RESUMO
BACKGROUND: Extubation failure is associated with increased mortality. Cough ineffectiveness may be associated with extubation failure, but its quantification for patients undergoing weaning from invasive mechanical ventilation (IMV) remains challenging. METHODS: Patients under IMV for more than 24 h completing a successful spontaneous T-tube breathing trial (SBT) were included. At the end of the SBT, we performed quantitative sonometric assessment of three successive coughing efforts using a sonometer. The mean of the 3-cough volume in decibels was named Sonoscore. RESULTS: During a 1-year period, 106 patients were included. Median age was 65 [51-75] years, mainly men (60%). Main reasons for IMV were acute respiratory failure (43%), coma (25%) and shock (17%). Median duration of IMV at enrollment was 4 [3-7] days. Extubation failure occurred in 15 (14%) patients. Baseline characteristics were similar between success and failure extubation groups, except percentage of simple weaning which was lower and MV duration which was longer in extubation failure patients. Sonoscore was significantly lower in patients who failed extubation (58 [52-64] vs. 75 [70-78] dB, P < 0.001). After adjustment on MV duration and comorbidities, Sonoscore remained associated with extubation failure. Sonoscore was predictive of extubation failure with an area under the ROC curve of 0.91 (IC95% [0.83-0.99], P < 0.001). A threshold of Sonoscore < 67.1 dB predicted extubation failure with a sensitivity of 0.93 IC95% [0.70-0.99] and a specificity of 0.82 IC95% [0.73-0.90]. CONCLUSION: Sonometric assessment of cough strength might be helpful to identify patients at risk of extubation failure in patients undergoing IMV.
Assuntos
Extubação , Tosse , Masculino , Humanos , Idoso , Feminino , Tosse/diagnóstico , Respiração Artificial , Coma , Curva ROCRESUMO
ACUTE RESPIRATORY FAILURE IN THE ELDERLY PATIENTS Acute respiratory failure (ARF) requiring an admission in intensive care unit in the old patients presents specific characteristics that must be considered for diagnosis, treatment and prognosis. Old patients are at increased risk of ARF after any assault. It is imperative to assess the prognosis of an old patient requiring invasive treatment in the ICU f or an ARF. Age is only one of the factor accounting for high mortality together with comorbidities, previous functional status, severity of the ARF and frailty. Simple and reliable tools are available to determine the degree of frailty. Thus, chronological age should not only be considered to determine the intensity of care; the concept of physiological age may better assist the clinician in his decision making. Management should be comprehensive and multi-professional; rehabilitation should be as early as possible, which emphasizes the absolute necessity of having a physiotherapist attached to the service.
INSUFFISANCE RESPIRATOIRE AIGUË CHEZ LE SUJET ÂGÉ L'insuffisance respiratoire aiguë (IRA) chez les personnes âgées présente des caractéristiques spécifiques qui doivent être prises en considération pour le diagnostic, le traitement et le pronostic de ces patients en réanimation. Les patients âgés présentent un risque accru d'IRA après une agression quelle qu'elle soit. Il est impératif d'évaluer le pronostic d'un patient âgé nécessitant un traitement invasif en soins critiques pour une IRA. L'âge et d'autres paramètres contribuent à la mortalité : la présence de comorbidités, l'état fonctionnel antérieur, la sévérité de l'IRA et la fragilité sont à prendre en compte. Des outils simples et fiables sont disponibles pour déterminer le degré de fragilité. Ainsi, l'âge chronologique ne devrait pas être seulement considéré pour déterminer l'intensité des soins ; le concept d'âge physiologique peut davantage aider le clinicien dans ses prises de décision. La prise en charge doit être globale et pluriprofessionnelle ; la rééducation doit être la plus précoce possible, ce qui souligne l'absolue nécessité qu'un kinésithérapeute soit attaché au service.
