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Among patients with a high risk of reintubation, spontaneous-breathing trials performed with pressure-support ventilation did not result in significantly more ventilator-free days at day 28 than T-piece trials.

Introduction The purpose of this study was to evaluate if ultrasound derived measures of diaphragm thickening, rather than diaphragm motion, can be used to predict extubation success or failure. Methods Sixty-three mechanically ventilated patients were prospectively recruited. Diaphragm thickness (tdi) was measured in the zone of apposition of the diaphragm to the rib cage using a 7–10 MHz ultrasound transducer. The percent change in tdi between end-expiration and end-inspiration (Δtdi%) was calculated during either spontaneous breathing (SB) or pressure support (PS) weaning trials. A successful extubation was defined as SB for >48 h following endotracheal tube removal. Results Of the 63 subjects studied, 27 patients were weaned with SB and 36 were weaned with PS. The combined sensitivity and specificity of Δtdi%≥30% for extubation success was 88% and 71%, respectively. The positive predictive value and negative predictive value were 91% and 63%, respectively. The area under the receiver operating characteristic curve was 0.79 for Δtdi%. Conclusions Ultrasound measures of diaphragm thickening in the zone of apposition may be useful to predict extubation success or failure during SB or PS trials.

Failure to establish an airway can be life-threatening. Although relatively rare, such cases tend to be underreported. Advances in visualization techniques may be helpful. Difficult intubation can often be anticipated and prepared for.

Oxygen is commonly administered after extubation. Although several devices are available, data about their clinical efficacy are scarce. To compare the effects of the Venturi mask and the nasal high-flow (NHF) therapy on PaO2/FiO2SET ratio after extubation. Secondary endpoints were to assess effects on patient discomfort, adverse events, and clinical outcomes. Randomized, controlled, open-label trial on 105 patients with a PaO2/FiO2 ratio less than or equal to 300 immediately before extubation. The Venturi mask (n = 52) or NHF (n = 53) were applied for 48 hours postextubation. PaO2/FiO2SET, patient discomfort caused by the interface and by symptoms of airways dryness (on a 10-point numerical rating scale), interface displacements, oxygen desaturations, need for ventilator support, and reintubation were assessed up to 48 hours after extubation. From the 24th hour, PaO2/FiO2SET was higher with the NHF (287 ± 74 vs. 247 ± 81 at 24 h; P = 0.03). Discomfort related both to the interface and to airways dryness was better with NHF (respectively, 2.6 ± 2.2 vs. 5.1 ± 3.3 at 24 h, P = 0.006; 2.2 ± 1.8 vs. 3.7 ± 2.4 at 24 h, P = 0.002). Fewer patients had interface displacements (32% vs. 56%; P = 0.01), oxygen desaturations (40% vs. 75%; P < 0.001), required reintubation (4% vs. 21%; P = 0.01), or any form of ventilator support (7% vs. 35%; P < 0.001) in the NHF group. Compared with the Venturi mask, NHF results in better oxygenation for the same set FiO2 after extubation. Use of NHF is associated with better comfort, fewer desaturations and interface displacements, and a lower reintubation rate. Clinical trial registered with www.clinicaltrials.gov (NCT 01575353).

Background Self-extubation is a common complication in intubated patients in the intensive care unit (ICU) and is associated with a high rate of reintubation. This study aimed to identify predictors of reintubation following self-extubation (SE) and assess the prognosis of these patients. Methods Data were extracted from the French ICU database, OutcomeRea™. The primary objective was to identify factors associated with reintubation within 48 h after self-extubation. Secondary objectives included evaluating the association between reintubation and mortality, ICU length of stay, and nosocomial pneumonia. Results Between November 1996 and May 2022, 12,917 patients were intubated in the ICU. Among them, 701 patients experienced SE without therapeutic limitations at the time, and 276 (39.4%) required reintubation. In adjusted analyses, the following factors were independently associated with reintubation: a higher non-neurological SOFA score on the day before SE (OR 1.16 [1.01; 1.34]; p = 0.03), duration of invasive mechanical ventilation > 7 days before SE (OR 1.79 [1.04; 3.26]; p = 0.04), enteral nutrition on the day of SE (OR 2.59 [1.75; 3.84]; p < 0.01) and the use of non-invasive ventilation (NIV) within 24 h after SE (OR 0.28 [0.16; 0.5];p < 0.01). Reintubation within 48 h after SE was independently associated with increased 28-day mortality (HR = 3.03 [1.79; 5.12]; p < 0.01) and 90-day mortality (HR = 2.86 [1.86; 4.4]; p < 0.01), a higher risk of nosocomial pneumonia (sdHR, 18.28 [7.70; 43.42]; p < 0.01), and a 13-day increase in ICU length of stay (p < 0.01). Conclusion Enteral nutrition on the day of SE, prolonged mechanical ventilation prior to SE, higher non-neurological SOFA scores, and use of NIV after SE were independently associated with the need for reintubation. Reintubation was also associated with increased mortality, a higher risk of nosocomial pneumonia, and prolonged ICU stay.

Purpose Pressure support is often used for extubation readiness testing, to overcome perceived imposed work of breathing from endotracheal tubes. We sought to determine whether effort of breathing on continuous positive airway pressure (CPAP) of 5 cmH 2 O is higher than post-extubation effort, and if this is confounded by endotracheal tube size or post-extubation noninvasive respiratory support. Methods Prospective trial in intubated children. Using esophageal manometry we compared effort of breathing with pressure rate product under four conditions: pressure support 10/5 cmH 2 O, CPAP 5 cmH 2 O (CPAP), and spontaneous breathing 5 and 60 min post-extubation. Subgroup analysis excluded post-extubation upper airway obstruction (UAO) and stratified by endotracheal tube size and post-extubation noninvasive respiratory support. Results We included 409 children. Pressure rate product on pressure support [100 (IQR 60, 175)] was lower than CPAP [200 (120, 300)], which was lower than 5 min [300 (150, 500)] and 60 min [255 (175, 400)] post-extubation (all p  < 0.01). Excluding 107 patients with post-extubation UAO (where pressure rate product after extubation is expected to be higher), pressure support still underestimated post-extubation effort by 126–147 %, and CPAP underestimated post-extubation effort by 17–25 %. For all endotracheal tube subgroups, ≤3.5 mmID ( n  = 152), 4–4.5 mmID ( n  = 102), and ≥5.0 mmID ( n  = 48), pressure rate product on pressure support was lower than CPAP and post-extubation (all p  < 0.0001), while CPAP pressure rate product was not different from post-extubation (all p  < 0.05). These findings were similar for patients extubated to noninvasive respiratory support, where pressure rate product on pressure support before extubation was significantly lower than pressure rate product post-extubation on noninvasive respiratory support ( p  < 0.0001, n  = 81). Conclusions Regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.

Background Extubation failure leading to reintubation is associated with high mortality. In patients at high-risk of extubation failure, clinical practice guidelines recommend prophylactic non-invasive ventilation (NIV) over high-flow nasal oxygen (HFNO) immediately after extubation. However, the physiological effects supporting the beneficial effect of NIV have been poorly explored. We hypothesized that NIV may reduce patient inspiratory efforts to a greater extent than HFNO after extubation. Methods In a prospective physiological study, patients at high-risk of extubation failure (> 65 years old or underlying cardiac or respiratory disease) were included to receive after planned extubation prophylactic NIV and HFNO in a randomized crossover order, followed by standard oxygen. Inspiratory efforts were assessed by calculation of the simplified esophageal pressure–time-product per minute (sPTP es in cmH 2 O s/min). Tidal volumes, distribution and homogeneity of ventilation were estimated using electrical impedance tomography. Results Twenty patients were retained in the analysis. Inspiratory efforts were lower with NIV than with HFNO (sPTP es 196 cm H 2 O s/min [116–234] vs. 220 [178–327], p  < 0.001) whereas tidal volumes were larger with NIV than with HFNO (8.4 mL/kg of predicted body weight [6.7–9.9] vs. 6.9 [5.3–8.6], p  = 0.005). There was a non-significant increase in dorsal region ventilation under NIV compared to HFNO. Conclusions In patients at high-risk of extubation failure, prophylactic NIV significantly decreased inspiratory efforts with increased tidal volumes compared to HFNO. The clinical benefits of NIV to prevent reintubation in patients at high-risk may be mediated by these physiological effects. Trial registration Clinicaltrials.gov: ID NCT04036175), retrospectively registered 17 June 2019.

The day of extubation is a critical time during an intensive care unit (ICU) stay. Extubation is usually decided after a weaning readiness test involving spontaneous breathing on a T-piece or low levels of ventilatory assist. Extubation failure occurs in 10 to 20% of patients and is associated with extremely poor outcomes, including high mortality rates of 25 to 50%. There is some evidence that extubation failure can directly worsen patient outcomes independently of underlying illness severity. Understanding the pathophysiology of weaning tests is essential given their central role in extubation decisions, yet few studies have investigated this point. Because extubation failure is relatively uncommon, randomized controlled trials on weaning are underpowered to address this issue. Moreover, most studies evaluated patients at low risk for extubation failure, whose reintubation rates were about 10 to 15%, whereas several studies identified high-risk patients with extubation failure rates exceeding 25 or 30%. Strategies for identifying patients at high risk for extubation failure are essential to improve the management of weaning and extubation. Two preventive measures may prove beneficial, although their exact role needs confirmation: one is noninvasive ventilation after extubation in high-risk or hypercapnic patients, and the other is steroid administration several hours before extubation. These measures might help to prevent postextubation respiratory distress in selected patient subgroups.

PurposeSpontaneous breathing trials (SBT) evaluate the patient's capacity to maintain inspiratory effort after extubation. SBT practices are heterogeneous and not individualised. The objective of this study was to assess which SBT best reproduces inspiratory effort after extubation in five critical illnesses.MethodsIn this multicentre randomized cross-over study, adult intensive care unit patients under invasive mechanical ventilation for at least 24-h and ready for extubation, underwent three 15-min SBTs in random order: pressure support ventilation level of 7-cmH2O with positive end-expiratory pressure (PEEP) level of 0-cmH2O (PSV7PEEP0), PSV 0-cmH2O with PEEP 0-cmH2O (PSV0PEEP0) and T-piece trial. Primary outcome was the variation of pressure–time-product per minute (PTPmin) between each SBT and 20-min after extubation. Five categories of critical illnesses were selected: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease (COPD) and miscellaneous.ResultsFive hundred measures of effort from 100 patients were analysed. PTPmin (cmH2O s/min, median and interquartile range, IQR) was 256 (208–321) after extubation, 192 (127–281) at the end of PSV7PEEP0 (p < 0.001 in comparison to after extubation), 291 (235–347) at the end of PSV0PEEP0 and 262 (198–338) at the end of T-piece (both no different from after extubation). One method of SBT in patients with brain injury (PSV0PEEP0), two in abdominal surgery (PSV0PEEP0 and T-piece) and miscellaneous patients (PSV7PEEP0 and T-piece) and all three methods in chest trauma and COPD exacerbation patients replicated reasonably accurately the postextubation effort to breathe.ConclusionUnassisted SBTs, namely PSV0PEEP0 and T-piece trial, are the most appropriate to replicate the postextubation effort to breathe.