Lai Chih-Cheng, Chen Chin-Ming, Chiang Shyh-Ren, Liu Wei-Lun, Weng Shih-Feng, Sung Mei-I, Hsing Shu-Chen, Cheng Kuo-Chen
Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying Department of Intensive Care Medicine Department of Internal Medicine, Chi Mei Medical Center Department of Chia Nan University of Pharmacy & Science, Tainan Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung Department of Safety Health and Environmental Engineering, Chung Hwa University of Medical Technology, Tainan, Taiwan.
Medicine (Baltimore). 2016 Oct;95(41):e4852. doi: 10.1097/MD.0000000000004852.
The aim of this study was to establish predictors for successfully planned extubation, which can be followed by medical personnel. The patients who were admitted to the adult intensive care unit of a tertiary hospital and met the following criteria between January 2005 and December 2014 were collected retrospectively: intubation > 48 hours; and candidate for extubation. The patient characteristics, including disease severity, rapid shallow breath index (RSBI), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), cuff leak test (CLT) before extubation, and outcome, were recorded. The CLT was classified as 2+ with audible flow without a stethoscope, 1+ with audible flow using a stethoscope, and negative (N) with no audible flow, even with a stethoscope. Failure to extubate was defined as reintubation within 48 hours. In total, 6583 patients were enrolled and 403 patients (6.1%) had extubation failures. Male patients dominated the patient cohort (4261 [64.7%]). The mean age was 64.5±16.3 years. The overall in-hospital mortality rate was 11.3%. The extubation failure rate for females was greater than males (7.7% vs 5.3%, P < 0.001). The group of patients who failed extubation were older (66.7 ± 14.4 vs 64.3 ± 16.4, P = 0.002), had higher APACHE II scores (16.8 ± 7.6 vs 15.9 ± 7.8, P = 0.023), lower coma scales (10.3 ± 3.7 vs 10.8 ± 3.7, P = 0.07), a higher RSBI (69.9 ± 37.3 vs 58.6 ± 30.3, P < 0.001), a lower MIP, and MEP (-35.6 ± 15.3 vs -37.8 ± 14.6, P = 0.0001 and 49.6 ± 28.4 vs 58.6 ± 30.2, P < 0.001, respectively), and a higher mortality rate (25.6% vs 10.5%, P < 0.001) compared to the successful extubation group. Based on multivariate logistic regression, a CLT of 2+ (odds ratio [OR] = 2.07, P < 0.001), a MEP ≥ 55 cmH2O (OR = 1.73, P < 0.001), and a RSBI < 68 breath/min/ml (OR = 1.57, P < 0.001) were independent predictors for successful extubation.This study identified 3 independent risk factors for successful extubation after a successful breathing trial, including a CLT of 2+, a MEP ≥ 55 cmH2O, and a RSBI < 68 breath/min/ml. Furthermore, a nomogram integrating these 3 parameters, which represented the combined consideration of the upper airway patentency, cough strength, and respiratory capacity, was developed to better predict extubation success.
本研究的目的是确定可供医务人员参考的成功计划拔管的预测指标。回顾性收集了2005年1月至2014年12月期间入住一家三级医院成人重症监护病房且符合以下标准的患者：插管时间>48小时；且为拔管候选人。记录患者特征，包括疾病严重程度、快速浅呼吸指数（RSBI）、最大吸气压力（MIP）、最大呼气压力（MEP）、拔管前的气囊漏气试验（CLT）以及结果。CLT分为：2+，即不用听诊器可闻及气流；1+，即使用听诊器可闻及气流；阴性（N），即即使使用听诊器也无气流声。拔管失败定义为在48小时内再次插管。总共纳入了6583例患者，其中403例（6.1%）拔管失败。患者队列中男性占主导（4261例[64.7%]）。平均年龄为64.5±16.3岁。总体院内死亡率为11.3%。女性的拔管失败率高于男性（7.7%对5.3%，P<0.001）。拔管失败的患者组年龄更大（66.7±14.4对64.3±16.4，P = 0.002），急性生理与慢性健康状况评分系统（APACHE II）得分更高（16.8±7.6对15.9±7.8，P = 0.023），昏迷评分更低（10.3±3.7对10.8±3.7，P = 0.07），RSBI更高（69.9±37.3对58.6±30.3，P<0.001），MIP和MEP更低（分别为-35.6±15.3对-37.8±14.6，P = 0.0001；49.6±28.4对58.6±30.2，P<0.001），与成功拔管组相比死亡率更高（25.6%对10.5%，P<0.001）。基于多因素逻辑回归分析，CLT为2+（比值比[OR]=2.07，P<0.001）、MEP≥55 cmH₂O（OR = 1.73，P<0.001）以及RSBI<68次/分钟/毫升（OR = 1.57，P<0.001）是成功拔管的独立预测指标。本研究确定了成功的呼吸试验后成功拔管的3个独立危险因素，包括CLT为2+、MEP≥55 cmH₂O以及RSBI<68次/分钟/毫升。此外，还制定了一个整合这3个参数的列线图，该列线图综合考虑了上气道通畅性、咳嗽强度和呼吸能力，以更好地预测拔管成功。
