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Abstract
BACKGROUND: Despite decades of research on predictors of extubation success, use of ventilatory support after extubation is common and 10–20% of patients require re-intubation. Proportional assist ventilation (PAV) mode automatically calculates estimated total work of breathing (total WOB). Here, we assessed the performance of total WOB to predict extubation failure in invasively ventilated subjects.
METHODS: This prospective observational study was conducted in 6 adult ICUs at an academic medical center. We enrolled intubated subjects who successfully completed a spontaneous breathing trial, had a rapid shallow breathing index < 105 breaths/min/L, and were deemed ready for extubation by the primary team. Total WOB values were recorded at the end of a 30-min PAV trial. Extubation failure was defined as any respiratory support and/or re-intubation within 72 h of extubation. We compared total WOB scores between groups and performance of total WOB for predicting extubation failure with receiver operating characteristic curves.
RESULTS: Of 61 subjects enrolled, 9.8% (n = 6) required re-intubation, and 50.8% (n = 31) required any respiratory support within 72 h of extubation. Median total WOB at 30 min on PAV was 0.9 J/L (interquartile range 0.7–1.3 J/L). Total WOB was significantly different between subjects who failed or were successfully extubated (median 1.1 J/L vs 0.7 J/L, P = .004). The area under the curve was 0.71 [95% CI 0.58–0.85] for predicting any requirement of respiratory support and 0.85 [95% CI 0.69–1.00] for predicting re-intubation alone within 72 h of extubation. Total WOB cutoff values maximizing sensitivity and specificity equally were 1.0 J/L for any respiratory support (positive predictive value [PPV] 70.0%, negative predictive value [NPV] 67.7%) and 1.3 J/L for re-intubation (PPV 26.3%, NPV 97.6%).
CONCLUSIONS: The discriminative performance of a PAV-derived total WOB value to predict extubation failure was good, indicating total WOB may represent an adjunctive tool for assessing extubation readiness. However, these results should be interpreted as preliminary, with specific thresholds of PAV-derived total WOB requiring further investigation in a large multi-center study.
- mechanical ventilation
- weaning
- noninvasive ventilation
- endotracheal tube
- rapid shallow breathing index
- extubation
Footnotes
- Correspondence: Sarina Fazio PhD RN. E-mail: safazio{at}ucdavis.edu
The authors have disclosed no conflicts of interest.
This research was supported by the UC Davis Clinical and Translational Science Center (National Center for Advancing Translational Sciences, UL1 TR000002) and the National Heart, Lung, and Blood Institute (T32 HL007013). This study is an investigator-initiated study. The funders had no role in the study design, clinical data collection, management, analysis, interpretation of the data, manuscript preparation, and the decision to submit for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Supplementary material related to this paper is available at http://www.rcjournal.com.
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