Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Davis, California; and Center for Nursing Science, UC Davis Health, Sacramento, California.
Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Davis, California.
Respir Care. 2023 Aug;68(8):1049-1057. doi: 10.4187/respcare.10225. Epub 2023 May 9.
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.
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.
Of 61 subjects enrolled, 9.8% ( 6) required re-intubation, and 50.8% ( 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, = .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%).
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.
尽管对拔管成功预测因素的研究已进行了数十年，但拔管后仍普遍使用通气支持，10-20%的患者需要重新插管。比例辅助通气（PAV）模式可自动计算估计的总呼吸功（总 WOB）。在此，我们评估了总 WOB 预测有创通气患者拔管失败的性能。
本前瞻性观察研究在一家学术医疗中心的 6 个成人 ICU 进行。我们纳入了成功完成自主呼吸试验、浅快呼吸指数 <105 次/分/L 且主要团队认为已准备好拔管的有创通气患者。在 30 分钟 PAV 试验结束时记录总 WOB 值。拔管失败定义为拔管后 72 小时内任何呼吸支持和/或重新插管。我们比较了两组之间的总 WOB 评分，并通过接收者操作特征曲线比较了总 WOB 预测拔管失败的性能。
在纳入的 61 名患者中，9.8%（6 名）需要重新插管，50.8%（31 名）在拔管后 72 小时内需要任何呼吸支持。PAV 试验 30 分钟时的中位总 WOB 为 0.9 J/L（四分位距 0.7-1.3 J/L）。拔管失败或成功的患者之间总 WOB 差异有统计学意义（中位数 1.1 J/L 与 0.7 J/L， =.004）。预测任何呼吸支持需求的曲线下面积为 0.71[95%CI 0.58-0.85]，预测拔管后 72 小时内单独重新插管的曲线下面积为 0.85[95%CI 0.69-1.00]。预测任何呼吸支持的总 WOB 截断值最大，灵敏度和特异性相等为 1.0 J/L（阳性预测值[PPV]70.0%，阴性预测值[NPV]67.7%），预测重新插管的总 WOB 截断值为 1.3 J/L（PPV 26.3%，NPV 97.6%）。
PAV 衍生的总 WOB 值预测拔管失败的判别性能良好，表明总 WOB 可能是评估拔管准备情况的辅助工具。然而，这些结果应被解释为初步结果，需要在一项大型多中心研究中进一步研究 PAV 衍生的总 WOB 的具体截断值。
