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Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis
Priscilla Ng1, Herng Lee Tan2, Yi-Jyun Ma2
1Duke-NUS Medical School, Singapore, Singapore.
Insights
Current pediatric extubation readiness assessments are poor predictors of extubation failure. The Compliance Rate Oxygenation Pressure (CROP) index shows promise, warranting further investigation for predicting extubation success in children.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Clinical Diagnostics
Background:
- Lack of consensus exists regarding best practices for assessing extubation readiness in pediatric patients.
- Existing pre-extubation assessments have not been definitively validated for predicting extubation failure (EF) in children.
Purpose of the Study:
- To systematically review and synthesize data on pre-extubation assessments used in children.
- To evaluate the diagnostic accuracy of these assessments in predicting extubation failure.
Main Methods:
- A comprehensive systematic search of major databases (PubMed, EMBASE, Web of Science, CINAHL, Cochrane) was conducted up to July 2021.
- Included studies were randomized controlled trials or observational studies in pediatric intensive care units assessing pre-extubation parameters and extubation outcomes.
- Meta-analysis was performed on studies reporting diagnostic test results for parameter combinations.
Main Results:
- 41 studies (8111 patients) were included; definitions of extubation failure were inconsistent.
- Fifty-five unique pre-extubation assessments were identified; key parameters included respiratory rate, PaCO2, tidal volume, rapid shallow breathing index (RSBI), and spontaneous breathing trials (SBT).
- Meta-analysis indicated poor predictive accuracy for most parameters. The Compliance Rate Oxygenation Pressure (CROP) index demonstrated the highest area under the curve (AUC=0.98), while SBT showed the highest specificity (0.93).
Conclusions:
- Current pre-extubation assessments are generally inadequate predictors of extubation failure in children.
- The CROP index, with its high AUC, warrants further investigation as a potential predictor of extubation failure.
- Standardizing the definition of extubation failure is crucial for improving the comparability and reliability of future research on pre-extubation assessments.
Introduction:
There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children.
Methods:
A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters.
Results:
In total, 41 of 11,663 publications screened were included (total patients, n = 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41, n = 1945), partial pressure of arterial carbon dioxide (10/41, n = 1379), tidal volume (13/41, n = 1945), rapid shallow breathing index (RBSI) (9/41, n = 1400), and spontaneous breathing trials (SBT) (13/41, n = 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity [0.57, 95% confidence interval (CI) 0.4-0.73] and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92-0.94).
Conclusions:
Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments.
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