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Background: Tracheal extubation is a critical risk phase for patients undergoing general anesthesia and is related to complications for the patient. In Sweden, registered nurse anesthetists and anesthesiologists perform extubations and share responsibility for the patient. While there is research regarding the medical and technical aspects of when to extubate, there is a lack of research regarding the experience of registered nurse anesthetists (RNAs) and anesthesiologists (ANs) and their reasons for deciding when to perform extubation. Clinical judgment is applied in making crucial decisions, and non-technical skills are essential in clinical practice. Aim: To describe and explore registered nurse anesthetists’ and anesthesiologists’ experiences of tracheal extubation in the anesthesia setting. Methods: This thesis was based on interviews with registered nurse anesthetists and anesthesiologists. In Study I, focus group interviews were performed with RNAs (n=20). Individual interviews were conducted with ANs (n=17) in Study II. Both studies employed qualitative content analysis to analyze data. In Study III, individual interviews were conducted with RNAs (n=20) to determine their main concerns during the extubation process. Observation and individual interviews were performed, and data were analyzed using grounded theory. In Study IV, the focus group interviews (Study I) with RNAs (n=20) and individual (Study II) interviews with ANs (n=17), were analyzed using reflexive thematic analysis, with Tanner’s model of clinical judgment as a lens. Findings: The results showed that RNAs (Study I) and ANs (Study II) described extubation as a process that begins when preparing for the anesthesia procedure and meeting the patient. From then, they continuously assessed and prepared the patient for extubation and assembled a unique extubation plan to prevent extubation failure. At extubations, they acted upon recognizable patterns and relied on experience and intuition. The RNAs

Background Sigh breaths may impact outcomes in acute hypoxemic respiratory failure (AHRF) during assisted mechanical ventilation. We investigated whether sigh breaths may impact mortality in predefined subgroups of patients enrolled in the PROTECTION multicenter clinical trial according to: 1.the physiological response in oxygenation to Sigh (responders versus non-responders) and 2.the set levels of positive end-expiratory pressure (PEEP) (High vs. Low-PEEP). If mortality differed between Sigh and No Sigh, we explored physiological daily differences at 7-days. Results Patients were randomized to pressure support ventilation (PSV) with Sigh (Sigh group) versus PSV with no sigh (No Sigh group). (1) Sighs were not associated with differences in 28-day mortality in responders to baseline sigh-test. Contrarily-in non-responders-56 patients were randomized to Sigh (55%) and 28-day mortality was lower with sighs (17%vs.36%, log-rank p = 0.031). (2) In patients with PEEP > 8cmH2O no difference in mortality was observed with sighs. With Low-PEEP, 54 patients were randomized to Sigh (48%). Mortality at 28-day was reduced in patients randomised to sighs (13%vs.31%, log-rank p = 0.021). These findings were robust to multivariable adjustments. Tidal volume, respiratory rate and ventilatory ratio decreased with Sigh as compared with No Sigh at 7-days. Ventilatory ratio was associated with mortality and successful extubation in both non-responders and Low-PEEP. Conclusions Addition of Sigh to PSV could reduce mortality in AHRF non-responder to Sigh and exposed to Low-PEEP. Results in non-responders were not expected. Findings in the low PEEP group may indicate that insufficient PEEP was used or that Low PEEP may be used with Sigh. Sigh may reduce mortality by decreasing physiologic dead space and ventilation intensity and/or optimizing ventilation/perfusion mismatch.

Background: Tracheal extubation is a critical risk phase for patients undergoing general anesthesia and is related to complications for the patient. In Sweden, registered nurse anesthetists and anesthesiologists perform extubations and share responsibility for the patient. While there is research regarding the medical and technical aspects of when to extubate, there is a lack of research regarding the experience of registered nurse anesthetists (RNAs) and anesthesiologists (ANs) and their reasons for deciding when to perform extubation. Clinical judgment is applied in making crucial decisions, and non-technical skills are essential in clinical practice. Aim: To describe and explore registered nurse anesthetists’ and anesthesiologists’ experiences of tracheal extubation in the anesthesia setting. Methods: This thesis was based on interviews with registered nurse anesthetists and anesthesiologists. In Study I, focus group interviews were performed with RNAs (n=20). Individual interviews were conducted with ANs (n=17) in Study II. Both studies employed qualitative content analysis to analyze data. In Study III, individual interviews were conducted with RNAs (n=20) to determine their main concerns during the extubation process. Observation and individual interviews were performed, and data were analyzed using grounded theory. In Study IV, the focus group interviews (Study I) with RNAs (n=20) and individual (Study II) interviews with ANs (n=17), were analyzed using reflexive thematic analysis, with Tanner’s model of clinical judgment as a lens. Findings: The results showed that RNAs (Study I) and ANs (Study II) described extubation as a process that begins when preparing for the anesthesia procedure and meeting the patient. From then, they continuously assessed and prepared the patient for extubation and assembled a unique extubation plan to prevent extubation failure. At extubations, they acted upon recognizable patterns and relied on experience and intuition. The RNAs

Background: Tracheal extubation is a critical risk phase for patients undergoing general anesthesia and is related to complications for the patient. In Sweden, registered nurse anesthetists and anesthesiologists perform extubations and share responsibility for the patient. While there is research regarding the medical and technical aspects of when to extubate, there is a lack of research regarding the experience of registered nurse anesthetists (RNAs) and anesthesiologists (ANs) and their reasons for deciding when to perform extubation. Clinical judgment is applied in making crucial decisions, and non-technical skills are essential in clinical practice. Aim: To describe and explore registered nurse anesthetists’ and anesthesiologists’ experiences of tracheal extubation in the anesthesia setting. Methods: This thesis was based on interviews with registered nurse anesthetists and anesthesiologists. In Study I, focus group interviews were performed with RNAs (n=20). Individual interviews were conducted with ANs (n=17) in Study II. Both studies employed qualitative content analysis to analyze data. In Study III, individual interviews were conducted with RNAs (n=20) to determine their main concerns during the extubation process. Observation and individual interviews were performed, and data were analyzed using grounded theory. In Study IV, the focus group interviews (Study I) with RNAs (n=20) and individual (Study II) interviews with ANs (n=17), were analyzed using reflexive thematic analysis, with Tanner’s model of clinical judgment as a lens. Findings: The results showed that RNAs (Study I) and ANs (Study II) described extubation as a process that begins when preparing for the anesthesia procedure and meeting the patient. From then, they continuously assessed and prepared the patient for extubation and assembled a unique extubation plan to prevent extubation failure. At extubations, they acted upon recognizable patterns and relied on experience and intuition. The RNAs

Assessing extubation readiness and determining the earliest safe time to extubate patients in the Pediatric Intensive Care Unit (PICU) are challenges clinicians face daily. Until recently, no consensus guidelines existed for managing pediatric extubation, and studies have concluded that the decision to extubate ultimately relies on clinician judgment. This variability in care leads to increased morbidity, mortality, and costs, arising from both unnecessary ventilator days due to delayed extubation and from re-intubation following extubation failure. The power of artificial intelligence could be harnessed to optimize identification of extubation readiness in the PICU. Deploying prediction models in the electronic health record (EHR) as clinical decision support tools could safely shorten extubation times by decreasing variation in care and identifying subsets of patients for earlier, safe extubation.The objective of this dissertation is to predict extubation readiness using methods that could be implemented as real-time clinical decision support in a health system. Chapter 1 explores how to handle missing longitudinal data for clinical prediction models. Chapter 2 compares machine learning models built with EHR data to predict extubation readiness. Chapter 3 demonstrates a novel method to integrate expert knowledge directly into machine learning models for this prediction problem. This project will advance extubation practices for critically ill children, yielding a predictive tool ready for prospective testing in the EHR that moves toward delivering high reliability healthcare for patients with respiratory failure.

BACKGROUND: Pneumonia from COVID-19 that results in ARDS may require invasive mechanical ventilation. This retrospective study assessed the characteristics and outcomes of subjects with COVID-19-associated ARDS versus ARDS (non-COVID) during the first 6 months of the COVID-19 pandemic in 2020. The primary objective was to determine whether mechanical ventilation duration differed between these cohorts and identify other potential contributory factors. METHODS: We retrospectively identified 73 subjects admitted between March 1 and August 12, 2020, with either COVID-19-associated ARDS (37) or ARDS (36) who were managed with the lung protective ventilator protocol and required >48 h of mechanical ventilation. Exclusion criteria were the following: <18 years old or the patient required tracheostomy or interfacility transfer. Demographic and baseline clinical data were collected at ARDS onset (ARDS day 0), with subsequent data collected on ARDS days 1-3, 5, 7, 10, 14, and 21. Comparisons were made by using the Wilcoxon rank-sum test (continuous variables) and chi-square test (categorical variables) stratified by COVID-19 status. A Cox proportional hazards model assessed the cause-specific hazard ratio for extubation. RESULTS: The median (interquartile range) mechanical ventilation duration among the subjects who survived to extubation was longer in those with COVID-19-ARDS versus the subjects with non-COVID ARDS: 10 (6-20) d versus 4 (2-8) d; P < .001. Hospital mortality was not different between the two groups (22% vs 39%; P = .11). The competing risks Cox proportional hazard analysis (fit among the total sample, including non-survivors) revealed that improved compliance of the respiratory system and oxygenation were associated with the probability of extubation. Oxygenation improved at a lower rate in the subjects with COVID-19-associated ARDS than in the subjects with non-COVID ARDS. CONCLUSIONS: Mechanical ventilation duration was longer in subjects with COV

Bakgrund och problemformulering: Extubation är ett avgörande moment inom anestesi. När patienten har tillfredsställande andningsmönster så kan trakealtuben tas ut ur patientens luftväg. Inga hundraprocentiga kriterier finns för hur extubationens utfall blir, utan utförs ofta utefter situation. Det är en komplex process som kräver noga övervakning och anpassning till varje patients individuella behov. Att bedöma, etablera och kontrollera luftvägen kräver att anestesisjuksköterskan har kunskap och erfarenhet av multidisciplinärt samarbete och etisk medvetenhet. För att undvika patientlidande är personcentrerad vård nödvändigt och kräver ett förhållningsätt baserat på omtanke. Riskerna för komplikation har inte tydligt minskat under åren och det upplevs svårt att planera och utföra en extubation. Syfte: Syftet var att undersöka anestesisjuksköterskan och anestesiologens erfarenheter av extubation. Metod: En systematisk litteraturöversikt med integrativ metod baserat på kvalitativa och kvantitativa artiklar. Artikelsökningen utfördes i databaser och webbsökning. Totalt inkluderades nio artiklar publicerade mellan år 2006–2022. Kvalitetsgranskning genomfördes utifrån CASP checklista av kvalitativa och randomiserad kontrollerad studie. Resultat: I resultatet framkommer det att erfarenhet är en betydande roll som ger bättre förutsättning för extubationen. Kommunikationsbrist, tidspress och bristande respekt påverkade anestesipersonal under utförandet. Planering och förberedelser är två viktiga faktorer för att underlätta handhavandet av extubation. Diskussion: Erfarenhet har en betydande roll för att skapa förutsättningar för trygghet, respekt och evidensbaserad vård. Anestesisjuksköterskor och anestesiologer har olika erfarenheter om extubation. Genom att öka kunskap gällande upplevelser av anestesipersonalens erfarenheter kan praktiska och teoretiska momentet kring extubering förbättras., Background and Problem Statement: Extubation is a crucial step in anaesthesia. When the patient has a satisfactory breathing pattern, the tracheal tube can be removed from the patient's airway. There are no one-hundred- precent criteria for the outcome of extubation; it is often preformed based on the situation. It is a complex process that requires careful monitoring and adaptation to each patient’s individual needs. Assessing, establishing and controlling the airway require that the anaesthesia nurse possesses knowledge and experience with multidisciplinary collaboration and ethical awareness. To avoid patient suffering, person-centred care is necessary, which requires an approach based on compassion. The risk of complications has not clearly decreased over the years, and planning and preforming an extubation are often perceived as challenging. Aim: The aim was to examine the anesthesia nurse and the anesthesiologist's experiences with extubation. Method: A systematic literature review using an integrative method based on qualitative and quantitative articles. Articles searches were conducted in the databases Cinahl, PubMed and Scopus, as well through web searches. A total of nine articles published between 2006 and 2022 were included. Quality assessment was preformed using CASP checklist for qualitative and randomised controlled studies. Results: The results indicate that experience is a significant factor that provides better conditions for successful extubation. Communication problems, time pressure and lack of respect affected anaesthesia personnel during the procedure. Planning and preparing are two important factors that facilitate the management of extubation. Discussion: Experience plays a significant role in creating conditions for safety, respect and evidence-based care. Anaesthesia nurses and anaesthesiologist have mixed options about extubations. By increasing knowledge about the experiences of anaesthesia personnel, both the practical and theoretical

SAMMANFATTNINGBakgrund: Specialistsjuksköterskor anser att extubation är svårare och mer komplext än intubation. Extubation kräver mycket fokus på patientens fysiska behov vilket kan försvåra för vårdpersonal att uppfylla patientens psykosociala behov. Forskning visar att patienter har obehagliga minnen från att vara intuberade och bli extuberade. Syftet: Syftet var att undersöka hur patienten görs delaktig vid extubation på intensivvårdsavdelning. Metod: Designen var en fokuserad etnografiskt observationsstudie med deduktiv ansats. Urvalet var patienter som opererades elektivt och vårdades postoperativt på Thoraxintensivvårdsavdelning vid ett universitetssjukhus. Tio patienter observerades när de blev extuberade av intensivvårdspersonalen. Sedan utfördes en semistrukturerad intervju om patientens erfarenhet av att bli extuberad och om de kände sig delaktiga. Resultat: För att göra patienten delaktig gav personalen information, var stöttande, närvarande och respekterade patientens värdighet och integritet. Detta gjorde personalen genom fysisk beröring, att benämna patienten med namn, samt att utföra extubation avskilt. Resultatet kan inte säkerställa att det går att etablera en vårdrelation under extubation då en vårdrelation endast etablerades vid två av tio tillfällen. Majoriteten av patienterna hade inga minnen av att bli extuberade. Slutsats: Personalen gjorde patienterna delaktiga under extubation genom att ge information, vara närvarande och stöttande samt genom att visa patienten värdighet och respekt. Patienterna kunde göras delaktiga utan att en vårdrelation etablerades, detta tyder på att begreppet vårdrelation behöver en tydligare definition. Trots att majoriteten av deltagarna inte hade minnen från extubationen bör de göras delaktiga., Background: Specialist nurses consider extubation more difficult and complext than intubation. Extubation requires a lot of focus on the patient's physical needs, which can prove it difficult for specialist nurses to fulfill the patient's psychosocial needs. Research shows that patients have unpleasant memories of being intubated and being extubated. Aim: The aim was to investigate how patient participation was fulfilled during extubation in a intensive care unit. Method: The design was a focused ethnographic observational study with a deductive approach. The sample was patients who underwent elective surgery and received postoperative care in the thoracic intensive care unit in a university hospital. Ten patients were observed as they were extubated by the intensive care personnel. A semi-structured interview was then conducted about the patient's experience of being extubated and whether they felt involved. Main result: To increase the patience participation, the staff were informative and supportive, present and respected the patient's dignity and privacy. Staff did this through physical touch, calling the patient by name, and performing extubation separately. The results cannot ensure that it is possible to establish a care relationship during extubation as a care relationship was only established on two out of ten occasions. The majority of patients had no memory of being extubated. Conclusion: Patient participation during extubation can be achieved through information, staff presence and support. It’s possible to achieve patientparticipant without establishing a caring relationship. The majority of participants did not have memories of extubation, however, patient participation should still be achieved.

SAMMANFATTNINGBakgrund: Specialistsjuksköterskor anser att extubation är svårare och mer komplext än intubation. Extubation kräver mycket fokus på patientens fysiska behov vilket kan försvåra för vårdpersonal att uppfylla patientens psykosociala behov. Forskning visar att patienter har obehagliga minnen från att vara intuberade och bli extuberade. Syftet: Syftet var att undersöka hur patienten görs delaktig vid extubation på intensivvårdsavdelning. Metod: Designen var en fokuserad etnografiskt observationsstudie med deduktiv ansats. Urvalet var patienter som opererades elektivt och vårdades postoperativt på Thoraxintensivvårdsavdelning vid ett universitetssjukhus. Tio patienter observerades när de blev extuberade av intensivvårdspersonalen. Sedan utfördes en semistrukturerad intervju om patientens erfarenhet av att bli extuberad och om de kände sig delaktiga. Resultat: För att göra patienten delaktig gav personalen information, var stöttande, närvarande och respekterade patientens värdighet och integritet. Detta gjorde personalen genom fysisk beröring, att benämna patienten med namn, samt att utföra extubation avskilt. Resultatet kan inte säkerställa att det går att etablera en vårdrelation under extubation då en vårdrelation endast etablerades vid två av tio tillfällen. Majoriteten av patienterna hade inga minnen av att bli extuberade. Slutsats: Personalen gjorde patienterna delaktiga under extubation genom att ge information, vara närvarande och stöttande samt genom att visa patienten värdighet och respekt. Patienterna kunde göras delaktiga utan att en vårdrelation etablerades, detta tyder på att begreppet vårdrelation behöver en tydligare definition. Trots att majoriteten av deltagarna inte hade minnen från extubationen bör de göras delaktiga., Background: Specialist nurses consider extubation more difficult and complext than intubation. Extubation requires a lot of focus on the patient's physical needs, which can prove it difficult for specialist nurses to fulfill the patient's psychosocial needs. Research shows that patients have unpleasant memories of being intubated and being extubated. Aim: The aim was to investigate how patient participation was fulfilled during extubation in a intensive care unit. Method: The design was a focused ethnographic observational study with a deductive approach. The sample was patients who underwent elective surgery and received postoperative care in the thoracic intensive care unit in a university hospital. Ten patients were observed as they were extubated by the intensive care personnel. A semi-structured interview was then conducted about the patient's experience of being extubated and whether they felt involved. Main result: To increase the patience participation, the staff were informative and supportive, present and respected the patient's dignity and privacy. Staff did this through physical touch, calling the patient by name, and performing extubation separately. The results cannot ensure that it is possible to establish a care relationship during extubation as a care relationship was only established on two out of ten occasions. The majority of patients had no memory of being extubated. Conclusion: Patient participation during extubation can be achieved through information, staff presence and support. It’s possible to achieve patientparticipant without establishing a caring relationship. The majority of participants did not have memories of extubation, however, patient participation should still be achieved.

BackgroundDespite decades of research on predictors of extubation success, use of ventilatory support after extubation is common and 10-20% of patients require re-intubation. Proportional assist ventilation (PAV) mode automatically calculates estimated total work of breathing (total WOB). Here, we assessed the performance of total WOB to predict extubation failure in invasively ventilated subjects.MethodsThis prospective observational study was conducted in 6 adult ICUs at an academic medical center. We enrolled intubated subjects who successfully completed a spontaneous breathing trial, had a rapid shallow breathing index < 105 breaths/min/L, and were deemed ready for extubation by the primary team. Total WOB values were recorded at the end of a 30-min PAV trial. Extubation failure was defined as any respiratory support and/or re-intubation within 72 h of extubation. We compared total WOB scores between groups and performance of total WOB for predicting extubation failure with receiver operating characteristic curves.ResultsOf 61 subjects enrolled, 9.8% (n = 6) required re-intubation, and 50.8% (n = 31) required any respiratory support within 72 h of extubation. Median total WOB at 30 min on PAV was 0.9 J/L (interquartile range 0.7-1.3 J/L). Total WOB was significantly different between subjects who failed or were successfully extubated (median 1.1 J/L vs 0.7 J/L, P = .004). The area under the curve was 0.71 [95% CI 0.58-0.85] for predicting any requirement of respiratory support and 0.85 [95% CI 0.69-1.00] for predicting re-intubation alone within 72 h of extubation. Total WOB cutoff values maximizing sensitivity and specificity equally were 1.0 J/L for any respiratory support (positive predictive value [PPV] 70.0%, negative predictive value [NPV] 67.7%) and 1.3 J/L for re-intubation (PPV 26.3%, NPV 97.6%).ConclusionsThe discriminative performance of a PAV-derived total WOB value to predict extubation failure was good, indicating total WOB may represent an adju

Bakgrund och problemformulering: Extubation är ett avgörande moment inom anestesi. När patienten har tillfredsställande andningsmönster så kan trakealtuben tas ut ur patientens luftväg. Inga hundraprocentiga kriterier finns för hur extubationens utfall blir, utan utförs ofta utefter situation. Det är en komplex process som kräver noga övervakning och anpassning till varje patients individuella behov. Att bedöma, etablera och kontrollera luftvägen kräver att anestesisjuksköterskan har kunskap och erfarenhet av multidisciplinärt samarbete och etisk medvetenhet. För att undvika patientlidande är personcentrerad vård nödvändigt och kräver ett förhållningsätt baserat på omtanke. Riskerna för komplikation har inte tydligt minskat under åren och det upplevs svårt att planera och utföra en extubation. Syfte: Syftet var att undersöka anestesisjuksköterskan och anestesiologens erfarenheter av extubation. Metod: En systematisk litteraturöversikt med integrativ metod baserat på kvalitativa och kvantitativa artiklar. Artikelsökningen utfördes i databaser och webbsökning. Totalt inkluderades nio artiklar publicerade mellan år 2006–2022. Kvalitetsgranskning genomfördes utifrån CASP checklista av kvalitativa och randomiserad kontrollerad studie. Resultat: I resultatet framkommer det att erfarenhet är en betydande roll som ger bättre förutsättning för extubationen. Kommunikationsbrist, tidspress och bristande respekt påverkade anestesipersonal under utförandet. Planering och förberedelser är två viktiga faktorer för att underlätta handhavandet av extubation. Diskussion: Erfarenhet har en betydande roll för att skapa förutsättningar för trygghet, respekt och evidensbaserad vård. Anestesisjuksköterskor och anestesiologer har olika erfarenheter om extubation. Genom att öka kunskap gällande upplevelser av anestesipersonalens erfarenheter kan praktiska och teoretiska momentet kring extubering förbättras., Background and Problem Statement: Extubation is a crucial step in anaesthesia. When the patient has a satisfactory breathing pattern, the tracheal tube can be removed from the patient's airway. There are no one-hundred- precent criteria for the outcome of extubation; it is often preformed based on the situation. It is a complex process that requires careful monitoring and adaptation to each patient’s individual needs. Assessing, establishing and controlling the airway require that the anaesthesia nurse possesses knowledge and experience with multidisciplinary collaboration and ethical awareness. To avoid patient suffering, person-centred care is necessary, which requires an approach based on compassion. The risk of complications has not clearly decreased over the years, and planning and preforming an extubation are often perceived as challenging. Aim: The aim was to examine the anesthesia nurse and the anesthesiologist's experiences with extubation. Method: A systematic literature review using an integrative method based on qualitative and quantitative articles. Articles searches were conducted in the databases Cinahl, PubMed and Scopus, as well through web searches. A total of nine articles published between 2006 and 2022 were included. Quality assessment was preformed using CASP checklist for qualitative and randomised controlled studies. Results: The results indicate that experience is a significant factor that provides better conditions for successful extubation. Communication problems, time pressure and lack of respect affected anaesthesia personnel during the procedure. Planning and preparing are two important factors that facilitate the management of extubation. Discussion: Experience plays a significant role in creating conditions for safety, respect and evidence-based care. Anaesthesia nurses and anaesthesiologist have mixed options about extubations. By increasing knowledge about the experiences of anaesthesia personnel, both the practical and theoretical

IMPORTANCE: Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality. OBJECTIVES: We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF. DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included. MAIN OUTCOMES AND MEASURES: We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported. RESULTS: Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality. CONCLUSION AND RELEVANCE: Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducin

Background: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. Aim: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. Participants: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). Method: A classic grounded theory approach with a qualitative design was used for this study. Findings: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged. Conclusion: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Background: Sedatives used during thoracic and abdominal surgery may affect hemodynamics, patient extubation time, length of stay in the intensive care unit, and the incidence of delirium. Aim: Perioperative assessment of the level sedation with propofol and dexmedetomidine, their effect on hemodynamics with determination of non-invasive cardiac output (esCCO), extubation time, duration of stay in ICU department and frequency of postoperative delirium. Methods: The study included 121 patients over 18 years of age who underwent thoracic and abdominal surgery and received dexmedetomidine or propofol infusion for sedation in the perioperative period. The main result of the study was the determination of extubation time and indicators of non-invasive monitoring of hemodynamics with measurement of cardiac output (esCCO) using the Nihon Kohden monitor. Secondary results of the study were the length of stay in the intensive care unit and hospital, the frequency of delirium. Results. Dexmedetomidine usage (n=52) as an intraoperative and postoperative sedative as opposed to propofol (n=69) was associated with a higher probability of extubation (HR=1.65, 95% CI =1.23–2.21, P=0.001). The longer duration of the operation was associated with a decrease in the probability of extubation (HR=0.83, 95% CI=0.62-0.94, P=0.029), and elderly patients were less likely to rapid extubation (HR=0.73; 95% CI=0.62-0.94, P=0.005). Baseline noninvasive cardiac output parameters of propofol and dexmedetomidine patients were 5.9±1.1 l/min and 6.1±0.6 l/min, respectively. At the end of the operation, the CO values were lower than baseline in patients in the propofol and dexmedetomidine groups by 11.9 % and 6.6 %, respectively. There was no significant association between dexmedetomidine use and length of stay in intensive care, or discharge from hospital (P=0.99 and P=0.54, respectively) and the incidence of delirium in ICU department (P=0.25). Conclusion: Perioperative use of dexmedetomidine was

Background: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. Aim: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. Participants: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). Method: A classic grounded theory approach with a qualitative design was used for this study. Findings: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged. Conclusion: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Neuromuscular Diseases (NMD) are a group of very heterogeneous nosological entities characterized by a primary or secondary alteration of the musculoskeletal cell. Peripheral nervous system or neuromuscular diseases present with varied symptoms, such as muscle weakness, pain, loss of sensation, difficulty walking, musculoskeletal alterations in the upper airway that can impede adequate ventilation, some diseases can also affect the functioning of the respiratory and even cardiac systems, the subject may require assisted respiration and life support. Even without the need to face a planned surgical procedure, as a consequence, they cause physical disability and demand specialized medical attention., Las Enfermedades Neuromusculares (ENM) son un grupo de entidades nosológicas muy heterogéneas caracterizadas por una alteración primaria o secundaria de la célula músculo-esquelética. Las enfermedades del sistema nervioso periférico o neuromusculares se presentan con síntomas variados, como debilidad muscular, dolor, pérdida de la sensibilidad, dificultad para caminar, alteraciones musculo esqueléticas en la vía aérea superior que pueden dificultar la ventilación adecuada, algunas enfermedades pueden afectar también al funcionamiento del sistema respiratorio e incluso del cardíaco, pudiendo el sujeto precisar de respiración asistida y soporte vital. Incluso sin la necesidad de enfrentar un procedimiento quirúrgico planificado, como consecuencia, causan discapacidad física y demandan atención médica especializada.

Purpose: Neurocritical care patients receive prolonged invasive mechanical ventilation (IMV), but there is poor specific information in this high-risk population about the liberation strategies of invasive mechanical ventilation. Methods: ENIO (NCT03400904) is an international, prospective observational study, in 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Neurocritical care patients with a Glasgow Coma Score (GCS) ≤ 12, receiving IMV ≥ 24 h, undergoing extubation attempt or tracheostomy were included. The primary endpoint was extubation failure by day 5. An extubation success prediction score was created, with 2/3 of patients randomly allocated to the training cohort and 1/3 to the validation cohort. Secondary endpoints were the duration of IMV and in-ICU mortality. Results: 1512 patients were included. Among the 1193 (78.9%) patients who underwent an extubation attempt, 231 (19.4%) failures were recorded. The score for successful extubation prediction retained 20 variables as independent predictors. The area under the curve (AUC) in the training cohort was 0.79 95% confidence interval (CI95) [0.71–0.87] and 0.71 CI95 [0.61–0.81] in the validation cohort. Patients with extubation failure displayed a longer IMV duration (14 [7–21] vs 6 [3–11] days) and a higher in-ICU mortality rate (8.7% vs 2.4%). Three hundred and nineteen (21.1%) patients underwent tracheostomy without extubation attempt. Patients with direct tracheostomy displayed a longer duration of IMV and higher in-ICU mortality than patients with an extubation attempt (success and failure). Conclusions: In neurocritical care patients, extubation failure is high and is associated with unfavourable outcomes. A score could predict extubation success in multiple settings. However, it will be mandatory to validate our findings in another prospective independent cohort.

Background: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. Aim: To obtain a deeper understanding of Registered Nurse Anesthetists’ main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. Participants: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). Method: A classic grounded theory approach with a qualitative design was used for this study. Findings: The RNAs’ main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: ‘Having a back-up plan’, ‘Getting into the right frame of mind’, ‘Evaluating the patient’s reactions’, ‘Using one’s own experience’, ‘Dealing with uncertainty’, ‘Pressure from others’, and ‘Being interrupted’. The theory, Safeguarding the patient in the process of extubation, emerged. Conclusion: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

BACKGROUND: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. AIM: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. PARTICIPANTS: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). METHOD: A classic grounded theory approach with a qualitative design was used for this study. FINDINGS: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged. CONCLUSION: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Aim: To determine predictors and outcomes of extubation failure in extremely preterm (EP) infants born <28 weeks' gestational age (GA). Method(s): Retrospective clinical audit across two tertiary-level neonatal intensive care units in Melbourne, Australia. Two-hundred and four EP infants who survived to their first extubation from mechanical ventilation. Extubation failure (re-intubation) within 7 days after the first extubation. Result(s): Lower GA (odds ratio [OR] 0.71, 95% confidence interval (CI), 0.61-0.89, P < 0.001) and higher pre-extubation measured mean airway pressure (MAP) on the mechanical ventilator (OR 1.9 [95% CI 1.41-2.51], P < 0.001) predicted extubation failure. The area under a receiver operating characteristic curve for GA and MAP was 0.77 (95% CI 0.70-0.82). After adjustment for GA, infants who experienced extubation failure had higher rates of bronchopulmonary dysplasia (P < 0.001), post-natal systemic corticosteroid treatment (P < 0.001), airway trauma (P < 0.003), longer durations of treatment with mechanical ventilation (P < 0.001), non-invasive respiratory support (P < 0.001), supplemental oxygen therapy (P = 0.05) and longer hospitalisation (P = 0.025). Conclusion(s): Lower GA and higher pre-extubation measured MAP were predictive of extubation failure within 7 days in extremely preterm infants. Extubation failure was associated with increased morbidity and extended periods of respiratory support and hospitalisation.Copyright © 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Aim: To determine predictors and outcomes of extubation failure in extremely preterm (EP) infants born <28 weeks' gestational age (GA). Method(s): Retrospective clinical audit across two tertiary-level neonatal intensive care units in Melbourne, Australia. Two-hundred and four EP infants who survived to their first extubation from mechanical ventilation. Extubation failure (re-intubation) within 7 days after the first extubation. Result(s): Lower GA (odds ratio [OR] 0.71, 95% confidence interval (CI), 0.61-0.89, P < 0.001) and higher pre-extubation measured mean airway pressure (MAP) on the mechanical ventilator (OR 1.9 [95% CI 1.41-2.51], P < 0.001) predicted extubation failure. The area under a receiver operating characteristic curve for GA and MAP was 0.77 (95% CI 0.70-0.82). After adjustment for GA, infants who experienced extubation failure had higher rates of bronchopulmonary dysplasia (P < 0.001), post-natal systemic corticosteroid treatment (P < 0.001), airway trauma (P < 0.003), longer durations of treatment with mechanical ventilation (P < 0.001), non-invasive respiratory support (P < 0.001), supplemental oxygen therapy (P = 0.05) and longer hospitalisation (P = 0.025). Conclusion(s): Lower GA and higher pre-extubation measured MAP were predictive of extubation failure within 7 days in extremely preterm infants. Extubation failure was associated with increased morbidity and extended periods of respiratory support and hospitalisation.Copyright © 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Introduction: Respiratory care of extremely preterm infants remains a challenge. The majority require invasive mechanical ventilation (MV), which is a contributing factor in developing bronchopulmonary dysplasia (BPD). It is important to keep MV to a minimum but there have been concerns that attempting extubation too early increases the risk for atelectasis, re-intubation, and further lung trauma. The aim of this study was to compare two different approaches to extubation. Methods: Single-center, retrospective cohort study including infants born at 22 + 0-25 + 6 weeks during 2005-2009 and 2011-2015, before and after implementing guidelines recommending delayed extubation. Primary outcomes were BPD, duration of MV and length of hospital stay. Results: Eighty-eight infants in the early era and 102 infants in the late era were included. Infants in the first period were younger at first extubation attempt, and a higher number of infants were extubated within 24 h, 72 h, and one week after birth. The number of infants re-intubated and postnatal age at re-intubation did not differ between the groups. The incidence of severe BPD was 28% in the early period compared to 48% in the later (p < 0.01). Infants in the late period had longer duration of MV (17 vs 27 days, p < 0.01) but similar length of hospital stay (118 vs 123, p = 0.21). Conclusion: After implementing guidelines recommending delayed extubation, the incidence of severe BPD was higher and the duration of MV was longer. This supports the strategy to attempt extubation early even in extremely preterm infants.

Background: Spontaneous breathing trial (SBT) has been used to predict the optimal time of weaning from ventilator. However, it remains controversial which trial should be preferentially selected. We aimed to compare and rank four common SBT modes including automatic tube compensation (ATC), pressure support ventilation (PSV), continuous positive airway pressure (CPAP), and T-piece among critically ill patients receiving mechanical ventilation (MV).Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies that investigated the comparative efficacy and safety of at least two SBT strategies among critically ill patients up to May 17, 2020. We estimated the surface under the cumulative ranking curve (SUCRA) to rank SBT techniques, and determined the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation method. Primary outcome was weaning success. Secondary outcomes were reintubation, SBT success, duration of acute care, and intensive care unit (ICU) mortality. Statistical analysis was conducted by using RevMan 5.4, Stata, and R software.Results: We enrolled 24 trials finally. Extubation success rate was significantly higher in ATC than that in T-piece (OR, 0.28; 95% CI, 0.13-0.64) or PSV (OR, 0.53; 95% CI, 0.32-0.88). For SBT success, ATC was better than other SBT techniques, with a pooled OR ranging from 0.17 to 0.42. For reintubation rate, CPAP was worse than T-piece (OR, 2.76; 95% CI, 1.08 to 7.06). No significant difference was detected between SBT modes for the length of stay in ICU or long-term weaning unit (LWU). Similar result was also found for ICU mortality between PSV and T-piece. Majority direct results were confirmed by network meta-analysis. Besides, AT

© 2020 Elsevier B.V. Background and Objective: To increase the success rate of invasive mechanical ventilation weaning in critically ill patients using Machine Learning models capable of accurately predicting the outcome of programmed extubations. Methods: The study population was adult patients admitted to the Intensive Care Unit. Target events were programmed extubations, both successful and failed. The working dataset is assembled by combining heterogeneous data including time series from Clinical Information Systems, patient demographics, medical records and respiratory event logs. Three classification learners have been compared: Logistic Discriminant Analysis, Gradient Boosting Method and Support Vector Machines. Standard methodologies have been used for preprocessing, hyperparameter tuning and resampling. Results: The Support Vector Machine classifier is found to correctly predict the outcome of an extubation with a 94.6% accuracy. Contrary to current decision-making criteria for extubation based on Spontaneous Breathing Trials, the classifier predictors only require monitor data, medical entry records and patient demographics. Conclusions: Machine Learning-based tools have been found to accurately predict the extubation outcome in critical patients with invasive mechanical ventilation. The use of this important predictive capability to assess the extubation decision could potentially reduce the rate of extubation failure, currently at 9%. With about 40% of critically ill patients eventually receiving invasive mechanical ventilation during their stay and given the serious potential complications associated to reintubation, the excellent predictive ability of the model presented here suggests that Machine Learning techniques could significantly improve the clinica

El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete., Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency.

The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts: 1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds; 2. The widely held belief that positive-pressure ventilation by mask can "break" laryngospasm is not supported by the otorhinolaryngology literature. We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.

Background: Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression. Case Description: Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches. Conclusion(s): To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.Copyright © 2020 Elsevier Inc.

Background: Extubation failure is common in extremely preterm (EP, <28 weeks' gestation) infants. Loss of functional residual capacity soon after extubation may contribute. We aimed to evaluate the relationship between pre-extubation mean airway pressure (MAP), post-extubation nasal continuous positive airway pressure (nCPAP) and extubation failure. Method(s): Two centre retrospective audit of the first extubation of EP infants conducted over a 2-year period. Extubation failure was defined as reintubation within 7 days. Result(s): Ninety-six of 204 (48%) infants required reintubation. In a multivariable regression model MAP was the only significant ventilation parameter affecting extubation success. A pre-extubation MAP >8 cm H2O was associated with extubation failure (F [5,198] = 6.9, p < 0.001). We also saw a relationship between pre-extubation MAP and post-extubation nCPAP level. Infants extubated to a pressure lower than the pre-extubation MAP were more likely to have extubation failure. Conclusion(s): In EP infants, it may be prudent use a nCPAP level at least equal to the set MAP on the mechanical ventilator.

Aim: To describe the first Australian cases of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) disease (COVID-19) pneumonia treated with the interleukin-6 receptor antagonist tocilizumab. Method(s): Retrospective, open-label, real-world, uncontrolled, single-arm case series conducted in 2 tertiary hospitals in NSW, Australia and 1 tertiary hospital in Victoria, Australia. Five adult male patients aged between 46 and 74 years with type 1 respiratory failure due to COVID-19 pneumonia requiring intensive care unit (ICU) admission and biochemical evidence of systemic hyperinflammation (C-reactive protein greater than 100 mg/L; ferritin greater than 700 mug/L) were administered variable-dose tocilizumab. Result(s): At between 13 and 26 days follow-up, all patients are alive and have been discharged from ICU. Two patients have been discharged home. Two patients avoided endotracheal intubation. Oxygen therapy has been ceased in three patients. Four adverse events potentially associated with tocilizumab therapy occurred in three patients: ventilator-associated pneumonia, bacteremia associated with central venous catheterization, myositis and hepatitis. All patients received broad-spectrum antibiotics, 4 received corticosteroids and 2 received both lopinavir/ritonavir and hydroxychloroquine. The time from first tocilizumab administration to improvement in ventilation, defined as a 25% reduction in fraction of inspired oxygen required to maintain peripheral oxygen saturation greater than 92%, ranged from 7 hours to 4.6 days. Conclusion(s): Tocilizumab use was associated with favorable clinical outcome in our patients. We recommend tocilizumab be included in randomized controlled trials of treatment for patients with severe COVID-19 pneumonia, and be considered for compassionate use in such patients pending the results of these trials.Copyright © 2020 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd

Background: The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa) and derived variables to explain the response to a fluid bolus. Method(s): The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa, the volume efficiency (Evol), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. Result(s): Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P =.03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P =.04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 =.48, P <.001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r =.55, P <.001). Conclusion(s): The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.Copyright © 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

Background: Extremely preterm infants born <28 weeks gestation often require invasive mechanical ventilation. To avoid bronchopulmonary dysplasia and other morbidities, clinicians aim to extubate to non-invasive respiratory support as soon as possible. However, extubation failure occurs in up to 60% of extremely preterm infants. Our aim was to compare non-invasive respiratory support modes used post-extubation in extremely preterm infants. Method(s): A systematic review performed according to PRISMA guidelines using Cochrane Neonatal Review Group methods. Data were pooled and analysed using Review Manager v5. Result(s): Five respiratory support modes were identified: nasal continuous positive airway pressure (nCPAP), nasal intermittent positive pressure ventilation (NIPPV), nasal high-flow (nHF), nasal high frequency oscillatory ventilation (nHFOV), and noninvasive neurally-adjusted ventilatory assistance (NI-NAVA). Twenty-three eligible studies were included in the quantitative synthesis. NIPPV delivered using any mode reduced risk of reintubation (RR 0.86 [95% CI 0.79, 0.94]). The effect was more pronounced in a subgroup of trials in which NIPPV was synchronized and delivered by a ventilator (RR 0.22 [95% CI 0.14, 0.37]). Nasal CPAP was superior to nHF in preventing reintubation (RR,-0.04 [95% CI,-0.08,-0.01]). Two small trials compared nCPAP using standard pressures with nHFOV and higher pressure nCPAP; both were underpowered, and no definitive recommendations could be made. No RCTs evaluated NI-NAVA. Conclusion(s): NIPPV when synchronised and ventilator derived may be superior than nCPAP when extubating extremely preterm infants. Promising new modes of respiratory support (nHFOV and NI-NAVA) require further evaluation before widespread use.

Background: This study aimed to compare recommendations in the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient with measured energy expenditure in obese, critically ill adults. Method(s): After enrollment, measured energy expenditure was attempted at baseline and twice weekly to extubation or day 14. Data are reported as median [interquartile range]. Result(s): Twenty patients were included. The median baseline and subsequent measured energy expenditures were 2438 [1807-2703] kcal and 2919 [2318-3362] kcal, respectively. Baseline measured energy expenditures were -491 [-788 to -323] kcal lower than subsequent measurements, and week 1 measurements were lower than those of week 2. The median bias between the guideline recommendation of 11-14 kcal/kg of actual body weight and measured expenditure at baseline was -950 [-1254 to -595] kcal/d and -1618 [-1820 to -866] kcal/d at subsequent measurements. Conclusion(s): Clinically significant variation was observed between measured expenditure and guideline recommendations at all time points.Copyright © 2020 American Society for Parenteral and Enteral Nutrition

Background: Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression. Case Description: Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches. Conclusion(s): To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.Copyright © 2020 Elsevier Inc.

Aim: To describe the first Australian cases of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) disease (COVID-19) pneumonia treated with the interleukin-6 receptor antagonist tocilizumab. Method(s): Retrospective, open-label, real-world, uncontrolled, single-arm case series conducted in 2 tertiary hospitals in NSW, Australia and 1 tertiary hospital in Victoria, Australia. Five adult male patients aged between 46 and 74 years with type 1 respiratory failure due to COVID-19 pneumonia requiring intensive care unit (ICU) admission and biochemical evidence of systemic hyperinflammation (C-reactive protein greater than 100 mg/L; ferritin greater than 700 mug/L) were administered variable-dose tocilizumab. Result(s): At between 13 and 26 days follow-up, all patients are alive and have been discharged from ICU. Two patients have been discharged home. Two patients avoided endotracheal intubation. Oxygen therapy has been ceased in three patients. Four adverse events potentially associated with tocilizumab therapy occurred in three patients: ventilator-associated pneumonia, bacteremia associated with central venous catheterization, myositis and hepatitis. All patients received broad-spectrum antibiotics, 4 received corticosteroids and 2 received both lopinavir/ritonavir and hydroxychloroquine. The time from first tocilizumab administration to improvement in ventilation, defined as a 25% reduction in fraction of inspired oxygen required to maintain peripheral oxygen saturation greater than 92%, ranged from 7 hours to 4.6 days. Conclusion(s): Tocilizumab use was associated with favorable clinical outcome in our patients. We recommend tocilizumab be included in randomized controlled trials of treatment for patients with severe COVID-19 pneumonia, and be considered for compassionate use in such patients pending the results of these trials.Copyright © 2020 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd

Background: The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa) and derived variables to explain the response to a fluid bolus. Method(s): The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa, the volume efficiency (Evol), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. Result(s): Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P =.03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P =.04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 =.48, P <.001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r =.55, P <.001). Conclusion(s): The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.Copyright © 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

Background: Extubation failure is common in extremely preterm (EP, <28 weeks' gestation) infants. Loss of functional residual capacity soon after extubation may contribute. We aimed to evaluate the relationship between pre-extubation mean airway pressure (MAP), post-extubation nasal continuous positive airway pressure (nCPAP) and extubation failure. Method(s): Two centre retrospective audit of the first extubation of EP infants conducted over a 2-year period. Extubation failure was defined as reintubation within 7 days. Result(s): Ninety-six of 204 (48%) infants required reintubation. In a multivariable regression model MAP was the only significant ventilation parameter affecting extubation success. A pre-extubation MAP >8 cm H2O was associated with extubation failure (F [5,198] = 6.9, p < 0.001). We also saw a relationship between pre-extubation MAP and post-extubation nCPAP level. Infants extubated to a pressure lower than the pre-extubation MAP were more likely to have extubation failure. Conclusion(s): In EP infants, it may be prudent use a nCPAP level at least equal to the set MAP on the mechanical ventilator.

Background: Extremely preterm infants born <28 weeks gestation often require invasive mechanical ventilation. To avoid bronchopulmonary dysplasia and other morbidities, clinicians aim to extubate to non-invasive respiratory support as soon as possible. However, extubation failure occurs in up to 60% of extremely preterm infants. Our aim was to compare non-invasive respiratory support modes used post-extubation in extremely preterm infants. Method(s): A systematic review performed according to PRISMA guidelines using Cochrane Neonatal Review Group methods. Data were pooled and analysed using Review Manager v5. Result(s): Five respiratory support modes were identified: nasal continuous positive airway pressure (nCPAP), nasal intermittent positive pressure ventilation (NIPPV), nasal high-flow (nHF), nasal high frequency oscillatory ventilation (nHFOV), and noninvasive neurally-adjusted ventilatory assistance (NI-NAVA). Twenty-three eligible studies were included in the quantitative synthesis. NIPPV delivered using any mode reduced risk of reintubation (RR 0.86 [95% CI 0.79, 0.94]). The effect was more pronounced in a subgroup of trials in which NIPPV was synchronized and delivered by a ventilator (RR 0.22 [95% CI 0.14, 0.37]). Nasal CPAP was superior to nHF in preventing reintubation (RR,-0.04 [95% CI,-0.08,-0.01]). Two small trials compared nCPAP using standard pressures with nHFOV and higher pressure nCPAP; both were underpowered, and no definitive recommendations could be made. No RCTs evaluated NI-NAVA. Conclusion(s): NIPPV when synchronised and ventilator derived may be superior than nCPAP when extubating extremely preterm infants. Promising new modes of respiratory support (nHFOV and NI-NAVA) require further evaluation before widespread use.

Background: This study aimed to compare recommendations in the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient with measured energy expenditure in obese, critically ill adults. Method(s): After enrollment, measured energy expenditure was attempted at baseline and twice weekly to extubation or day 14. Data are reported as median [interquartile range]. Result(s): Twenty patients were included. The median baseline and subsequent measured energy expenditures were 2438 [1807-2703] kcal and 2919 [2318-3362] kcal, respectively. Baseline measured energy expenditures were -491 [-788 to -323] kcal lower than subsequent measurements, and week 1 measurements were lower than those of week 2. The median bias between the guideline recommendation of 11-14 kcal/kg of actual body weight and measured expenditure at baseline was -950 [-1254 to -595] kcal/d and -1618 [-1820 to -866] kcal/d at subsequent measurements. Conclusion(s): Clinically significant variation was observed between measured expenditure and guideline recommendations at all time points.Copyright © 2020 American Society for Parenteral and Enteral Nutrition

Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency., El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete.

Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency., El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete.

Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency., El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete.

Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency., El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete.

Weaning from mechanical ventilation is the process of disconnecting or removing artificial ventilatory support. There are no absolute criteria to prevent a failed weaning or without complications but it is advisable to use protocols with their pre-dictors and weaning criteria to minimize unwanted consequences. The objective was to establish the knowledge, attitudes and practices of respiratory care professionals in the weaning of mechanical ventilation in public and private centers in the city of Guayaquil. The research design was quantitative, not experimental, transversal, observational, with a descriptive approach. The sample consisted of 214 respiratory therapists from 6 private clinics and 8 public hospitals in the city of Guayaquil to which a survey of sixteen questions was applied as a data collection instrument. As a result, it was obtained that 58% of therapists use weaning protocols, ensuring that 98% of cases are indicated by the doctor and only 2% per-form weaning on their own decision. Regarding the evaluation of the hemodynamics of the patient, 88.3% of respiratory therapists expressed using the Tobin index, respiratory rate / tidal volume ratio (f / Vt). Likewise, the measurement of the vital capacity or the Pimax to measure muscular strength is applied by 57.0% with respect to the use of IV corticosteroids before extubation 4.7% (10/214) expressed never using them. In conclusion, not all respiratory therapists use the weaning criteria with equal frequency., El destete de la ventilación mecánica es el proceso de desconexión o retirada del soporte ventilatorio artificial. No existen criterios absolutos para prevenir un destete fallido o exento de complicaciones, pero es aconsejable utilizar protocolos con sus predictores y criterios de destete para minimizar consecuencias indeseadas. Como objetivo se propuso establecer los conocimientos, actitudes y prácticas de los profesionales del cuidado respiratorio en el destete de la ventilación mecánica en centros públicos y privados de la ciudad de Guayaquil. El diseño de la investigación fue cuantitativo, no experimental, transversal, observacional, con enfoque descriptivo. La muestra estuvo constituida por 214 terapistas respiratorios de 6 clínicas privadas y 8 hospitales públicos de la ciudad de Guayaquil a los cuales se les aplico una encuesta de dieciséis preguntas como instrumento de recolección de datos. Como resultado se obtuvo que 58% de los terapistas usan protoco-los de destete, asegurando que el 98% de los casos es indicado por el médico y solo el 2% realizan el destete por decisión propia. En cuanto a la evaluación de la hemodinámica del paciente, 88,3% de los terapistas respiratorios expresaron usar el índice de Tobin, cociente frecuencia respiratoria/volumen tidal (f/Vt). Así mismo, la medición de la capacidad vital o la Pi-máx. para medir fuerza muscular es aplicado por 57,0% y respecto al uso de corticoides IV previo a la extubación 4,7% (10/214) expresaron nunca usarlos. Como conclusión no todos los terapistas respiratorios utilizan con igual frecuencia los criterios de destete.