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A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
Contemporary Trends in Pediatric Extubation Failure and Noninvasive Respiratory Support Use
Jeremy M Loberger1, Mitchell Moore2, Matthew Scanlon3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL.
Insights
Post-extubation non-invasive respiratory support in children nearly doubled over a decade, reducing extubation failure (EF) risk by 10%. While EF is linked to morbidity, it does not increase mortality.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Support Strategies
- Mechanical Ventilation Outcomes
Background:
- Prolonged mechanical ventilation in children increases morbidity and mortality risks.
- Timely extubation requires balancing extubation failure (EF) against prolonged non-invasive support.
- Understanding trends in EF and respiratory support is crucial for pediatric critical care.
Purpose of the Study:
- To investigate changes in EF risk factors, rates, and post-extubation non-invasive respiratory support practices from 2013-2022.
- To evaluate patient-centered outcomes associated with these changes.
- To identify trends in pediatric extubation management over a decade.
Main Methods:
- Retrospective cross-sectional study of 132,712 pediatric encounters (age < 19) requiring invasive mechanical ventilation ≥ 24 hours.
- Data analyzed from the Virtual Pediatric Intensive Care, LLC quality improvement database (2013-2022).
- Logistic regression used to identify EF risk factors and assess outcome associations.
Main Results:
- Overall EF rate was 8.5%; post-extubation non-invasive support use nearly doubled (20.9% to 39.9%).
- EF rates slightly decreased (≤7 days: 12.3% to 11.0%).
- Younger age, specific diagnoses (renal, respiratory, cardiac), and longer pre-extubation ventilation were associated with increased EF odds. EF correlated with longer ICU and hospital stays but not mortality.
Conclusions:
- Post-extubation non-invasive support has significantly increased, correlating with a modest reduction in EF.
- High-risk pediatric populations may benefit, but potential overuse in low-risk groups warrants consideration.
- Extubation failure is associated with significant morbidity but not increased mortality in pediatric patients.
Background:
Prolonged invasive mechanical ventilation (IMV) is associated with morbidity and mortality in children. Timely extubation is essential and must balance the competing risks of extubation failure (EF) and prolonged use of noninvasive respiratory support after extubation.
Research Question:
Did EF risk factors, EF rates, noninvasive respiratory support after extubation practices, and patient-centered outcomes changed between 2013 and 2022?
Study Design And Methods:
Retrospective cross-sectional study of patients younger than 19 years receiving IMV for ≥ 24 hours and extubated between 2013 and 2022 from 158 North American sites in the Virtual Pediatric Intensive Care, LLC, quality improvement database.
Results:
One hundred thirty-two thousand seven hundred twelve unique encounters were included. The overall EF rate was 8.5%. Postextubation noninvasive respiratory support use nearly doubled (2013 vs 2022: 20.9% vs 39.9%; relative risk [RR], 1.90 [95% CI, 1.83-1.98]; P < .01), whereas EF decreased slightly (≤ 48 hours: 8.9% vs 8.1%; RR, 0.92 [95% CI, 0.85-0.99]; P = .03; ≤ 7 days: 12.3% vs 11.0%; RR, 0.89 [95% CI, 0.83-0.95]; P < .01). Logistic regression identified increased odds of EF associated with younger age (< 6 weeks: OR, 1.39 [95% CI, 1.31-1.47]; P < .01; 6 weeks-12 months: OR, 1.24 [95% CI, 1.18-1.30]; P < .01), primary renal diagnosis (OR, 1.25 [95% CI, 1.04-1.48]; P = .01), respiratory diagnosis (OR, 1.15 [95% CI, 1.07-1.23]; P < .01), and cardiac diagnosis (OR, 1.10 [95% CI, 1.04-1.16]; P < .01), and ≥ 7 days of invasive ventilation before extubation (OR, 1.26 [95% CI, 1.21-1.32]; P < .01). EF rates were unchanged over time for patients with 0 or 1 risk factor. EF was associated with longer mechanical ventilation duration (11.6 days vs 4.0 days; P < .01), longer pediatric ICU length of stay (18.8 days vs 7.9 days; P < .01), and longer hospital length of stay (31.0 days vs 15.0 days; P < .01), but not with all-cause risk-adjusted mortality (8.5% vs 8.6%; RR, 1.16 [95% CI, 0.97-1.38]; P = .73).
Interpretation:
Our results demonstrate that in the last decade, noninvasive respiratory support after extubation has nearly doubled, with an approximately 10% reintubation risk reduction. High-risk groups may benefit, but overuse may exist in low-risk groups with respect to EF. EF is associated with morbidity, but not increased mortality.
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