Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
Department of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA.
Crit Care Med. 2020 Aug;48(8):1165-1174. doi: 10.1097/CCM.0000000000004418.
Extubation failure is multifactorial, and most tools to assess extubation readiness only evaluate snapshots of patient physiology. Understanding variability in respiratory variables may provide additional information to inform extubation readiness assessments.
Secondary analysis of prospectively collected physiologic data of children just prior to extubation during a spontaneous breathing trial. Physiologic data were cleaned to provide 40 consecutive breaths and calculate variability terms, coefficient of variation and autocorrelation, in commonly used respiratory variables (i.e., tidal volume, minute ventilation, and respiratory rate). Other clinical variables included diagnostic and demographic data, median values of respiratory variables during spontaneous breathing trials, and the change in airway pressure during an occlusion maneuver to measure respiratory muscle strength (maximal change in airway pressure generated during airway occlusion [PiMax]). Multivariable models evaluated independent associations with reintubation and prolonged use of noninvasive respiratory support after extubation.
Acute care, children's hospital.
Children were included from the pediatric and cardiothoracic ICUs who were greater than 37 weeks gestational age up to and including 18 years who were intubated greater than or equal to 12 hours with planned extubation. We excluded children who had a contraindication to an esophageal catheter or respiratory inductance plethysmography bands.
Noninterventional study.
A total of 371 children were included, 32 of them were reintubated. Many variability terms were associated with reintubation, including coefficient of variation and autocorrelation of the respiratory rate. After controlling for confounding variables such as age and neurologic diagnosis, both coefficient of variation of respiratory rate(p < 0.001) and low PiMax (p = 0.002) retained an independent association with reintubation. Children with either low PiMax or high coefficient of variation of respiratory rate had a nearly three-fold higher risk of extubation failure, and when these children developed postextubation upper airway obstruction, reintubation rates were greater than 30%.
High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children, with very high rates of extubation failure when these children develop postextubation upper airway obstruction.
拔管失败是多因素的，大多数评估拔管准备情况的工具仅评估患者生理状态的快照。了解呼吸变量的可变性可能为评估拔管准备情况提供额外信息。
对自主呼吸试验期间即将拔管的儿童的前瞻性收集生理数据进行二次分析。对生理数据进行清理，以提供 40 个连续呼吸，并计算常用呼吸变量（即潮气量、分钟通气量和呼吸频率）的变异系数和自相关。其他临床变量包括诊断和人口统计学数据、自主呼吸试验期间呼吸变量的中位数以及在阻塞试验期间测量呼吸肌力量时气道压力的变化（气道阻塞期间产生的气道压力最大变化[PiMax]）。多变量模型评估了与再插管和拔管后长时间使用无创呼吸支持相关的独立因素。
急性护理，儿童医院。
纳入胎龄大于 37 周且最长至 18 岁、插管时间大于或等于 12 小时且计划拔管的儿科和心胸 ICU 患儿。我们排除了有食管导管或呼吸感应体容积描记带禁忌证的患儿。
非干预性研究。
共纳入 371 例患儿，其中 32 例再插管。许多变异系数与再插管有关，包括呼吸频率的变异系数和自相关。在控制年龄和神经诊断等混杂因素后，呼吸频率变异系数（p < 0.001）和低 PiMax（p = 0.002）均与再插管独立相关。呼吸频率变异系数低或低 PiMax 的患儿拔管失败的风险增加近三倍，当这些患儿发生拔管后上气道梗阻时，再插管率大于 30%。
自主呼吸试验期间呼吸可变性高与儿童拔管失败独立相关，当这些患儿发生拔管后上气道梗阻时，拔管失败率非常高。
