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Published on: July 18, 2025
Evaluating the Association of Extubation Readiness Testing Performance Variables With Reintubation After Pediatric
Matthew J Foglia1, Elizabeth J Thompson1,2, Jennifer I Sherwin1
1Drs. Foglia, Thompson, Sherwin, Allareddy, and Rotta and Mr. Miller are affiliated with the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.
Insights
Extubation readiness tests (ERTs) in children after cardiac surgery did not predict re-intubation. Breathing frequency and tidal volume (VT) during ERTs were not associated with extubation failure in this study.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiovascular Surgery
- Respiratory Physiology
Background:
- Extubation readiness tests (ERTs) guide extubation decisions post-cardiac surgery.
- Current ERT criteria in children lack robust validation.
- This study investigates ERT performance and re-intubation risk.
Purpose of the Study:
- To evaluate the association between ERT parameters and re-intubation in pediatric cardiac surgery patients.
- To determine if higher breathing frequency or lower tidal volume (VT) during ERTs predict extubation failure.
Main Methods:
- Retrospective cohort study of 268 children (<18 years) post-cardiac surgery (STAT category ≥3).
- Invasive mechanical ventilation >24 hours was required for inclusion.
- Primary outcome: extubation failure within 48 hours; secondary: time from ERT to extubation.
Main Results:
- 11.2% of subjects (30/268) experienced extubation failure.
- Higher ERT breathing frequency was observed in the re-intubated group (P=.01).
- Multivariable analysis showed no association between re-intubation and breathing frequency, VT, or RSBI.
Conclusions:
- Final ERT breathing frequency, VT, and RSBI are not predictive of re-intubation in this pediatric cardiac surgery cohort.
- Current ERT criteria may not adequately identify children at risk for extubation failure.
- Further research is needed to refine ERT protocols for this population.
Background:
Patient performance on extubation readiness tests (ERTs) informs the decision to extubate after cardiac surgery. ERT pass criteria at our center include age-based breathing frequencies and weight-adjusted tidal volumes (VT). Evidence validating these criteria in children after cardiac surgery is limited. We hypothesized that higher breathing frequency and/or lower VT during the final ERT prior to extubation, even if meeting pass criteria, would be associated with re-intubation within 48 h.
Methods:
This was an observational, retrospective cohort study involving children <18 years of age receiving invasive mechanical ventilation for >24 h after cardiac surgery for Society of Thoracic Surgery (STAT) Mortality category ≥3 from May 2022 to April 2024. The primary outcome was extubation failure. The secondary outcome was the interval between the first passed ERT and extubation. Factors associated with re-intubation were explored using univariate and multivariable analyses.
Results:
Two hundred sixty-eight subjects met inclusion criteria with a median (interquartile range) age of 58.5 (6.1-210.2) days and weight of 4.2 (3.3-7.5) kg. Thirty (11.2%) subjects experienced extubation failure. These subjects had a higher breathing frequency during the ERT (42 [36-52] vs 36 [28-44] breaths/min, P = .01). On univariate analysis, subjects who required re-intubation were younger, had longer courses of invasive mechanical ventilation, and more frequently received preoperative invasive mechanical ventilation, delayed sternal closure, or were in a higher STAT category. Multivariable analysis revealed no association between re-intubation and breathing frequency (adjusted odds ratio [aOR] = 1.02, 95% CI: 0.99-1.06), VT (aOR = 1.0, 95% CI: 0.78-1.25), or the Rapid Shallow Breathing Index (RSBI; expressed as breathing frequency/VT) (aOR = 1.11, 95% CI: 0.96-1.27). The interval between the first passed ERT and extubation did not differ between groups (1.4 [0.5-3.6] vs 1.2 [0.4-2.4] days, P = .22).
Conclusions:
There was no association between the final ERT breathing frequency, VT, or RSBI and re-intubation within 48 h.
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