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Published on: August 2, 2024
Extubation Failure and Tracheostomy Placement in Children with Acute Neurocritical Illness
Ellen C Cohn1, Tammy S Robertson2, Stacey A Scott2
1Department of Clinical Research, Children's Health - Children's Medical Center Dallas, 1935 Medical District Drive, Dallas, TX, 75235, USA.
Insights
A weak or absent cough reflex significantly increases the risk of extubation failure and tracheostomy placement in pediatric neurocritical care patients. This finding highlights a key predictor for these adverse outcomes in vulnerable children.
Area of Science:
- Pediatric Critical Care Medicine
- Neurocritical Care
- Respiratory Physiology
Background:
- Limited data exists on risk factors for extubation failure (EF) and tracheostomy placement in pediatric neurocritical care (NCC) patients.
- Identifying these factors is crucial for improving patient outcomes and resource allocation.
Purpose of the Study:
- To identify demographic, neurologic, pulmonary, and clinical risk factors associated with extubation failure (EF) and tracheostomy placement in pediatric NCC patients.
- To analyze predictive factors for EF and tracheostomy placement following extubation attempts.
Main Methods:
- Retrospective chart review of intubated pediatric patients (>24 hours) with acute neurocritical illness.
- Bivariate and multivariate statistical analyses were performed to assess associations with EF and tracheostomy placement.
- Analysis included first and second extubation attempt groups, examining predictive factors for outcomes within 48 hours to 7 days.
Main Results:
- Neuromuscular weakness was associated with the highest risk for EF and tracheostomy placement.
- Patients with a weak/absent cough had a significantly higher risk of EF (RR 9.4) and tracheostomy placement (RR 6.7) compared to those with a strong cough.
- Glasgow Coma Score (GCS), endotracheal tube secretions, and pulmonary variables were not significantly associated with EF or tracheostomy placement.
Conclusions:
- A weak or absent cough reflex is a significant predictor of extubation failure in pediatric NCC patients.
- This finding underscores the importance of assessing cough reflex as part of the extubation readiness evaluation in this population.
- Early identification of patients with impaired cough may guide proactive management to prevent tracheostomy placement.
Background:
There is a lack of data describing the risk factors for extubation failure (EF) or tracheostomy placement in pediatric neurocritical care (NCC) patients.
Methods:
A retrospective chart review of children admitted to the pediatric intensive care unit who were intubated for >24 h with an acute neurocritical illness and had an extubation attempt. Bivariate and multivariate statistical analysis was performed to determine significant associations of demographic, neurologic, pulmonary, and clinical variables with EF and tracheostomy placement. Analysis of predictive factors for EF (within 48 h) and tracheostomy placement during the hospitalization was conducted on a first extubation attempt group (n = 193) and a second attempt group (n = 23) who experienced either EF or a "late re-intubation" (>48 h-7 days).
Results:
Traumatic brain injury (37.3%) and seizures/status epilepticus (31.4%) were the most common diagnoses with neuromuscular weakness patients having the highest risk for EF and tracheostomy placement. EF occurred in 20/193 (10.4%) patients after their first attempt and 6/23 (26.1%) after a second attempt. Compared to those with a fair/strong cough, patients with a weak/absent cough had a relative risk (RR) of 9.4 for EF (95% CI, 4.9-17.9, p < 0.001) and 6.7 (95% CI, 2.3-18.9, p = 0.01) for tracheostomy placement on the first and second attempts, respectively. Glasgow Coma Score (GCS), endotracheal tube (ETT) secretion characteristics, and pulmonary variables were not associated with EF or tracheostomy placement.
Conclusions:
A weak/absent cough reflex is associated with an increased risk of failing extubation and placement of a tracheostomy in intubated pediatric NCC patients.
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