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Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
A Prospective Evaluation of Routine Extubation Criteria in Children with Upper Respiratory Symptoms Undergoing
T Wesley Templeton1, L Daniela Smith1, Tim Mosher1
1Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Insights
The "Big Five" extubation criteria predict successful extubation in children, even with upper respiratory symptoms. This finding supports using these criteria for assessing extubation readiness in pediatric patients.
Area of Science:
- Pediatric Anesthesiology
- Critical Care Medicine
- Respiratory Therapy
Background:
- Previous research identified five key indicators for extubation readiness in children: tidal volume >5 mL/kg, conjugate gaze, facial grimace, purposeful movement, and eye opening.
- These indicators, termed the "Big Five," are crucial for assessing emergence from anesthesia, primarily with inhalational agents.
Purpose of the Study:
- To determine if the "Big Five" criteria predict extubation success in children with upper respiratory symptoms.
- To compare the predictive value of the "Big Five" in children with and without upper respiratory symptoms.
Main Methods:
- A study involving 756 children (≤9 years) undergoing awake extubation.
- Patients were categorized into cohorts based on preoperative assessment of upper respiratory symptoms.
- The primary analysis included patients meeting at least three of the "Big Five" criteria at extubation.
Main Results:
- The positive predictive value for successful extubation was 94.7% in children without upper respiratory symptoms and 93.9% in those with symptoms.
- The difference in predictive value between the two groups was 0.8%, which was below the 5% clinical equivalence margin.
Conclusions:
- The presence of three or more "Big Five" criteria is equivalently predictive of successful awake extubation in children, regardless of upper respiratory symptom status.
- These findings support the use of the "Big Five" criteria for assessing extubation readiness in pediatric patients with or without upper respiratory symptoms.
Background:
A previous study has shown that tidal volume greater than 5 ml/kg, conjugate gaze, facial grimace, purposeful movement, and eye opening are predictive of emergence and extubation readiness in children anesthetized primarily with inhalational agents. The hypothesis was that having any three of the aforementioned Big Five criteria will be similarly predictive of extubation success even if upper respiratory symptoms are present.
Methods:
After verbal consent, 756 patients 7 yr of age or younger were extubated awake. A parental questionnaire was performed preoperatively to assess upper respiratory symptoms and risk factors for respiratory adverse events. Based on this questionnaire, patients were assigned to either the non-upper respiratory infection symptom cohort or the upper respiratory infection symptom cohort. The presence or absence of the Big Five and other routine extubation criteria were recorded at extubation. Patients were included in the primary analysis only if they achieved three or more of the Big Five at the time of extubation. Awake extubations were graded as successful, intervention required, or major intervention required, according to a standard rubric. Intervention required and major intervention required were combined as a single outcome for the primary analysis. The positive predictive value of successful extubation was compared between the two cohorts using an equivalence analysis. The clinical equivalence margin was set at less than 5%.
Results:
The positive predictive value of successful extubation with three or more of the Big Five criteria in the non-upper respiratory infection symptom cohort was 94.7% (95% CI, 92.5 to 97.0%) and 93.9% (95% CI, 91.5 to 96.3%) in the upper respiratory infection symptom cohort. The effect size (95% CI) was 0.8% (95% CI, -2.6 to 4.2%). This was below the clinical equivalence margin of 5%.
Conclusions:
The presence of three or more of the Big Five criteria appears to be equivalently predictive of successful awake extubation in patients with upper respiratory symptoms when compared to patients with no upper respiratory symptoms.
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