Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures

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Abstract

Background

Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation.

Methods

The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure.

Results

Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797–8.864), P < 0.0001 and OR 2.067 (1.217–3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877–6.138), P < 0.0001 and OR 2.067 (1.217–3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047–3.362), P = 0.03 and OR 3.240 (1.786–5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187–3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087–3.518), P = 0.025), copious secretions (OR 4.066 (2.268–7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052–4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100–3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001).

Conclusions

Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies.

Trial registration

ClinicalTrials.gov, NCT 02450669. Registered on 21 May 2015.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2150-6) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 44

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Weaning from mechanical ventilation.

J-M Boles, J Bion, A. Connors … (2007)

Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.

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Effect of failed extubation on the outcome of mechanical ventilation.

Scott K Epstein, Ronald Ciubotaru, John B. Wong (1997)

To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation. Prospective cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital. The failed extubation group consisted of all patients reintubated within 72 h or within 7 days (if continuous ICU care had been required) of extubation. All others were considered to be successfully extubated. Study end points included hospital death vs survival, the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation, the likelihood of requiring > or = 7 or > or = 14 days of ICU care after extubation, and the need for transfer to either a long-term care or rehabilitation facility among the survivors. Of 289 intubated patients, 247 (85%) were successfully extubated, and 42 (15%) required reintubation for failed extubation (time to reintubation 1.5+/-0.2 days). Reintubation for extubation failure resulted in 12 additional days of mechanical ventilation. When compared with successfully extubated patients, reintubated patients were more likely to die in the hospital (43% vs 12%; p or = 14 days in the ICU after extubation, and six times (p<0.001) more likely to need transfer to a long-term care or rehabilitation facility if they survived. After adjusting for severity of illness and comorbid conditions, extubation failure had a significant independent association with increased risk for death, prolonged ICU stay, and transfer to a long-term care or rehabilitation facility. Extubation failure may serve as an additional independent marker of severity of illness. Alternatively, poor outcomes may be etiologically related to extubation failure. If the latter proves to be the case, identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practices may reduce mortality, duration of ICU stay, and need for transfer to a long-term care facility.

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Outcomes of extubation failure in medical intensive care unit patients.

Laurent Brochard, Anatole Harrois, Christian Brun-Buisson … (2011)

Extubation failure is associated with a poor prognosis, but the respective roles for reintubation per se and underlying disease severity remain unclear. Our objectives were to evaluate the impact of failed extubation, whether planned or unplanned, on patient outcomes and to identify a patient subset at risk for extubation failure. Prospective 1-yr observational study with daily data collection. : Thirteen-bed medical intensive care unit in a teaching hospital. Consecutive patients requiring invasive mechanical ventilation were screened and followed until discharge or death. None. Of 168 planned extubations in 340 patients, 26 (15%) failed. Of these 26 patients, seven (27%) had pneumonia and 13 (50%) died after reintubation. Compared with successfully extubated patients, the patients with failed extubation were not significantly different regarding disease severity, mechanical ventilation duration, or blood gas values. Age and underlying diseases were the only factors associated with extubation failure, and extubation failure occurred in 34% of patients >65 yrs with chronic cardiac or respiratory disease compared with only 9% of other patients (p 65 yrs with underlying chronic cardiac or respiratory disease are at high risk for extubation failure and subsequent pneumonia and death. Contrasting with successful extubation, failed planned or unplanned extubation was followed by marked clinical deterioration, suggesting a direct and specific effect of extubation failure and reintubation on patient outcomes.

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Author and article information

Contributors

Samir Jaber: (33) 4 67 33 72 71 , s-jaber@chu-montpellier.fr

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 23 September 2018

Publication date PMC-release: 23 September 2018

Publication date Collection: 2018

Volume: 22

Electronic Location Identifier: 236

Affiliations

[1 ]PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295 Montpellier, cedex 5 France

[2 ]ISNI 0000 0001 2322 4179, GRID grid.410528.a, Université Cote d’Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, ; Nice, France

[3 ]GRID grid.4817.a, Intensive Care & Anesthesiology Department, , University of Nantes, Hotel-Dieu Hospital, ; Nantes, France

[4 ]Intensive Care Department, Sainte Musse Hospital, Toulon, France

[5 ]Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Nantes, France

[6 ]Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018 Paris, France

[7 ]Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010 Créteil Cedex, France

[8 ]GRID grid.4817.a, Intensive Care & Anesthesiology Department, University of Nantes, Laennec Nord Hospital, ; Nantes, France

[9 ]ISNI 0000 0004 0472 0283, GRID grid.411147.6, Département Anesthésie Réanimation, CHU Angers, ; 49933 Angers, Cedex 9 France

[10 ]Medical-Surgical Intensive Care Unit, General Hospital Centre, Argenteuil, France

[11 ]Medical-Surgical Intensive Care Unit, General Hospital Centre, Le Puy-en-Velay, France

[12 ]Hôpitaux Universitaires de Strasbourg, Pôle Anesthésie Réanimation Chirurgicale SAMU, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation Chirurgicale, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d’Accueil EA3072 “Mitochondrie, stress oxydant et protection musculaire”, Strasbourg, France

[13 ]ISNI 0000 0000 9961 060X, GRID grid.157868.5, Medical Intensive Care Unit, , Montpellier University Hospital, ; Montpellier, France

[14 ]ISNI 0000 0000 9961 060X, GRID grid.157868.5, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, ; 34295 Montpellier, cedex 5 France

[15 ]IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France

[16 ]APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Univ, Marseille, France

[17 ]ISNI 0000 0001 2300 6614, GRID grid.413328.f, Medical Intensive Care Unit, , University of Paris-Diderot, Saint Louis Hospital, ; Paris, France

Article

Publisher ID: 2150

DOI: 10.1186/s13054-018-2150-6

PMC ID: 6151191

PubMed ID: 30243304

SO-VID: a955f86c-4147-4f23-828a-718ef2a45041

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.