The Decision to Extubate in the Intensive Care Unit
- 15 June 2013
- journal article
- review article
- Published by American Thoracic Society in American Journal of Respiratory and Critical Care Medicine
- Vol. 187 (12), 1294-1302
- https://doi.org/10.1164/rccm.201208-1523ci
Abstract
The day of extubation is a critical time during an intensive care unit (ICU) stay. Extubation is usually decided after a weaning readiness test involving spontaneous breathing on a T-piece or low levels of ventilatory assist. Extubation failure occurs in 10 to 20% of patients and is associated with extremely poor outcomes, including high mortality rates of 25 to 50%. There is some evidence that extubation failure can directly worsen patient outcomes independently of underlying illness severity. Understanding the pathophysiology of weaning tests is essential given their central role in extubation decisions, yet few studies have investigated this point. Because extubation failure is relatively uncommon, randomized controlled trials on weaning are underpowered to address this issue. Moreover, most studies evaluated patients at low risk for extubation failure, whose reintubation rates were about 10 to 15%, whereas several studies identified high-risk patients with extubation failure rates exceeding 25 or 30%. Strategies for identifying patients at high risk for extubation failure are essential to improve the management of weaning and extubation. Two preventive measures may prove beneficial, although their exact role needs confirmation: one is noninvasive ventilation after extubation in high-risk or hypercapnic patients, and the other is steroid administration several hours before extubation. These measures might help to prevent postextubation respiratory distress in selected patient subgroups.Keywords
This publication has 81 references indexed in Scilit:
- Noninvasive Ventilation and Weaning in Patients with Chronic Hypercapnic Respiratory FailureAmerican Journal of Respiratory and Critical Care Medicine, 2011
- Central venous saturation is a predictor of reintubation in difficult-to-wean patients*Critical Care Medicine, 2010
- Echocardiography: a help in the weaning processCritical Care, 2010
- A bench study of intensive-care-unit ventilators: new versus old and turbine-based versus compressed gas-based ventilatorsIntensive Care Medicine, 2009
- Respiratory weakness is associated with limb weakness and delayed weaning in critical illness*Critical Care Medicine, 2007
- Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients*Critical Care Medicine, 2005
- Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care UnitJAMA, 2004
- Cough Peak Flows and Extubation OutcomesSocial psychiatry. Sozialpsychiatrie. Psychiatrie sociale, 2003
- Predictors of Extubation Outcome in Patients Who Have Successfully Completed a Spontaneous Breathing TrialSocial psychiatry. Sozialpsychiatrie. Psychiatrie sociale, 2001
- Effect of Intrathoracic Pressure on Left Ventricular PerformanceThe New England Journal of Medicine, 1979