High-Risk Extubation Readiness Testing for Children With Cardiac Critical Illness
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Published on: April 7, 2023
Chen Yun Goh1, Herng Lee Tan2, Yi-Jyun Ma2
1Respiratory Therapy Service, Division of Allied Health Specialties, KK Women's and Children's Hospital, Singapore goh.chen.yun@kkh.com.sg.
Insights
Implementing a high-risk extubation readiness test (ERT) protocol in intubated cardiac patients significantly reduced peri-extubation complications. This quality improvement initiative demonstrated a lower composite outcome of extubation failure and need for respiratory support.
Area of Science:
- Critical Care Medicine
- Cardiology
- Respiratory Therapy
Background:
- Protocolized extubation readiness tests (ERT), including spontaneous breathing trials (SBT), are crucial for intubated patients.
- This study focused on improving peri-extubation outcomes in cardiac patients undergoing mechanical ventilation.
Purpose of the Study:
- To evaluate the effectiveness of a high-risk ERT protocol in addition to a standard-risk protocol for intubated cardiac patients.
- To assess the impact on extubation failure and the need for post-extubation respiratory support.
Main Methods:
- A quality improvement project involving 213 intubated cardiac subjects.
- Implementation of a standard-risk ERT protocol (pressure support plus PEEP) followed by a high-risk ERT protocol (PEEP alone).
- Comparison of composite outcomes, ventilator duration, and postextubation respiratory support use between protocol phases.
Main Results:
- The high-risk ERT protocol was associated with a significant reduction in the composite outcome of extubation failure and rescue noninvasive respiratory support (adjusted odds ratio 0.20, P = .037).
- No significant increase in ventilator duration or use of planned noninvasive respiratory support was observed.
- While the overall composite outcome trended lower across phases, only the high-risk protocol showed statistical significance after adjustment.
Conclusions:
- Implementation of a high-risk ERT protocol in intubated cardiac patients led to improved peri-extubation outcomes.
- The findings support the use of tailored, high-risk ERT protocols to optimize patient recovery after mechanical ventilation.
Background:
A protocolized extubation readiness test (ERT), including a spontaneous breathing trial (SBT), is recommended for patients who are intubated. This quality-improvement project aimed to improve peri-extubation outcomes by using a high-risk ERT protocol in intubated cardiac patients in addition to a standard-risk protocol.
Methods:
After baseline data collection, we implemented a standard-risk ERT protocol (pressure support plus PEEP), followed by a high-risk ERT protocol (PEEP alone) in cardiac subjects who were intubated. The primary outcome, a composite of extubation failure and rescue noninvasive respiratory support, was compared between phases. Ventilator duration and use of postextubation respiratory support were balancing measures.
Results:
A total of 213 cardiac subjects who were intubated were studied, with extubation failure and rescue noninvasive respiratory support occurring in 10 of 213 (4.7%) and 8 of 213 (3.8%), respectively. We observed a reduction in the composite outcome among the 3 consecutive phases (5/29 [17.2%], 10/110 [9.1%] vs 3/74 [4.1%]; P = .10), but this did not reach statistical significance. In the logistic regression model when adjusting for admission type, the high-risk ERT protocol was associated with a significant reduction of the composite outcome (adjusted odds ratio 0.20, 95% CI 0.04-0.091; P = .037), whereas the standard-risk ERT protocol was not (adjusted odds ratio 0.48, 95% CI 0.15-1.53; P = .21). This was not accompanied by a longer ventilator duration (2.0 [1.0, 3.0], 2.0 [1.0-4.0], vs adjusted odds ratio 2.0 [95% [1.0-6.0]; P = .99) or an increased use of planned noninvasive respiratory support (10/29 [35.5%], 35/110 [31.8%], vs 25/74 [33.8%]; P > .99).
Conclusions:
In this quality-improvement project, a high-risk ERT protocol was implemented with improvement in peri-extubation outcomes among cardiac subjects.
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