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Abstract

Background:

Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO₂/FiO₂), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched.

Aim:

To identify variables that are predictive of ExtF and related outcomes.

Method:

Prospective observational longitudinal study. Consecutively presenting patients (n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU.

Results:

The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO₂/FiO₂ was <150 and 11 times when it was ≥450. Also, a reassuring PaO₂/FiO₂ value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function.

Conclusion:

The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.

Keywords

Cardiac surgery extubation failure neurocognitive function outcome RSBI

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References

Coulson

Mullany

Reid

et al . Measuring the quality of perioperative care in cardiac surgery. Eur Heart J Qual Care Clin Outcomes 2017; 3: 11–19.

Myles

PS.

Meaningful outcome measures in cardiac surgery. J Extra Corpor Technol 2014; 46: 23–27.

Engoren

Blum

JM.

A comparison of the rapid shallow breathing index and complexity measures during spontaneous breathing trials after cardiac surgery. J Crit Care 2013; 28: 69–76.

Beverly

Brovman

Malapero

et al . Unplanned reintubation following cardiac surgery: Incidence, timing, risk factors, and outcomes. J Cardiothorac Vasc Anesth 2016; 30: 1523–1529.

Rady

Ryan

Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 1999; 27: 340–347.

Yazdanian

Azarfarin

Aghdaii

et al . Cardiac variables as main predictors of endotracheal reintubation rate after cardiac surgery. J Tehran Heart Cent 2013; 8: 42–47.

Barbosa

Silva

Borges

Costa Mde

et al . Application of mechanical ventilation weaning predictors after elective cardiac surgery. Braz J Cardiovasc Surg 2015; 30: 605–609.

Khamiees

Raju

DeGirolamo

et al . Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120: 1262–12.

Miu

Joffe

Yanez

et al . Predictors of reintubation in critically ill patients. Respir Care 2014; 59: 178–185.

10.

Mokhlesi

Tulaimat

Gluckman

et al . Predicting extubation failure after successful completion of a spontaneous breathing trial. Respir Care 2007; 52: 1710–1717.

11.

Salam

Tilluckdharry

Amoateng-Adjepong

et al . Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004; 30: 1334–1339.

12.

Chen

et al . Involuntary cough strength and extubation outcomes for patients in an ICU. Chest 2010; 137: 777–782.

13.

Knaus

Draper

Wagner

et al . APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818–829.

14.

Charlson

Pompei

Ales

et al . A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987; 40: 373–383.

15.

Yang

Tobin

MJ.

A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324: 1445–1450.

16.

Frutos-Vivar

Ferguson

Esteban

et al . Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130: 1664–1671.

17.

Kacmarek

Dimas

Mack

CW.

Essentials of respiratory care – E-book. St. Louis, Missouri: Elsevier Health Sciences, 2013.

18.

Bernard

Artigas

Brigham

et al . The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818–824.

19.

Guerin

Reignier

Richard

et al . Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368: 2159–2168.

20.

Garcia-Delgado

Navarrete

Garcia-Palma

et al . Postoperative respiratory failure after cardiac surgery: Use of noninvasive ventilation. J Cardiothorac Vasc Anesth 2012; 26: 443–447.

21.

Sağıroğlu

Baysal

Çopuroğlu

et al . Does early use of bilevel positive airway pressure (bipap) in cardiothoracic intensive care unit prevent reintubation? Int J Clin Exp Med 2014; 7: 3439–3446.

22.

Mendes

de Souza

Machado

et al . Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: A comparison between artificial neural networks and logistic regression models. Arch Med Sci 2015; 11: 756–763.

23.

Siregar

Groenwold

de Mol

et al . Evaluation of cardiac surgery mortality rates: 30-day mortality or longer follow-up? Eur J Cardiothorac Surg 2013; 44: 875–883.

24.

Cassiere

Fishbein

et al . Outcomes of patients with prolonged intensive care unit length of stay after cardiac surgery. J Cardiothorac Vasc Anesth 2016; 30: 1550–1554.

25.

Takaki

Kadiman

Tahir

et al . Modified rapid shallow breathing index adjusted with anthropometric parameters increases predictive power for extubation failure compared with the unmodified index in postcardiac surgery patients. J Cardiothorac Vasc Anesth 2015; 29: 64–68.

26.

Danaga

Gut

Antunes

et al . Evaluation of the diagnostic performance and cut-off value for the rapid shallow breathing index in predicting extubation failure. J Bras Pneumol 2009; 35: 541–547.

27.

Karthika

Al Enezi

Pillai

et al . Rapid shallow breathing index. Ann Thorac Med 2016; 11: 167–176.

28.

Boles

Bion

Connors

et al . Weaning from mechanical ventilation. Eur Respir J 2007; 29: 1033–1056.

29.

Brochard

Thille

AW.

What is the proper approach to liberating the weak from mechanical ventilation?

Crit Care Med 2009; 37: S410–S415.

30.

Altemeier

Sinclair

SE.

Hyperoxia in the intensive care unit: why more is not always better. Curr Opin Crit Care 2007; 13: 73–78.

31.

Wang

Zhang

Huang

et al . Predictors of extubation failure in neurocritical patients identified by a systematic review and meta-analysis. PLoS One 2014; 9: e112198.

32.

Fontes

Swift

Phillips-Bute

et al . Predictors of cognitive recovery after cardiac surgery. Anesth Analg 2013; 116: 435–442.

33.

Feiner

Weiskopf

RB.

Evaluating pulmonary function: An assessment of PaO2/FIO2. Crit Care Med 2017; 45: e40-e48.

34.

Soltis

LM.

Role of the clinical nurse specialist in improving patient outcomes after cardiac surgery. AACN Adv Crit Care 2015; 26: 35–42.

35.

Hawkes

Foxcroft

Yerrell

Clinical guideline for nurse-led early extubation after coronary artery bypass: An evaluation. J Adv Nurs 2010; 66: 2038–2049.

36.

Rose

Nelson

Johnston

et al . Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit. Am J Crit Care 2007; 16: 434–443; quiz 44.

37.

Villa

Manara

Palese

Nurses’ near-decision-making process of postoperative patients’ cardiosurgical weaning and extubation in an Italian environment. Intensive Crit Care Nurs 2012; 28: 41–49.

38.

Hancock

Easen

PR.

The decision-making processes of nurses when extubating patients following cardiac surgery: An ethnographic study. Int J Nurs Stud 2006; 43: 693–705.

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Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment