONCLUSIONS AND RELEVANCE: Among extubated patients at low risk for reintubation, the use of high-flow nasal cannula oxygen compared with conventional oxygen therapy reduced the risk of reintubation within 72 hours.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01191489.

Effect of mechanical cleaning of endotracheal tubes with sterile urethral catheters to reduce biofilm formation in ventilator patients. (Tarquinio)

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Liu W, Zuo Z, Ma R, Zhang X. Effect of mechanical cleaning of endotracheal tubes with sterile urethral catheters to reduce biofilm formation in ventilator patients. Pediatr Crit Care Med. 2013 Sep;14(7):e338-43.

Full-text for Children’s and Emory users.

OBJECTIVES: To investigate the effectiveness of mechanical cleaning with sterile urethral catheters to prevent formation of biofilms on endotracheal tubes.

METHODS: Forty-five children were randomized in equal numbers to endotracheal tube cleaning group for three times a day (group A), twice daily (group B), or to a control group with no endotracheal tube cleaning (group C). Bacterial studies and confocal laser scanning microscopy were performed to assess bacterial colonization and biofilm thickness on the internal surface of the endotracheal tube.

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Extubation during pediatric extracorporeal membrane oxygenation: a single-center experience. (Ruth)

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Anton-Martin P, Thompson MT, Sheeran PD, Fischer AC, Taylor D, Thomas JA.
Extubation during pediatric extracorporeal membrane oxygenation: a single-center
experience*. Pediatr Crit Care Med. 2014 Nov;15(9):861-9.

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OBJECTIVES: Describe aspects of one center’s experience extubating infants and children during extracorporeal membrane oxygenation.

DESIGN: Retrospective review of medical records.

SETTING: Seventy-one-bed critical care service (PICU and cardiovascular ICU) in a large urban tertiary children’s hospital.

PATIENTS: Pediatric and neonatal patients supported on extracorporeal membrane oxygenation between 1996 and 2013 who were either not intubated or extubated greater than 24 hours during their extracorporeal membrane oxygenation course.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Sixteen of 511 patients on extracorporeal membrane oxygenation were extubated for at least 24 hours during their extracorporeal membrane oxygenation courses. Fourteen had respiratory failure and two had cardiac disease. Five patients died while on extracorporeal membrane oxygenation, but the cause of death was not related to complications associated with extubation. Extubated patients were supported a median of 19.7 days on extracorporeal membrane oxygenation, with a median extubation latency (time between cannulation and first extubation) of 6.2 days and a median extubation duration of 5.5 days. Mean time extubated was 43% of the total time on extracorporeal membrane oxygenation. Two patients were reintubated briefly or had a laryngeal mask airway placed for decannulation (n = 1). The remaining patients were extubated within 5 days of decannulation, weeks afterward (n = 2), transferred to outside facilities (n = 2), or died during extracorporeal membrane oxygenation support (n = 5). We also observed no complications directly attributable to extubation and spontaneous reaeration of consolidated lungs in acute respiratory distress syndrome in extubated patients on extracorporeal membrane oxygenation.
CONCLUSION: Extubation and discontinuation of mechanical ventilation appear feasible in patients requiring long-term extracorporeal membrane oxygenation. Emergency procedure planning may need to be modified in extubated patients on extracorporeal membrane oxygenation.

Daytime versus nighttime extubations: A comparison of reintubation, length of stay, and mortality. (Petrillo)

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Tischenkel BR, Gong MN, Shiloh AL, Pittignano VC, Keschner YG, Glueck JA,
Cohen HW, Eisen LA. Daytime Versus Nighttime Extubations: A Comparison of
Reintubation, Length of Stay, and Mortality. J Intensive Care Med. 2014 Apr 24.
[Epub ahead of print]

PURPOSE: Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time.

METHODS: A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm.

RESULTS: Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night (P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night.

CONCLUSIONS: Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

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