ABSTRACT
BACKGROUND: This was an evaluation of intra-individual variation of the cuff-leak test (ΔCLT) immediately post-intubation and pre-extubation, as a predictor of post-extubation stridor. METHODS: Prospective, clinical investigation in the ICU of a non-university hospital. CLTs were performed immediately after intubation (T0) and before extubation (T1) to evaluate the differences in cuff leak (ΔCLT = CL(T1) - CL(T0)). RESULTS: We included 104 mechanically ventilated subjects in the study over a 12-month period. The incidence of post-extubation stridor was 6.7%. Stridor was more common in females of short stature. ΔCLT was considered as significant when CL(T1) - CL(T0) was negative. The sensitivity and the specificity of the test were 86% and 48%, respectively. When we tested the pre-extubation CLT alone with a threshold of 130 mL as a predictor of post-extubation stridor, the sensitivity and the specificity of the test were 86% and 76%, respectively. CONCLUSIONS: The intra-individual variation of CLT immediately post-intubation and pre-extubation does not improve the accuracy of a standard pre-extubation CLT to predict post-extubation stridor. Moreover, the standard pre-extubation CLT did not appear in our study to be an ideal test to detect post-extubation stridor. Larger studies should be performed before generalizing these preliminary results.
Subject(s)
Airway Extubation , Respiratory Sounds/diagnosis , Aged , Aged, 80 and over , Airway Extubation/instrumentation , Female , Humans , Laryngeal Edema/complications , Laryngeal Edema/prevention & control , Male , Prospective Studies , ROC Curve , Respiratory Function Tests , Respiratory Sounds/etiology , Sensitivity and SpecificityABSTRACT
OBJECTIVE: To describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients. DESIGN: Observational study. SETTING: A 10-bed ICU of a general hospital. PATIENTS: Eighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS. INTERVENTIONS: The healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 microg/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO2=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart. RESULTS: Withholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h. CONCLUSION: This four-step protocol may promote medical decision making on end-of-life care.
