Classification of Outcome of Patients with Failure to Wean
Prospective, Multicenter 6-Month Cohort Study of the Outcome of Weaning (Eur Respir J, 2010) [MEDLINE]: n = 510
Definition
Simple Wean: weaning after passing the first spontaneous breathing trial
Difficult Weaning: failure of first spontaneous breathing trial, then requiring ≤3 spontaneous breathing trials or 7 days to pass a spontaneous breathing trial
Prolonged Weaning: failure of at least 3 spontaneous breathing trials or require >7 days to pass a spontaneous breathing trial
Incidence by Category
Simple Weaning: 59%
Difficult Weaning: 26%
Prolonged Weaning: 14%
Outcome
Hospital Mortality was Increased in Patients with Prolonged Weaning (32%), But Not Difficult Weaning (13%) (p=0.0205)
In Multivariate Logistic Reression Model, Prolonged Weaning (But Not Difficult Weaning) was Associated with an Increased Risk of Death
Ventilator-Free Days and ICU-Free Days were Decreased in Both the Difficult and Prolonged Weaning Groups
Study of Outcome of Weaning (Am J Respir Crit Care Med, 2011) [MEDLINE]; n = 4,968
Incidence by Category
Simple Weaning: 55%
Difficult Weaning: 39%
Prolonged Weaning: 6%
Variables Associated with Prolonged Weaning
SAPS II Score (Odds Ratio Per Unit of Simplified Acute Physiology Score II, 1.01; 95% confidence interval [CI], 1.001–1.02)
Duration of Mechanical Ventilation Prior to First Weaning (Odds Ratio Per Day, 1.10; 95% CI, 1.06–1.13)
Chronic Pulmonary Disease Other than COPD (Odds Ratio 13.23; 95% CI, 3.44–51.05
Pneumonia as the Reason to Start Mechanical Ventilation (Odds Ratio 1.82; 95% CI, 1.07–3.08)
Level of PEEP Before Weaning (Odds Ratio Per Unit,1.09; 95% CI, 1.04–1.14)
Prolonged Weaning Group Had a Nonsignificant Trend Toward a Higher Rate of Reintubation, Tracheostomy
Prolonged Weaning Group Had a Significant Longer Length of Stay and Higher ICU Mortality Rate (Odds Ratio for Death, 1.97;95% CI, 1.17–3.31)
Baseline Brain Natriuretic Peptide (BNP) Measured Before First Weaning Trials Has Been Found to Be Higher in Patients with Subsequent Weaning Failure and Levels Correlate with Weaning Duration (Intensive Care Med, 2006) [MEDLINE]
Myocardial Injury After Non-Cardiac Surgery (MINS) Has Been Identified as a Risk Factor for Weaning Failure in Patients Who Have Undergone Abdominal Surgery (Independent of Age, Lower Preoperative Left Ventricular Ejection Fraction, and Postoperative Hypoalbuminemia (PLoS One, 2014) [MEDLINE]
Weaning-Induced Pulmonary Edema (WiPO) Has Been Identified as a Risk Factor for Weaning Failure (Crit Care, 2016) [MEDLINE]: risk of WIPO was increased by presence of COPD, prior structural cardiomyopathy. and obesity (to a lesser extent)
Weaning Strategies Which Include the Use of PEEP During a Pressure Support Trial Can Mask the Presence of Weaning-Associated Cardiac Dysfunction, Since PEEP is a Treatment for Heart Failure (Intensive Care Med, 2010) [MEDLINE]
Spontaneous Breathing Trial-Induced Increases in Extravascular Lung Water (Indexed for Ideal Body Weight), Plasma Protein Concentrations, Hemoglobin Concentration, and BNP are Reliable Alternatives to the Swan-Ganz Catheter for Diagnosing Weaning-Induced Pulmonary Edema (Crit Care Med, 2014) [MEDLINE]
Thoracic Ultrasound Demonstrating B-Lines ≥6 on Four Anterior Points Allows the Diagnosis Weaning-Induced Pulmonary Edema (Intensive Care Med, 2019) [MEDLINE]
Passive Leg Raise Prior to Weaning Trial May Predict Weaning Failure Due to Cardiac Dysfunction (Intensive Care Med, 2015) [MEDLINE]
Stress Echocardiography May Be Useful to Detect Silent Diastolic Dysfunction, Systolic Dysfunction, or Mitral Regurgitation Which May Impact Weaning (J Crit Care, 2017) [MEDLINE]
Depression Has Been Demonstrated in 42% of Patients During Weaning from Prolonged Mechanical Ventilation and Patients with Depression were More Likely to Experience Weaning Failure and Death (Intensive Care Med, 2010) [MEDLINE]
Delirium (Assessed by CAM-ICU at the Time of the First Weaning Trial) Has Been Found to Be Associated with Weaning Failure (Respirology, 2016) [MEDLINE]
Note that in a Patient with Chronic Hypoventilation (Chronic Hypoxemic, Hypercapnic Respiratory Failure) Who Has Been Inadvertently Overventilated During Their Course Prior to Weaning, Compensatory Renal Bicarbonate Excretion Decreases the Serum Bicarbonate Below the Patient’s Baseline (i.e. a “Relative Metabolic Acidosis), Resulting in Hypercapnia (at Their Baseline pCO2) with Undesirable Acidemia During Weaning Trials
Small Diameter Endotracheal Tube/Tracheostomy (Respir Care, 2012) [MEDLINE]
This Can Be Overcome by Switching from T-Piece trial to Pressure Support, Which Allows the Pressure Support to Overcome the Resistance of the Smaller Diameter Artificial Airway (Intensive Care Med, 2006) [MEDLINE]
Inability to Progress to Increasing Patient Workload During Successive Spontaneous Breathing Trials
Management
Clinical Efficacy-Changing the Weaning Modality in Patients with Failure to Wean
Comparative Trial of T-Piece, Intermittent Mandatory Ventilation (IMV) and Pressure Support (PS) Ventilator Weaning (Am J Respir Crit Care Med, 1994) [MEDLINE]: n = 109 patients who failed an initial spontaneous breathing trial
After Failing an Initial Spontaneous Breathing Trial, Patients were Randomized to Groups
After Excluding Patients Whose Weaning was Terminated for Complications Unrelated to the Weaning Process, Pressure Support Weaning Failure was Lowest (8%), as Compared to T-Piece and SIMV Weaning (p<0.025)
Critique
Trial Allowed Patient to Undergo Up to 3 T-Piece Trials (2 hrs Each) in a 24 hr Period Which May Have Resulted in Respiratory Muscle Fatigue, Which May Have Slowed the Weaning Process
Respiratory Muscle Fatigue Can Take Up to 24 hrs to Resolve ( J Appl Physiol, 1985) [MEDLINE]
Spanish Randomized Trial of T-Piece (Once Daily or Two-Three Times Daily), Synchronized Intermittent Mandatory Ventilation (SIMV) and Pressure Support (PS) Ventilator Weaning (NEJM, 1995) [MEDLINE]: n = 130 patients who failed an initial spontaneous breathing trial
After Failing an Initial Spontaneous Breathing Trial, Patients were Randomized to Groups
Once Daily Spontaneous Breathing Trials with T-Piece
Multiple (2-3) Times Daily Spontaneous Breathing Trials with T-Piece
Once Daily Trial of Spontaneous Breathing with T-Piece Led to Extubation 3x More Quickly than Intermittent Mandatory Ventilation Weaning and Twice as Quickly as Pressure Support Weaning
Multiple (2-3) Daily Spontaneous Breathing Trials with T-Piece and Daily Spontaneous Breathing Trials with T-Piece were Equally Effective
Trial Allowed Patient to Be Extubated After a Successful 2 hr Spontaneous Breathing Trial: fatigue was less likely to occur in this trial
Conclusions
While T-Piece and Pressure Spontaneous Breathing Trials are Probably Comparable, IMV is Notably Inferior
During IMV, the Respiratory Neuromuscular System Poorly Adapts to Changing Respiratory Workloads Between the Supported (Mandatory) and Unsupported (Spontaneous) Breaths
Muscle Contraction During Lower Levels of IMV is Similar During Both Supported (Mandatory) and Unsupported (Spontaneous) Breaths (Anesthesiology, 1994) [MEDLINE]
This Drawback of IMV Can Be Mitigated to Some Extent by Using Adding Pressure Support to IMV for the “Spontaneous” Breaths (Chest, 1994) [MEDLINE]
Clinical Efficacy-Management of Pleural Effusions in Patients with Failure to Wean
Study of Effect of Pleural Effusion Drainage in Mechanically-Ventilated Patients (Ann Am Thorac Soc, 2014) [MEDLINE]
Drainage of Large (≥500 mL) Pleural Effusions Improved Oxygenation and End-Expiratory Lung Volume
Oxygenation Improvement Correlated with Increased Lung Volume and a Decrease in Transpulmonary Pressure (Less So Though in Patients with ARDS)
Clinical Efficacy-Heart Failure Management in Patients with Failure to Wean
Randomized, Controlled Multicenter Trial of BNP-Guided Fluid Management During Ventilator Weaning (Am J Respir Crit Care Med. 2012) [MEDLINE]
BNP-Guided Fluid Management Decreased the Duration of Weaning without Increasing Adverse Events, Especially in Patients with Left Ventricular Systolic Dysfunction
Clinical Efficacy-Nitroglycerin Treatment of Patients with Failure to Wean
Small Non-Randomized Trial of Nitroglycerin for Difficult to Wean COPD Patients (Crit Care, 2010) [MEDLINE]: n = 12
In Difficult to Wean COPD Patients, Mean Arterial Pressure Increased, Rate-Pressure Product Increased, Mean Pulmonary Artery Pressure Increased, Pulmonary Capillary Wedge Pressure Increased, and Mixed Venous Oxygen Saturation Decreased During Failing Weaning Trials
During Weaning with Nitroglycerin Infusion in Difficult to Wean COPD Patients, These Parameters Did Not Change
Nitroglycerin Infusion Allowed a Successful Weaning Trial in 92% of Cases and a Extubation in 88% of Cases
Clinical Efficacy-Supportive in Patients with Failure to Wean
Study of Relaxation Biofeedback During Weaning (Am Rev Respir Dis, 1990) [MEDLINE]
Relaxation Biofeedback Has Been Demonstrated to Decrease Weaning Time
General Recommendations
While T-Piece and Pressure Spontaneous Breathing Trials are Probably Comparable in Patients Who Fail to Wean, Most Clinicians Use Pressure Support Trials with Graded Levels of Support (Per Patient Tolerance)
Once Daily Spontaneous Breathing Trials are Probably Recommended to Avoid Fatigue
Ongoing Assessment of Factors Potentially Contributing to Failure to Wean Should Continue on a Daily Basis
If the Patient Then Tolerates Spontaneous Breathing Trial, Patient Should Be Returned to Normal Ventilator Mode for One Hour of Rest Prior to Extubation (Intensive Care Med, 2017) [MEDLINE]
Once Extubated, Prophylactic Noninvasive Ventilation (NIPPV) Can Be Considered in High-Risk Patients
Tracheostomy (see Tracheostomy): may be required for refractory failure to wean
In Tracheostomized Patients Requiring Prolonged Ventilation in a Long-Term Acute Care Facility, Unassisted Breathing Via Tracheostomy Resulted in Shorter Weaning Times, as Compared to Pressure Support (JAMA, 2013) [MEDLINE]
Weaning Mode Had No Effect on 6 and 12-Month Mortality Rates
Importantly, in This Study, Approximately 37% of Patients Could Have Been Weaned in the ICU and May Not Have Required Transfer to the LTAC for Weaning
Once Tracheostomy Has Been Placed, Patients Typically are Considered for Transfer to a Long-Term Acute Care (LTAC) Facility for Prolonged Ventilator Weaning
Long-Term Care Facilities Specialize in Specialized Rehabilitation and Ventilator Weaning
Long-Term Acute Care Facility Admissions Have Increased from 13,732 in 1997 to 40,353 in 2006, with Annual Costs Increasing from from $484 Million to $1.325 Billion (JAMA, 2010) [MEDLINE]
In the “Ventilation Outcomes Study”, Post-Critical Illness Ventilator-Dependent Patients Admitted to LTAC Facilities Had a Mean APACHE III Score of 35, >90% of Patients Had ≥3 Indwelling Lines/Tubes, and 42% of Patients Had ≥Stage 2 Decubitus Ulcers (Chest, 2007) [MEDLINE]
Preparation for Extubation
Required Pre-Extubation Criteria
Resolution (or Significant Improvement) in Condition Which Initially Resulted in Intubation (ARDS, Pneumonia, Cardiogenic Pulmonary Edema, Inability to Protect Airway, etc)
Performance of Successful Weaning Trial: required in most cases
Exception-Patient Intubated for Short Period of Time During Recovery from General Anesthesia
Exception-Patient Being Terminally Extubated During End of Life Care
Adequate Mental Status (Typically with Glasgow Coma Scale ≥8) with Intact Ability to Protect Airway
Adequate Ability to Cough
Assessed by Clinical Examination, White Card Test, Spirometry, etc
Low Amount of Secretions (Generally Requiring Suctioning Less than Every 2-3 hrs)
Thick Secretions are Usually Only a Significant Factor in the Presence of a Weak Cough
Pre-Extubation Checklist
Discontinue Tube Feeding (2-4 hrs Before Extubation)
Some Patients with Ileus/High Residual Volumes May Require that Tube Feedings Be Held for Longer Periods Prior to Extubation
Prepare Suction Set-Up and Bag-Valve-Mask (BVM) Ventilation System
Setup is Critical in Case Reintubation is Required
Place Patient in Upright Position to Optimize Diaphragmatic Function
Suction Oral Cavity, Above the Endotracheal Tube Cuff, and the Lower Airways
Administer Bronchodilators (If Appropriate)
Discontinuation of Tube Feedings (Enteral Nutrition) Prior to Extubation
Clinical Efficacy
French Trial of Discontinuation of Tube Feedings (Enteral Nutrition) Prior to Extubation (Lancet Respir Med, 2023) [MEDLINE]: n = 1,130
In the Intention-to-Treat Population, Extubation Failure Occurred in 17.2% of Patients Receiving Continued Enteral Nutrition Until Extubation vs 17.5% of Fasting Patients, Meeting the Defined Non-Inferiority Criterion (Absolute Difference -0·4%; 95% CI: -5.2 to 4.5)
In the Per-Protocol Population, Extubation Failure Occurred in 17.0% of Patients Receiving Continued Enteral Nutrition vs 17.9% of Fasting Patients (Absolute Difference -0·9%; 95% CI: -5.6 to 3.7)
Pneumonia within 14 Days of Extubation Occurred in 1.6% of Patients Receiving Continued Enteral Nutrition vs 2.5% of Fasting Patients (Rate Ratio 0.77; 95% CI: 0.22 to 2.69)
Timing of Extubation (Daytime vs Nightime)
Data are Inconclusive with Regard to Daytime vs Nightime Extubation
Retrospective Cohort Study of Extubation During Daytime vs Nighttime (J Intensive Care Med, 2016) [MEDLINE]
ICU Extubations at Night Were Not Associated Higher Likelihood of Reintubation, Length of Stay, or Mortality Rate, as Compared to those During the Day
Multilevel Multivariable Regression Analyses of Extubation (Daytime vs Nighttime) in ICU Patients (JAMA Intern Med, 2016) [MEDLINE]
Approximately 20% of Patients are Extubated During Nighttime Hours
Nighttime Extubations were Associated with Higher ICU Mortality Rate, Higher Hospital Mortality Rate, as Compared to Daytime Extubations
Study of Extubation (Daytime vs Nighttime) in Cardiac Surgery Patients (J Thorac Cardiovasc Surg, 2019) [MEDLINE]
Extubation Overnight was Not Associated with Increased Mortality Rate or Reintubation Rate
Standard Flow Nasal Cannula Oxygen (2-6 LPM) is Typically Applied, as Required
Some Patients Who are Deemed to Be at Low Risk for Reintubation But with Significant Hypoxemia, May Benefit from High-Flow Nasal Cannula (as Described Below)
Randomized, Controlled, Open-Label Trial of High-Flow Nasal Cannula in Extubated Patients with pO2/FIO2 <300 (J Crit Care, 2010) [MEDLINE]: n = 105
After Extubation, High-Flow Nasal Cannla was Associated with Improved Oxygenation for the Same FGIO2, as Compared to Venturi Mask
Trial of High-Flow Nasal Cannula in Extubated Patients Who Required High-Flow Oxygen (Am J Respir Crit Care Med, 2014) [MEDLINE]
After Extubation, High-Flow Nasal Cannula were as Effective as High-Flow Face Mask Oxygen
Tolerance of High-Flow Nasal Cannula was Better than High-Flow Face Mask
French Multicenter Randomized OPERA Study of Early Postextubation High-Flow Nasal Cannula After Major Abdominal Surgery (Intensive Care Med, 2016) [MEDLINE]: n = 220
In Patients Undergoing Major Abdominal Surgery, Early Postextubation Preventive High-Flow Nasal Cannula Oxygen Did Not Result in Improved Pulmonary Outcomes, as Compared with Standard Oxygen Therapy
Spanish Randomized Trial of High-Flow Nasal Cannula Oxygen in Patients at Low Risk for Reintubation (JAMA, 2016) [MEDLINE]: n = 527
In Extubated Patients at Low Risk for Reintubation, the High-Flow Nasal Cannula Oxygen Decreased the Risk of Reintubation within 72 hrs, as Compared to Conventional Oxygen Therapy
Postextubation NIPPV Can Be Applied Using a Variety of Strategies
Early Extubation (Before a Patient Has Passed a Spontaneous Breathing Trial), Followed by Immediate Application of Postextubation NIPPV (i.e. NIPPV as an Extension of Invasive Mechanical Ventilation)
Extubation After After a Patient Had Passed a Spontaneous Breathing Trial, Followed by Immediate/Prompt Application of Postextubation NIPPV (i.e. Prophylactic to Decrease the Risk of Reintubation)
Extubation, Followed by the Application of Postextubation NIPPV Only When the Patient Appears to Manifest Worsening Respiratory Status (i.e. Rescue Therapy to Mitigate the Risk of Reintubation)
After Thoracoabdominal Surgery, Prophylactic Post-Extubation NIPPV Decreased Pulmonary Morbidity and Length of Stay (Chest, 2005) [MEDLINE]
In At-Risk Patients (with Risk Factors Such as Hypercapnia, Congestive Heart Failure, Ineffective Cough and Excessive Tracheobronchial Secretions, More Than One Failure of a Weaning Trial, More Than One Comorbid Condition, and Upper Airway Obstruction), Prophylactic NIPPV for First 48 hrs After Extubation Decreased Reintubation Rate and Mortality Rate (Am J Respir Crit Care Med, 2006) [MEDLINE]
Randomized Trial of Prophylactic NIPPV vs Usual Care in Extubated Patients Who were at Risk for Reintubation (Am J Respir Crit Care Med, 2006) [MEDLINE]
Overall, NIPPV Decreased the Reintubation Rate and ICU Mortality Rate
In the Subgroup of Chronically Hypercapnic Patients (Identified by the Presence of Hypercapnia with pCO2 ≥45 mm Hg During Spontaneous Breathing Trial), NIPPV Decreased the Reintubation Rate, ICU Mortality Rate, and 90-Day Mortality Rate
In 12 Studies with Predominantly COPD Patients, Postextubation NIPPV Decreased the Mortality Rate and Ventilator-Associated Pneumonia Rate
Meta-Analysis of NIPPV in Postextubation Respiratory Failure (Indian J Crit Care, 2013) [MEDLINE]
Prophylactic NIPPV Improved Reintubation and Hospital Mortality Rates
Therapeutic NIPPV Only Improved ICU Length of Stay, But Did Not Impact the Reintubation or Mortality Rate
Systematic Review and Meta-Analysis of Trials Using NIPPV for Prevention or Treatment of Acute Respiratory Failure or as a Tool to Facilitate Early Extubation (Crit Care Med, 2015) [MEDLINE]: n = 78 trials
NIPPV Decreased the Mortality Rate in Patients Treated for Acute Respiratory Failure (Due to COPD Exacerbation, Pulmonary Edema, Postoperative Acute Respiratory Failure, and Mixed Etiologies)
NIPPV Decreased the Mortality Rate When Used to Prevent Acute Respiratory Failure
NIPPV Did Not Decrease the Mortality Rate When Used to Facilitate Early Extubation
Cochrane Systematic Review of NIPPV as a Weaning Strategy in Adults with Acute Respiratory Failure (Population with Predominantly COPD) (CMAJ, 2014) [MEDLINE]: n= 16 trials (n = 994 patients)
Most of Patients in Trials Had COPD
NIPPV Decreased the Mortality Rate and Pneumonia Rate without Increasing the Risk of Weaning Failure or Reintubation
In Subgroup Analysis, Mortality Benefits were Significantly Greater in Patients with COPD
Systematic Review and Meta-Analysis of Trials Using NIPPV for Prevention or Treatment of Acute Respiratory Failure or as a Tool to Facilitate Early Extubation (Crit Care Med, 2015) [MEDLINE]: n = 78 trials
Overall (in All Populations), NIPPV Decreased the Mortality Rate (at Longest F/U) with Relative Risk 0.73 (95% CI: 0.66–0.81) (p<0.001): number needed to treat = 19
Facilitation of Early Extubation
NIPPV Did Not Decrease the Mortality Rate (at Longest F/U) with Relative Risk 0.81 (95% CI: 0.51–1.30) (p=0.39)
Pooled Analysis of Use of Postextubation NIPPV in High-Risk Patients (Chest, 2017) [MEDLINE]: n = 5 trials
High-Risk Factors: COPD, CHF, hypercapnia, older age, and a higher severity of illness
NIPPV was Favored Postextubation Over Standard Care in High-Risk Patients (RR, 1.14; 95% CI: 1.05-1.23)
NIPPV was Significantly Better than Conventional Therapy for ICU Length of Stay (Mean Difference –2.48 Days; 95% CI, –4.03 to –0.93) and Short-Term Mortality (RR 0.37; 95% CI: 0.19-0.70)
Trial of Early Extubation to Immediate NIPPV in Patients with Hypoxemic Respiratory Failure (Intensive Care Med, 2018) [MEDLINE]: n = 130
In Highly Selected Hypoxemic Patients, Early Extubation Followed by Immediate NIPPV Decreased the Duration of Invasive Mechanical Ventilation without Affecting ICU Length of Stay
Incidence of VAP, Rate of Patients Requiring Sedative Infusion, and Hospital Length of Stay were All Decreased in the Early Extubation Group, as Compared to Control
No Difference was Observed in ICU or Hospital Mortality Rate, Number of Treatment Failures, Severe Events, and Tracheostomy Rate
UK Randomized Breathe Trial of Early Extubation to NIPPV in General Population of Patients with Respiratory Failure (JAMA, 2018) [MEDLINE]: n = 364
The Median Time to Liberation was 4.3 Days in the NIPPV Group vs 4.5 Days in the Invasive Ventilation Group (Adjusted Hazard Ratio, 1.1; 95% CI: 0.89-1.40)
The NIPPV Group Received Less Invasive Ventilation (Median, 1 Day vs 4 Days; Incidence Rate Ratio, 0.6; 95% CI: 0.47-0.87) and Fewer Total Ventilator Days (Median, 3 Days vs 4 Days; Incidence Rate Ratio, 0.8; 95% CI: 0.62-1.0)
There was No Significant Difference in Reintubation Rates, Tracheostomy Rates, or Mortality Rates
Adverse Events Occurred in 24.7% of Patients in the NIPPV Group vs 25.8% of Patients in the Invasive Ventilation Group
In Patients Requiring Mechanical Ventilation in Whom a Spontaneous Breathing Trial Had Failed, Early Extubation to NIPPV Did Not Shorten time to Liberation from Any Ventilation
Systematic Review of Postextubation NIPPV in Patients with Respiratory Failure (Intensive Care Med, 2018) [MEDLINE]
Postextubation NIPPV Decreased Hospital Mortality, Decreased VAP Incidence, and Decreased ICU Length of Stay
Effect was Most Beneficial in Patients with COPD
Small Randomized Trial of Early Extubation with Immediate Postextubation NIPPV in Highly-Selected Patients with Hypoxemic Respiratory Failure (Intensive Care Med, 2019) [MEDLINE]: n = 130
In Highly-Selected Hypoxemic Patients, Early Extubation with Immediate Postextubation NIPPV Decreased Ventilator Days, But Did Not Impact ICU Length of Stay
No Significant Difference in ICU Mortality, Hospital Mortality, Number of Treatment Failures, Severe Event Rate, or Tracheostomy Rate
Recommendations (American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline for Liberation from Mechanical Ventilation in Critically Ill Adults) (Chest, 2017) [MEDLINE]
Management of Patients at High Risk for Post-Extubation Respiratory Failure
For Patients at High Risk for Extubation Failure (Hypercapnia, COPD, Congestive Heart Failure, or Other Serious Comorbidities) Who Have Been Receiving Mechanical Ventilation for >24 hrs, and Who Have Passed a Spontaneous Breathing Trial, Extubation to Preventative Noninvasive Positive-Pressure Ventilation (NIPPV) is Recommended (Strong Recommendation, Moderate Quality of Evidence)
Apply NIPPV Immediately After Extubation to Maximize the Outcome Benefit
Extubation Failure
Epidemiology
Statistics
Extubation Failure Occurs in Approximately 10-15% of Extubated Patients
Study of Extubation Failure in Patients Following a Spontaneous Breathing Trial (Chest, 2006) [MEDLINE]: n = 900
Extubation Failure Occured in Approximately 13.4% of Patients
Cohort Study Using Data from the Project IMPACT Database of 185 ICU’s in the United States (Crit Care Med, 2017) [MEDLINE]: n = 98,367
Reintubation Rate for ICU Patients Extubated from Mechanical Ventilation was 10%
Median Time to Reintubation was 15 hrs (Interquartile Range: 2-45 hrs)
Of the Patients Who Required Reintubation in the ICU, 90% Did So Within the First 96 hrs After Initial Extubation
Extubation Failure Increases the Mortality Rate
Extubation Failure is Associated with 43% Mortality Rate, vs 12% in Those Who Were Successfully Extubated (Chest, 1997) [MEDLINE]
Multicenter Retrospective Cohort Study of Time to Reintubation in Critically Ill Patients Who Experienced Extubation Failure (Crit Care, 2023) [MEDLINE]: n = 1,849 patients underwent reintubation among 48,082 extubated patients
After Adjustment for Potential Confounders, Multivariable Analysis Demonstrated a Significant Association Between Reintubation and Increased In-Hospital and ICU Mortality Rates (Adjusted Hazard Ratio 1.520, 95% CI: 1.359-1.700, and Adjusted Hazard Ratio 1.325, 95% CI: 1.076-1.633, Respectively)
Among the Reintubated Patients, 56.1%) were Reintubated within 24 hrs After Extubation, 22.6% at 24-48 hrs, 10.7%) at 48-72 hrs, 6.0% at 72-96 hrs, and 4.6% at 96-120 hrs
Multivariable Cox Proportional Hazard Analysis Demonstrated that In-Hospital and ICU Mortality Rates were Highest in Patients Reintubated at 72-96 hrs (Adjusted Hazard Ratio 1.528, 95% CI: 1.062-2.197, and Adjusted Hazard Ratio 1.334, 95% CI: 0.756-2.352, Respectively; Referenced to Reintubation within 24 hrs
Predictors of Extubation Failure
Predictors of Extubation Failure
Weak Cough (Cough Peak Expiratory Flow ≤60 L/min)
Requirement for Frequent Suctioning (Sputum Volume >2.5 mL/hr)
Glasgow Coma Score <8
Positive Fluid Balance in the 24 hrs Preceding Extubation
Pneumonia as the Initial Etiology of Respiratory Failure
Age ≥65 y/o with Severe Chronic Cardiac and Pulmonary Disease
Decreased/Absent Endotracheal Tube Cuff Leak
Supporting Data
Study of Predictors of Successful Extubation in Neurosurgical Patients (Am J Respir Crit Care Med, 2001) [MEDLINE]
Multivariate Analysis Demonstrated that Glasgow Coma Scale Score (GCS) (p<0.0001) and pO2/FIO2 Ratio (p<0.0001) Were Associated with Extubation Success
Odds of Successful Extubation Increased by 39% with Each GCS Score Increment
GCS Score ≥8 at Extubation was Associated with Success in 75% of Cases, as Compared to 33% for a GCS Score <8 (p<0.0001)
Study of Predictors of Extubation Failure(Chest, 2001) [MEDLINE]
Inability to Moisten an Index Card Held 1-2 cm from the End of the Endotracheal Tube with 3-4 Coughs is 3x More Likely to Fail Extubation
Study of Cough Peak Flow as a Predictor of Extubation Failure (Chest, 2003) [MEDLINE]: n = 95
Patients with Cough Peak Expiratory Flow ≤60 L/min were 5x More Likely to Have Extubation Failure and Were 19x More Likely to Die During that Hospital Stay
Risk Factors for Extubation Failure Include Low Cough Peak Flow (≤60 L/min), Increased Endotracheal Secretions (Secretions >2.5 ml/hr), and Inability to Complete 4 Simple Tasks (Open Eyes, Follow with Eyes, Grasp Hand, Stick Out Tongue) (Intensive Care Med, 2004) [MEDLINE]
Failure Rate was 100% for Patients with All 3 Risk factors, as Compared to 3% for Those with 0 Risk Factors (RR=23.2; 95% CI: 3.2-167.2)
Presence of Any 2 of the Risk Factors had a Sensitivity of 71% and Specificity of 81% in Predicting Extubation Failure
Patients Who Failed a Trial of Extubation were 3.8x More Likely to Have Any 2 Risk Factors, as Compared to Those Who were Successful
Multicountry Study of Predictors of Extubation Failure (Chest, 2006) [MEDLINE]: n = 900 Patients
Pneumonia as the Reason for Initial Intubation: odds ratio 1.77 (95% CI: 1.10-2.84)
Positive Fluid Balance: odds ratio 1.70 (95% CI: 1.15-2.53)
Elevated Rapid Shallow Breathing Index (RSBI): odds ratio 1.009 per unit (95% CI: 1.003-1.015)
Analysis Allowed Partitioning of Risk Using Multiple Variables
French Study of Peak Cough Expiratory Flow as a Predictor of Extubation Success (Intensive Care Med, 2009) [MEDLINE]: n = 130
Inability to Cough on Command or a Peak Cough Expiratory Flow ≤35 l/min Predicted Extubation Failure with a Sensitivity of 79% and a Specificity of 71%
Risk of Extubation Failure was 24% for the Patients Who Did Not Cough on Command or with a Peak Cough Expiratory Flow ≤35 l/min and 3.5% for those with a Peak Cough Expiratory Flow >35 l/min (RR = 6.9 (95% CI: 2-24; P = 0.002)
Mean Peak Cough Flow of Patients Who Failed Extubation (36.3 +/- 15 L/min) was Significantly Lower than the One of Patients Who Succeeded (63.6 +/- 32 L/min) (P<0.001)
Study of Extubation Failure (Crit Care Med, 2011) [MEDLINE]
Extubation Failure Rate was 15%
Patients >65 y/o with Underlying Chronic Cardiac or Pulmonary Disease were at High Risk for Extubation Failure and Subsequent Pneumonia and Death
Prospective Observational Study of Risk Factors for Extubation Failure (Crit Care Med, 2015) [MEDLINE]: n = 225
Ineffective Cough, Prior Duration of Mechanical Ventilation >7 Days, and Severe Left Ventricular Systolic Dysfunction were Stronger Predictors of Extubation Failure tahn Delirium or ICU-Acquired Weakness
Only 33% of Patients Who Required Reintubation were Considered High Risk for Extubation Failure by the Providers Caring for the Patient
Common Etiologies of Extubation Failure
Hypoxemia (i.e. Hypoxemic Respiratory Failure) (see Hypoxemia)
Mechanisms
Incomplete Resolution of Lung Process Which Led to Intubation (ARDS, Cardiogenic Pulmonary Edema, Pneumonia, etc)
New-Onset Cardiogenic Pulmonary Edema Associated with Removal of Positive-Pressure Ventilation (and Increased Venous Return to the Right Side of Heart)
Management
Supplemental Oxygen Therapy
High-Flow Nasal Cannula (HFNC) (see Oxygen): commonly used in this setting
High Work of Breathing Related to Low Lung Compliance (Due to Recovering ARDS, Cardiogenic Pulmonary Edema, Pneumonia, etc) and/or Increased Airway Resistance (Due to Bronchospasm, etc)
New-Onset Cardiogenic Pulmonary Edema Associated with Removal of Positive-Pressure Ventilation (and Increased Venous Return to the Right Side of Heart)
Excessive Endotracheal Tube Mobility (Due to Improper Fixation)
Female Gender
Glasgow Coma Score <8
History of Asthma
Inadequate Sedation
Large Endotracheal Tube (>7 mm in Females, >8 mm in Males)
Low Ratio of Patient Height/Endotracheal Tube Diameter
Prolonged Intubation
Ratio of Endotracheal Tube/Laryngeal Diameter >45% on Computed Tomography
Traumatic Intubation
Prognosis
Postextubation Stridor is Associated with Increased Duration of Mechanical Ventilation and Increased ICU Length of Stay (J Intensive Care Med, 2019) [MEDLINE]
Physiology
Endotracheal Intubation Can Result in Injury to Oropharynx/Larynx/Trachea
Laryngeal Edema and Mucosal Ulceration Occurs in Almost All Patients Who Have Been Intubated for ≥4 Days (Crit Care, 2009) [MEDLINE]
Laryngeal Injuries are Usually Reversible (Typically within 1 mo of Extubation) (Crit Care, 2009) [MEDLINE]
Common Mechanisms
Laryngeal Injury with Vocal Cord Edema: most common etiology
Upper Airway Secretions: common etiology
Cricoarytenoid Dislocation: uncommon etiology
Tracheal Stenosis/Obstruction: rare etiology
Diagnosis
Endotracheal Tube Cuff Leak Test (See Above): generally recommended only for patients who are deemed to be at high risk for postextubation stridor
Laryngeal Ultrasound: has been reported to be useful for assessing laryngeal patency (J Crit Care, 2013) [MEDLINE]
Simultaneous Assessment of Cough and Endotracheal Tube Cuff Leak: lack of audible cough and cuff leak indicates a 10x increased risk of postextubation stridor(J Crit Care, 2004) [MEDLINE]
While Laryngeal Injury is Common, Postextubation Stridor Has Been Reported to Occur in <10% of Unselected Critically Ill Patients (J Intensive Care Med, 2019) [MEDLINE]
Prevention
General Comments
Corticosteroids are Generally Recommended Only for Patients Who Have Failed an Endotracheal Tube Cuff Leak Test or Patients Who Have Failed Extubation Due to Laryngeal Edema
Methylprednisolone (Solumedrol) (see Methylprednisolone): 20 mg q4hrs x 4 doses
Intravenous Methylprednisolone was Effective in Decreasing the Risk of Postextubation Stridor in Patients with Endotracheal Tube Cuff Leak Volume <24% of Tidal Volume (Crit Care Med, 2006) [MEDLINE]
Systematic Review of Corticosteroids in the Prevention and Treatment of Postextubation Stridor in Unselected Neonates, Children and Adults Demonstrated No Benefit in Preventing Extubation Stridor (Cochrane Database Syst Rev, 2009) [MEDLINE]
Meta-Analysis in Mechanically-Ventilated Patients Who Have Failed an Endotracheal Tube Cuff Leak Test Demonstrated that Glucocorticoids Decreased the Incidence of Postextubation Stridor (11% vs 32%; RR 0.35; 95% CI: 0.20–0.63) and the Reintubation Rate (6% vs 17%; RR 0.32; 95% CI: 0.14–0.76) (Am J Respir Crit Care Med, 2017) [MEDLINE]
Prophylactic Multiple Dose Dexamethasone is Effective in Decreasing the Incidence of Postextubation Stridor in Adult Patients at High Risk for Postextubation Laryngeal Edema (Crit Care, 2007) [MEDLINE]
Systematic Review of Corticosteroids in the Prevention and Treatment of Postextubation Stridor in Unselected Neonates, Children and Adults Demonstrated No Benefit in Preventing Extubation Stridor (Cochrane Database Syst Rev, 2009) [MEDLINE]
Meta-Analysis in Mechanically-Ventilated Patients Who Have Failed an Endotracheal Tube Cuff Leak Test Demonstrated that Glucocorticoids Decreased the Incidence of Postextubation Stridor (11% vs 32%; RR 0.35; 95% CI: 0.20–0.63) and the Reintubation Rate (6% vs 17%; RR 0.32; 95% CI: 0.14–0.76)(Am J Respir Crit Care Med, 2017) [MEDLINE]
Management
Nebulized Racemic Epinephrine (Racepinephrine) (see Epinephrine)
Recommendations (American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline for Liberation from Mechanical Ventilation in Critically Ill Adults) (Am J Respir Crit Care Med, 2017) [MEDLINE]
Cuff Leak Test in Should Be Performed in Mechanically Ventilated Adults Who Meet Extubation Criteria and are Deemed to Be High Risk for Postextubation Stridor (Conditional Recommendation, Very Low Certainty of Evidence)
Criteria for High Risk
Female Sex
Traumatic Intubation
Intubation for >6 Days
Large Endotracheal Tube
Reintubated after an Unplanned Extubation
For Adults Who Have Failed a Cuff Leak Test But are Otherwise Ready for Extubation, Administering Systemic Steroids for at Least 4 hrs Before Extubation is Recommended (Conditional Recommendation, Moderate Certainty of Evidence)
References
Failure to Wean
The reduction of weaning time from mechanical ventilation using tidal volume and relaxation biofeedback. Am Rev Respir Dis. 1990;141(5 Pt 1):1214 [MEDLINE]
Pattern of recovery from diaphragmatic fatigue over 24 hours. J Appl Physiol (1985). 1995;79(2):539 [MEDLINE]
Influence of pressure and flow-triggered synchronous intermittent mandatory ventilation on inspiratory muscle work. Crit Care Med. 1994;22(12):1933 [MEDLINE]
Synchronized intermittent mandatory ventilation with and without pressure support ventilation in weaning patients with COPD from mechanical ventilation. Chest. 1994;105(4):1204 [MEDLINE]
Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150:896-903 [MEDLINE]
A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995; 332:345-350 [MEDLINE]
Disorders of the respiratory muscles. Am J Respir Crit Care Med. 2003;168(1):10 [MEDLINE]
Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest. 2003;124(1):297 [MEDLINE]
B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med. 2006 Oct;32(10):1529-36 [MEDLINE]
Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing. Intensive Care Med. 2006;32(1):165 [MEDLINE]
Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease. Crit Care Med. 2007 Jan;35(1):96-105 [MEDLINE]
Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation. Chest. 2007;131(1):76 [MEDLINE]
Changes in B-type natriuretic peptide improve weaning outcome predicted by spontaneous breathing trial. Crit Care Med. 2008 May;36(5):1421-6 [MEDLINE]
Echocardiographic diagnosis of pulmonary artery occlusion pressure elevation during weaning from mechanical ventilation. Crit Care Med. 2009 May;37(5):1696-701 [MEDLINE]
Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study. Crit Care. 2010;14(6):R204 [MEDLINE]
Long-term acute care hospital utilization after critical illness. JAMA. 2010;303(22):2253 [MEDLINE]
Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med. 2010;36(5):828 [MEDLINE]
Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med. 2010 Jul;36(7):1171-9 [MEDLINE]
Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J. 2010;35(1):88 [MEDLINE]
Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med. 2011 Aug;184(4):430-7 [MEDLINE]
Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med. 2012 Dec;186(12):1256-63 [MEDLINE]
Different tracheotomy tube diameters influence diaphragmatic effort and indices of weanability in difficult to wean patients. Respir Care. 2012;57(12):2012 [MEDLINE]
Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA. 2013;309(7):671 [MEDLINE]
Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc. 2014 Sep;11(7):1018-24 [MEDLINE]
Extravascular lung water, B-type natriuretic peptide, and blood volume contraction enable diagnosis of weaning-induced pulmonary edema. Crit Care Med. 2014 Aug;42(8):1882-9 [MEDLINE]
Myocardial injury after surgery is a risk factor for weaning failure from mechanical ventilation in critical patients undergoing major abdominal surgery. PLoS One. 2014;9(11):e113410 [MEDLINE]
Passive leg raising performed before a spontaneous breathing trial predicts weaning-induced cardiac dysfunction. Intensive Care Med. 2015 Mar;41(3):487-94 [MEDLINE]
Cardiac dysfunction induced by weaning from mechanical ventilation: incidence, risk factors, and effects of fluid removal. Crit Care. 2016;20(1):369 [MEDLINE]
Impact of delirium on weaning from mechanical ventilation in medical patients. Respirology. 2016;21(2):313 [MEDLINE]
Noninvasive monitoring of cardiac output during weaning from mechanical ventilation: a pilot study Amer J Crit Care. 2016;25:257
Left ventricular diastolic dysfunction–an independent risk factor for weaning failure from mechanical ventilation. Anaesth Intensive Care. 2016;44(4):466 [MEDLINE]
Stress echocardiography in patients who experienced mechanical ventilation weaning failure. J Crit Care. 2017;39:66 [MEDLINE]
Lung ultrasound allows the diagnosis of weaning-induced pulmonary oedema. Intensive Care Med. 2019;45(5):601 [MEDLINE]
Discontinuation of Tube Feedings (Enteral Nutrition) Prior to Extubation
Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: an open-label, cluster-randomised, parallel-group, non-inferiority trial. Lancet Respir Med. 2023 Apr;11(4):319-328. doi: 10.1016/S2213-2600(22)00413-1 [MEDLINE]
Timing of Extubation (Daytime vs Nightime)
Daytime Versus Nighttime Extubations: A Comparison of Reintubation, Length of Stay, and Mortality. J Intensive Care Med. 2016 Feb;31(2):118-26 [MEDLINE]
Association Between Overnight Extubations and Outcomes in the Intensive Care Unit. JAMA Intern Med. 2016;176(11):1651 [MEDLINE]
Is routine extubation overnight safe in cardiac surgery patients? J Thorac Cardiovasc Surg. 2019;157(4):1533 [MEDLINE]
High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care. 2010 Sep;25(3):463-8 [MEDLINE]
Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282 [MEDLINE]
Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: a French multicentre randomised controlled trial (OPERA). Intensive Care Med. 2016;42(12):1888 [MEDLINE]
Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA. 2016;315(13):1354 [MEDLINE]
Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2003;(4):CD004127[MEDLINE]
Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009 May 21;338:b1574. doi: 10.1136/bmj.b1574 [MEDLINE]
Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD004127. doi: 10.1002/14651858.CD004127.pub2 [MEDLINE]
Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014 Feb 18;186(3):E112-22. doi: 10.1503/cmaj.130974 [MEDLINE]
Noninvasive ventilation and survival in acute care settings: a comprehensive systematic review and metaanalysis of randomized controlled trials. Crit Care Med. 2015 Apr;43(4):880-8. doi: 10.1097/CCM.0000000000000819 [MEDLINE]
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Chest. 2017 Jan;151(1):166-180. doi: 10.1016/j.chest.2016.10.036 [MEDLINE]
Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis. Intensive Care Med. 2018;44(12):2192 [MEDLINE]
Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med. 2018 Dec 10. doi: 10.1007/s00134-018-5478-0 [MEDLINE]
Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial. JAMA. 2018;320(18):1881 [MEDLINE]
Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med. 2019;45(1):62 [MEDLINE]
Extubation Failure
General
Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001;163(3 Pt 1):658 [MEDLINE]
Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120(4):1262 [MEDLINE]
Cough peak flows and extubation outcomes. Chest. 2003;124(1):262 [MEDLINE]
Putting it all together to predict extubation outcome. Intensive Care Med. 2004;30(7):1255 [MEDLINE]
Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med. 2004;30(7):1334 [MEDLINE]
Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest. 2005 Aug;128(2):821-8 [MEDLINE]
Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006 Jan 15;173(2):164-70. Epub 2005 Oct 13 [MEDLINE]
Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;130(6):1664-1671 [MEDLINE]
Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg. 2008 Apr;247(4):617-26. doi: 10.1097/SLA.0b013e3181675829 [MEDLINE]
Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med. 2009;35(6):1090 [MEDLINE]
Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009 Sep 26;374(9695):1082-8. doi: 10.1016/S0140-6736(09)61038-2. Epub 2009 Aug 12 [MEDLINE]
Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005 Nov;33(11):2465-70 [MEDLINE]
Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39(12):2612 [MEDLINE]
Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study. Crit Care Med. 2015;43(3):613 [MEDLINE]
Cumulative Probability and Time to Reintubation in U.S. ICUs. Crit Care Med. 2017;45(5):835 [MEDLINE]
Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study. Crit Care. 2023 Sep 30;27(1):378. doi: 10.1186/s13054-023-04668-3 [MEDLINE]
Postextubation Stridor
Laryngeal injuries secondary to nasogastric tubes. Ann Otol Rhinol Laryngol. 1981;90(5 Pt 1):469 [MEDLINE]
Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg. 1994;111(4):453 [MEDLINE]
Association between reduced cuff leak volume and postextubation stridor. Chest. 1996;110(4):1035 [MEDLINE]
The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002;28(9):1267 [MEDLINE]
Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. 2003;29(1):69 [MEDLINE]
How to identify patients with no risk for postextubation stridor? J Crit Care. 2004;19(1):23 [MEDLINE]
The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care. 2005;50(12):1632 [MEDLINE]
Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med. 2006;34(5):1345 [MEDLINE]
Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J. 2006;27(2):384 [MEDLINE]
Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care. 2007;11(4):R72 [MEDLINE]
12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007;369(9567):108 [MEDLINE]
Risk factors evaluation and the cuff leak test as predictors for postextubation stridor. J Med Assoc Thai. 2008;91(5):648 [MEDLINE]
Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev. 2009 [MEDLINE]
Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care. 2009;13(6):233 [MEDLINE]
Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound. J Crit Care. 2013 Oct;28(5):675-80 [MEDLINE]
Cuff Leak Test for the Diagnosis of Post-Extubation Stridor. J Intensive Care Med. 2019 May;34(5):391-396. doi: 10.1177/0885066617700095 [MEDLINE]
