TY - JOUR
AU - Cancio, Leopoldo C
AB - Abstract Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case–control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case–control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively. Critically ill burn patients are at risk of developing respiratory failure, requiring support with mechanical ventilation.1,2 Mechanical ventilation is associated with increased risk of complications such as laryngotracheal injury,3 ventilator-associated pneumonia,4 and ventilator-induced lung injury. Thus, it is in the best interest of the mechanically ventilated patient to be extubated as soon as possible. However, patients who fail extubation have worse outcomes compared to those who undergo successful extubation,5 as reintubation is associated with an increased incidence of nosocomial pneumonia,6 as well as up to a 12-fold increased mortality risk in critically ill patients.7–10 Many parameters have been developed to aid in determining when extubation is appropriate. The most well-known is the rapid shallow breathing index (RSBI), introduced by Yang and Tobin in 1991, who demonstrated RSBI to be the most accurate predictor of extubation failure.11 Other studies have challenged the accuracy of RSBI in predicting extubation failure in various critical-care populations.12,13 A study on extubation failure in trauma patients found that RSBI was nearly identical in both failed and successful extubations.13 Furthermore, they found that the RSBI was most useful only when it was abnormal, indicating RSBI to be a more accurate predictor of extubation failure than of success. They concluded that RSBI should not be relied on by itself to predict extubation outcomes, but needs to be interpreted in the context of other patient variables. Approximately 6 to 20% of burn patients also experience inhalation injury,14,15 with a majority requiring mechanical ventilation. Inhalation injury patients are at higher risk of developing pneumonia and typically require larger volumes of fluid for burn-shock resuscitation, both of which can increase the duration of mechanical ventilation.16–20 Extubation outcomes in this population have not been studied to date. Extubation failure has been studied in many critically ill populations, but infrequently in the burn population.5,21 The goal of this study was to examine the prevalence of extubation failure in burn patients, as well as explore the impact of inhalation injury and other clinical variables on extubation outcome. METHODS We conducted an Institutional Review Board approved performance improvement project where we conducted a retrospective analysis of 851 consecutive adult patients admitted to our Burn Intensive Care Unit (BICU) from January 2009 to December 2017 who required intubation within the first 24 hours after injury. Patients were excluded if they were extubated within 24 hours of intubation, if they underwent tracheostomy without first being extubated, if they died without being extubated, or if they self-extubated. Duplicate and incomplete patient records were removed. The study population was assessed for extubation outcome after their first extubation. Patients with diagnosed inhalation injury via bronchoscopy were placed on the volumetric diffusive ventilator (VDR-4), a form of high-frequency percussive ventilation. The patients were also treated with nebulized heparin as part of their therapy. All intubated patients received nebulized bronchodilators while on the ventilator. Extubation failure was defined as unplanned reintubation within 72 hours of a planned extubation. Extubation success was defined as the absence of mechanical ventilation at 72 hours after extubation. The patients were evaluated at least daily by the intensive-care physician to determine readiness to extubate. Standard weaning parameters for the BICU were utilized for both patients with and without inhalation injury, which included meeting criteria during daily spontaneous breathing trials (SBTs) as outlined in Table 1. Prior to collecting weaning parameter data, all patients had to demonstrate an air leak around the endotracheal tube. The ultimate decision to extubate was made by the intensive-care clinician on the basis of SBT data, as well as the patient’s hemodynamic stability, responsiveness, ability to follow commands, strength of cough, and ability to clear secretions. Table 1. Weaning parameters used to guide readiness for extubation Weaning parameter . Criteria for extubation . Minute ventilation < 10 liter/min Respiratory rate (RR) < 35 breaths/min Tidal volume (TV) > 5 ml/kg Rapid shallow breathing index (RR/TV) < 105 Negative inspiratory force > 20 cm H2O Weaning parameter . Criteria for extubation . Minute ventilation < 10 liter/min Respiratory rate (RR) < 35 breaths/min Tidal volume (TV) > 5 ml/kg Rapid shallow breathing index (RR/TV) < 105 Negative inspiratory force > 20 cm H2O Open in new tab Table 1. Weaning parameters used to guide readiness for extubation Weaning parameter . Criteria for extubation . Minute ventilation < 10 liter/min Respiratory rate (RR) < 35 breaths/min Tidal volume (TV) > 5 ml/kg Rapid shallow breathing index (RR/TV) < 105 Negative inspiratory force > 20 cm H2O Weaning parameter . Criteria for extubation . Minute ventilation < 10 liter/min Respiratory rate (RR) < 35 breaths/min Tidal volume (TV) > 5 ml/kg Rapid shallow breathing index (RR/TV) < 105 Negative inspiratory force > 20 cm H2O Open in new tab Demographic data collected for each patient included age, sex, body mass index, total body surface area (TBSA) burned, and presence or absence of inhalation injury. Inhalation injury was diagnosed by fiberoptic bronchoscopy within 24 hours of admission. Vital signs, including heart rate, mean arterial blood pressure, and respiratory rate were recorded during the weaning period prior to extubation. Ventilator settings during SBTs prior to extubation were collected, to include positive end expiratory pressure (PEEP), spontaneous tidal volume, and percentage of inspired oxygen (FiO2). Total number of ventilator days prior to extubation attempt were collected. Arterial-blood-gas data during SBTs before extubation were collected. Other clinical variables were chosen based on their projected relevance to extubation outcome; these included mean urine output in the hours prior to extubation, as well as hemoglobin and serum sodium as surrogates for volume status. Additional analysis included a case–control matched cohort that was matched based on age, TBSA, and sex in order to examine factors that could predict extubation failure. Statistical Analysis Results were expressed as means and standard deviations (SD), medians and interquartile ranges (IQR), or number of patients and percentages, as appropriate. Student’s t test and the Mann–Whitney U test were used to evaluate continuous variables, and the chi square test or the Fisher’s Exact Test to evaluate categorical variables, as appropriate. Two-tailed P values less than .05 were considered statistically significant. ANCOVA (analysis of covariance) models were performed on the continuous variables comparing the changes over time for those who succeeded extubation and those who failed. Logistic regression was performed for factors that were below the conventional cutoff for significance (P < .10) to assess impact on extubation outcome. All statistical procedures were accomplished with JMP (SASS Institute, Cary NC, Version 13.2). RESULTS Of the 851 intubated BICU patients, 252 were excluded due to undergoing tracheostomy or dying prior to extubation, whereas 16 patients were excluded due to incomplete records. Of the 583 patients that were analyzed, 511 (87.6%) were successfully extubated, whereas 72 (12.3%) failed extubation. Of the 511 successful extubations, 120 (23.5%) were positive for inhalation injury, whereas the 72 failed extubations had 8 (11.1%) cases of inhalation injury (Figure 1). Figure 1. Open in new tabDownload slide Flow diagram of included patients in this study. ICU, intensive care unit; II, inhalation injury. In the propensity-matched cohort analysis, variables that were found to be significant when comparing successful to failed extubation included presence of inhalation injury, as well as heart rate and pH prior to extubation (Tables 2 and 3). The presence of inhalation injury was protective against extubation failure, possibly reflecting a conservative extubation strategy in these patients (Figure 2). An increased heart rate and lower pH prior to extubation were found to be associated with failure; these differences however are clinically quite small. Table 2. Case–control matched cohort analysis . Extubation success (n = 46) . Extubation failure (n = 52) . P . Age (mean + SD) 51 + 16 51 + 19 .84 TBSA (mean + SD) 21 + 14 27 + 23 .10 Male sex (n, %) 43 (95%) 47 (90%) .88 BMI (mean + SD) 28.9 + 5.2 30.0 + 7.5 .13 (+) II (n, %) 12 (26.0%) 8 (11.1%) .04* . Extubation success (n = 46) . Extubation failure (n = 52) . P . Age (mean + SD) 51 + 16 51 + 19 .84 TBSA (mean + SD) 21 + 14 27 + 23 .10 Male sex (n, %) 43 (95%) 47 (90%) .88 BMI (mean + SD) 28.9 + 5.2 30.0 + 7.5 .13 (+) II (n, %) 12 (26.0%) 8 (11.1%) .04* *Statistically significant. Data presented as mean ± standard deviation or number and percentages as appropriate. TBSA, total body surface area; BMI, body mass index; II, inhalation injury. Open in new tab Table 2. Case–control matched cohort analysis . Extubation success (n = 46) . Extubation failure (n = 52) . P . Age (mean + SD) 51 + 16 51 + 19 .84 TBSA (mean + SD) 21 + 14 27 + 23 .10 Male sex (n, %) 43 (95%) 47 (90%) .88 BMI (mean + SD) 28.9 + 5.2 30.0 + 7.5 .13 (+) II (n, %) 12 (26.0%) 8 (11.1%) .04* . Extubation success (n = 46) . Extubation failure (n = 52) . P . Age (mean + SD) 51 + 16 51 + 19 .84 TBSA (mean + SD) 21 + 14 27 + 23 .10 Male sex (n, %) 43 (95%) 47 (90%) .88 BMI (mean + SD) 28.9 + 5.2 30.0 + 7.5 .13 (+) II (n, %) 12 (26.0%) 8 (11.1%) .04* *Statistically significant. Data presented as mean ± standard deviation or number and percentages as appropriate. TBSA, total body surface area; BMI, body mass index; II, inhalation injury. Open in new tab Table 3. Evaluating clinical variables between the two cohorts . Extubation success . Extubation failure . P . Ventilator days 5.9 + 2.2 6.4 + 2.2 .07 Heart rate 97 + 18 113 + 19 .0011* MAP 80 + 8 80 + 12 .33 Respiratory rate 17.0 + 5 19.0 + 5 .10 RSBI 82 + 16 84 + 10 .55 FiO2 0.39 + 0.08 0.38 + 0.08 .4 PEEP 6 + 2.5 7.2 + 2.4 .11 pH 7.44 + 0.05 7.38 + 0.05 .045* PaO2 106 (94–120) 99.5 (85–112) .20 PFR 370 + 80 350 + 66 .83 PaCO2 40 + 3.8 41 + 7.0 .55 GCS 11 + 2.3 9 + 2.5 .77 Hourly urine output 84 (49–139) 82 (40–129) .83 Hemoglobin 9.8 + 1.9 9.4 + 2 .51 Serum sodium 142 + 7 135 + 6.2 .57 . Extubation success . Extubation failure . P . Ventilator days 5.9 + 2.2 6.4 + 2.2 .07 Heart rate 97 + 18 113 + 19 .0011* MAP 80 + 8 80 + 12 .33 Respiratory rate 17.0 + 5 19.0 + 5 .10 RSBI 82 + 16 84 + 10 .55 FiO2 0.39 + 0.08 0.38 + 0.08 .4 PEEP 6 + 2.5 7.2 + 2.4 .11 pH 7.44 + 0.05 7.38 + 0.05 .045* PaO2 106 (94–120) 99.5 (85–112) .20 PFR 370 + 80 350 + 66 .83 PaCO2 40 + 3.8 41 + 7.0 .55 GCS 11 + 2.3 9 + 2.5 .77 Hourly urine output 84 (49–139) 82 (40–129) .83 Hemoglobin 9.8 + 1.9 9.4 + 2 .51 Serum sodium 142 + 7 135 + 6.2 .57 *Statistically significant. Data presented as either means ± standard deviations or median (interquartile ranges) as appropriate. MAP, mean arterial pressure; RSBI, Rapid Shallow Breathing Index; FiO2, fraction of inspired oxygen; PEEP, positive end expiratory pressure; PaO2, partial pressure of oxygen as measured on arterial blood gas; PFR, PaO2 to FiO2 ratio; PaCO2, partial pressure of carbon dioxide as measured on arterial blood gas; GCS, Glasgow coma scale. Open in new tab Table 3. Evaluating clinical variables between the two cohorts . Extubation success . Extubation failure . P . Ventilator days 5.9 + 2.2 6.4 + 2.2 .07 Heart rate 97 + 18 113 + 19 .0011* MAP 80 + 8 80 + 12 .33 Respiratory rate 17.0 + 5 19.0 + 5 .10 RSBI 82 + 16 84 + 10 .55 FiO2 0.39 + 0.08 0.38 + 0.08 .4 PEEP 6 + 2.5 7.2 + 2.4 .11 pH 7.44 + 0.05 7.38 + 0.05 .045* PaO2 106 (94–120) 99.5 (85–112) .20 PFR 370 + 80 350 + 66 .83 PaCO2 40 + 3.8 41 + 7.0 .55 GCS 11 + 2.3 9 + 2.5 .77 Hourly urine output 84 (49–139) 82 (40–129) .83 Hemoglobin 9.8 + 1.9 9.4 + 2 .51 Serum sodium 142 + 7 135 + 6.2 .57 . Extubation success . Extubation failure . P . Ventilator days 5.9 + 2.2 6.4 + 2.2 .07 Heart rate 97 + 18 113 + 19 .0011* MAP 80 + 8 80 + 12 .33 Respiratory rate 17.0 + 5 19.0 + 5 .10 RSBI 82 + 16 84 + 10 .55 FiO2 0.39 + 0.08 0.38 + 0.08 .4 PEEP 6 + 2.5 7.2 + 2.4 .11 pH 7.44 + 0.05 7.38 + 0.05 .045* PaO2 106 (94–120) 99.5 (85–112) .20 PFR 370 + 80 350 + 66 .83 PaCO2 40 + 3.8 41 + 7.0 .55 GCS 11 + 2.3 9 + 2.5 .77 Hourly urine output 84 (49–139) 82 (40–129) .83 Hemoglobin 9.8 + 1.9 9.4 + 2 .51 Serum sodium 142 + 7 135 + 6.2 .57 *Statistically significant. Data presented as either means ± standard deviations or median (interquartile ranges) as appropriate. MAP, mean arterial pressure; RSBI, Rapid Shallow Breathing Index; FiO2, fraction of inspired oxygen; PEEP, positive end expiratory pressure; PaO2, partial pressure of oxygen as measured on arterial blood gas; PFR, PaO2 to FiO2 ratio; PaCO2, partial pressure of carbon dioxide as measured on arterial blood gas; GCS, Glasgow coma scale. Open in new tab Figure 2. Open in new tabDownload slide Demographics of extubation success vs extubation failure patients. ANCOVA analysis of all continuous variables revealed a significant difference in mean sodium and mean pH between those who succeeded extubation and those who failed. Sodium values trending higher immediately proceeding extubation for those designated as extubation successes, possibly reflective of lower intravascular volume status (Figure 3). pH values trending toward slight alkalosis (highest value 7.44) were more associated with extubation success. No other continuous variables demonstrated significant trends in ANCOVA analysis. Figure 3. Open in new tabDownload slide ANCOVA analysis of sodium and pH. The x-axis is the intervals of time with each point representing data collection of sodium or pH, respectively. Dashed line—extubation success, Solid line—extubation failure. The sodium and pH levels were collected during spontaneous breathing trials over the patients’ hospital course prior to extubation. Logistic regression of TBSA, respiratory rate, pH, inhalation injury, and heart rate retained the presence of inhalation injury and heart rate as independent predictors of extubation outcome (P = .02 and .002, respectively). DISCUSSION This study demonstrated an extubation failure rate of 12.3% in burn patients, with a lower rate of failure in patients with inhalation injury. The optimal rate of extubation failure has yet to be established in any critical-care population, and current literature reports a range of failure rates from 4% to 23%.21 This study of burn patients exhibits a lower extubation failure rate than previous burn studies, which are up to 30%.21,22 However, patient inclusion criteria vary between these studies. In addition, subjective factors influence decision-making by providers and are difficult to quantify. Overall, in the absence of predictors that convey 100% accuracy, a certain failure rate is necessary in order to prevent prolonged intubation and the associated complications. Due to this variability, identification of risk factors associated with extubation failure is desirable. In our propensity-cohort analysis, elevated heart rate, mild acidemia, the absence of inhalation injury and a sodium trending lower prior to extubation were associated with extubation failure. The elevated heart rate is difficult to apply in clinical assessment of readiness to extubate due to the hypermetabolic state caused by burn injury. Furthermore, a 10 bpm difference may not be clinically significant. Acidemia, primarily respiratory in nature, is a frequent cause of intubation, so it is not surprising that acidotic patients would not successfully extubate. However, the acidosis in this study was mild and likely not clinically significant. A study with larger power may full elucidate the value of these two variables. We found that an increasing sodium trend predicted successful extubation. Although the physiology of sodium and water balance in burn patients is complex, this finding may point to a lower volume status and therefore better pulmonary function to tolerate extubation. Volume status is notoriously difficult to determine in the burn patient who experience rapid and large-volume shifts beginning with initial resuscitation. Insensible fluid losses remain near impossible to quantify given a wound burden in various stages of healing. Markers of volume status associated with significant clinical outcomes are desired. The impact of inhalation injury on extubation outcome continues to be controversial. This study demonstrated that the presence of inhalation injury was associated with fewer extubation failures. The lower rate of extubation failure is likely reflective of a more conservative extubation strategy in patients with inhalation injury. First, this may reflect concerns about the airway or about pulmonary toilet. Second, patients with inhalation injury may experience an increased metabolic rate relative to TBSA- and age-matched counterparts without inhalation injury. This increased metabolic demand is met by increased minute ventilation and, in particular, an increase in the respiratory rate,23 which may confound the interpretation of standard weaning parameters. Other burn studies demonstrated no effect of inhalation injury on extubation outcome, but their inclusion criteria and weaning parameters varied or were not specified.21,22 The weaning parameters in this study were liberal and RSBI was under the established value of 105 for all of the attempted extubations. Using these parameters as an early screening tool during spontaneous breathing trials made them largely nondiscriminatory but also conveys their established value in the assessment of extubation readiness but also demonstrates other factors exist that influence extubation outcome. The limitations of this study include its retrospective nature, and the inability to evaluate other variables which may influence extubation outcome. For example, cough strength is important to one’s ability to clear secretions after extubation, but was not quantified in this study; all patients were noted to have “a cough” and an intact gag reflex prior to extubation. Quantity and characteristics of secretions have been reported to impact extubation outcome, but were not collected.22 Additionally, the complete effect of inhalation injury on extubation outcome should include the grade of inhalation injury. CONCLUSION This study demonstrated a moderately low extubation failure rate in burn patients, as well as factors that could aid in the prediction of extubation outcome. Trending important values of gas exchange and volume status should play a key role in determining the readiness to extubate a burn patient. Conflict of interest statement. The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army Medical Department, Department of the Army, DoD, or the U.S. Government. REFERENCES 1. Saffle JR , Sullivan JJ, Tuohig GM, Larson CM. Mulitple organ failure in patients with thermal injury . Crit Care Med 1993 ; 21 : 1673 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Lund T , Goodwin CW, McManus WF, et al. Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy . Ann Surg 1985 ; 201 : 374 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Rashkin MC , Davis T. 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Google Scholar Crossref Search ADS PubMed WorldCat Published by Oxford University Press on behalf of the American Burn Association 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the American Burn Association 2020.
TI - Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors
JO - Journal of Burn Care & Research
DO - 10.1093/jbcr/iraa162
DA - 2021-03-04
UR - https://www.deepdyve.com/lp/oxford-university-press/extubation-failure-in-a-burn-intensive-care-unit-examination-of-xgdOfSlpST
SP - 177
EP - 181
VL - 42
IS - 2
DP - DeepDyve
ER -