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Dead Space to Tidal Volume Ratio Is Associated With Higher Postextubation Support in Children
Jonathan A Gehlbach1, Andrew G Miller2, Christoph P Hornik3
1Department of Pediatrics, Division of Pediatric Critical Care Medicine, The University of Illinois College of Medicine, Peoria, Illinois. jgehlb2@uic.edu.
Insights
The dead-space-to-tidal-volume ratio (VD/VT) did not predict extubation success in children. However, a higher VD/VT was linked to increased need for respiratory support after extubation.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Mechanical Ventilation
Background:
- Extubation failure in children is linked to prolonged mechanical ventilation, hospital stays, and mortality.
- The dead-space-to-tidal-volume ratio (VD/VT) has been explored as a predictor of successful extubation.
- This study investigated the association between VD/VT and extubation outcomes in pediatric patients.
Purpose of the Study:
- To determine if an elevated dead-space-to-tidal-volume ratio (VD/VT) predicts extubation failure in children.
- To assess the relationship between VD/VT and the level of respiratory support required postextubation.
Main Methods:
- A prospective, observational cohort study of pediatric patients (<18 years) undergoing extubation.
- Daily VD/VT measurements were obtained using arterial blood gas analysis and volumetric capnography.
- Respiratory support levels (low vs. high) and need for re-intubation were monitored for 48 hours postextubation.
Main Results:
- Of 189 subjects, 12% (23) required re-intubation.
- No significant difference in final VD/VT was found between successful extubation and extubation failure groups (median 0.28 vs. 0.29, P = .87).
- Higher VD/VT was significantly associated with increased need for respiratory support postextubation (median 0.32 vs. 0.25, P < .001).
Conclusions:
- VD/VT was not a significant predictor of extubation success in this pediatric cohort.
- VD/VT demonstrated a significant association with the level of respiratory support required after extubation.
- Further research is needed to explore VD/VT's role in managing postextubation respiratory support to potentially reduce failure rates.
Background:
Extubation failure is associated with increased duration of mechanical ventilation, length of hospital stay, and mortality. An elevated dead-space-to-tidal-volume ratio (VD/VT) has been proposed as a predictor of successful extubation in children. We hypothesized that a higher VD/VT value would be associated with extubation failure and higher postextubation respiratory support.
Methods:
This was a prospective, observational, cohort study. All subjects were < 18 y old and were extubated in the pediatric multidisciplinary ICU or the cardiac ICU at an academic medical center from June 2016 through March 2017. Using arterial blood gas analysis and mainstream volumetric capnography, daily VD/VT measurements were obtained on intubated subjects using an automated algorithm. Respiratory support upon extubation was based on the clinical team's judgment and defined as low (ie, room air or nasal cannula) or high (ie, high-flow nasal cannula, CPAP, or bi-level positive airway pressure). Subjects were monitored for 48 h after extubation for escalation in respiratory support and need for re-intubation.
Results:
Of 189 subjects included in the analysis, 166 were successfully extubated and 23 (12%) required re-intubation. There was no significant difference in final VD/VT between those who extubated successfully and those who failed extubation, with a median VD/VT of 0.28 (interquartile range [IQR] 0.20-0.37) vs 0.29 (IQR 0.21-0.33), respectively (P = .87). Those who received a high level of support upon extubation had a higher VD/VT than those who received a low level of support, with a median of 0.32 (IQR 0.23-0.39) vs 0.25 (IQR 0.16-0.30), respectively (P < .001). This association remained significant when controlling for age, duration of intubation, and cyanotic congenital heart disease (odds ratio 1.63, 95% CI 1.18-2.24).
Conclusions:
There was no significant relationship between VD/VT and extubation success, although VD/VT was associated with the level of respiratory support provided following extubation. Further studies should investigate whether the use of VD/VT can help reduce extubation failure rates with varying levels of postextubation respiratory support.
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