Early Identification of Extubation Failure Using Integrated Pulmonary Index and High-Risk Factors.

BACKGROUND: Early detection and prevention of extubation failure offers the potential to improve patient outcome. The primary aim of this study was to compare the predictive ability of the Integrated Pulmonary Index and presence of high-risk factors in determining extubation failure. METHODS: A retrospective cross-sectional study of intubated adult subjects receiving mechanical ventilation for > 24 h was conducted at an academic medical center. The primary outcome was extubation failure, defined as the need for re-intubation or rescue noninvasive ventilation within 48 h after planned extubation. RESULTS: Among 216 subjects, 170 (78.7%) were successfully extubated, and 46 (21.3%) failed extubation. Extubation failure group had higher body mass index (26.21 vs 28.5 kg/m2, P = .033), rapid shallow breathing index during spontaneous breathing trial (43 vs 53.5, P = .02), and APACHE II score (11.86 vs 15.73, P < .001). Presence of ≥3 high-risk factors (odds ratio 3.11 [95% CI 1.32-7.31], P = .009), APACHE II > 12 on extubation day (odds ratio 2.98 [95% CI 1.22-7.27], P = .02), and Integrated Pulmonary Index decrease within 1 h after extubation (odds ratio 7.74 [95% CI 3.45-17.38], P < .001) were independently associated with extubation failure. The failed extubation group had higher ICU mortality (8.8% vs 19.6%; absolute difference 10.7% [95% CI -1.9% to 23.4%], P = .040) and hospital mortality (10% vs 22%; absolute difference 16.1% [95% CI 2.2-30%], P = .005) compared to the successful group. CONCLUSIONS: Among subjects receiving mechanical ventilation for > 24 h, decreasing Integrated Pulmonary Index within the first hour postextubation was a predictor of extubation failure and was superior to other weaning variables collected in this retrospective study. The presence of ≥ 3 high-risk factors was also independently associated with extubation failure. Future clinical studies are required to prospectively test the ability of postextubation Integrated Pulmonary Index monitoring to guide additional interventions designed to reduce re-intubation rates and improve patient outcome.

Implementing a Multidisciplinary Prone Positioning Team.

ABSTRACT: The coronavirus disease 2019 pandemic has escalated clinical needs while interrupting regular processes and straining resources. Striving to deliver optimal care to infected patients with respiratory failure, Rush University Medical Center in Chicago created a multidisciplinary team to provide manual prone positioning safely and efficiently. Team members' experiences, which they shared through a survey, help to illustrate the advantages of a multidisciplinary approach and suggest opportunities to enhance the effectiveness of such a team.

Challenges in Brain Death Determination and Apnea Testing for Patients with COVID-19.

INTRODUCTION: Apnea testing remains essential for the clinical evaluation of brain death determination. In patients who test positive for SARS-CoV-2, disconnecting the patient from the ventilator and introducing high flow oxygen into the endotracheal tube increases the risk for aerosolization of airway secretions and exposure of the examiner. METHODS: Case report of a patient with an intracerebral hemorrhage that evolved to significant cerebral edema and herniation, who underwent apnea test using a method involving a t-piece and an HME filter. RESULTS: Patient successfully pronounced brain dead using a safe method to minimize exposure to SARS-CoV-2. CONCLUSION: At a time where healthcare workers are at high risk of exposure to COVID-19, the above described method is a safe process for apnea testing in declaration of brain death.

Evaluation of Endotracheal Tube Scraping on Airway Resistance.

BACKGROUND: Spontaneous breathing trials (SBTs) are used to assess the readiness for discontinuation of mechanical ventilation. When airway resistance (Raw) is elevated, the imposed work of breathing can lead to prolongation of mechanical ventilation. Biofilm and mucus build-up within the endotracheal tube (ETT) can increase Raw. Scraping the ETT can remove the biofilm build-up and decrease mechanical Raw. The primary aim of this study was to evaluate the impact of ETT scraping on Raw. The secondary aim was to determine whether decreasing Raw would impact subsequent SBT success. METHODS: Intubated, mechanically ventilated subjects were enrolled if they failed an SBT and had an Raw of > 10 cm H2O/L/s. SBT failure was based on institutional guidelines, and Raw was calculated by subtracting the difference between the measured peak and plateau pressures using a square flow waveform with an inspiratory flow set at 60 L/min. The endOclear device was inserted into the ETT and withdrawn per manufacturer's guidelines. Scraping was repeated until the ETT was cleared. Change in Raw was compared pre- and post-ETT scraping using a paired t test. A Mann-Whitney U test evaluated the difference in percentage change in Raw between SBT groups. RESULTS: Twenty-nine subjects completed the study. The mean pre- and post-ETT scraping Raw values were 15.17 ± 3.83 and 12.05 ± 3.19 cm H2O/L/s, respectively (P < .001). Subsequent SBT success was 48%; however, there was no difference in percentage change in Raw between subsequent passed SBT (18.61% [interquartile range 8.90-33.93%]) and failed SBT (23.88% [interquartile range 0.00-34.80%]), U = 78.5, z = -0.284, P = .78. No adverse events were noted with ETT scraping. CONCLUSIONS: This study demonstrated that ETT scraping can reduce Raw. The decrease in Raw post-ETT scraping did not affect subsequent SBT success.