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Background: Although there are many reasons for extubation failure, maintaining negative or lower positive fluid balances 24 hours before extubation may be a key measure for successful extubation. Aim: To assess the predictive value of fluid balance before extubation and its outcome in mechanically ventilated cases in the intensive care unit (ICU). Study Design: This retrospective cohort study involved collecting clinical data from patients undergoing mechanical ventilation in Lanzhou general adult ICU from January 2022 to December 2022. Based on extubation outcomes, the patients were divided into a successful extubation group and a failed extubation group. Their fluid balance levels 24 h before extubation were compared with analyse the predictive value of fluid balance on extubation outcomes in patients undergoing mechanical ventilation. Results: In this study, clinical data from 545 patients admitted to a general adult ICU were collected. According to the inclusion and exclusion criteria, 265 (48.6%) patients were included, of which 197 (74.3%) were successfully extubated; extubation was unsuccessful in 68 (25.7%) patients. The total intake and fluid balance levels in patients in the failed extubation group 24 h before extubation were significantly higher than those in the successful extubation group, with a median of 2679.00 (2410.44–3193.50) mL versus 2435.40 (1805.04–2957.00) mL, 831.50 (26.25–1407.94) mL versus 346.00 (−163.00–941.50) mL. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut‐off value for predicting extubation outcomes was 497.5 mL (sensitivity 64.7%, specificity 59.4%) for fluid balance 24 h before extubation. The area under the ROC curve was 0.627 (95% confidence interval [CI] 0.547–0.707). Based on the logistic regression model, cumulative fluid balance >497.5 mL 24 h before extubation could predict its outcomes in mechanically ventilated patients in the ICU (OR = 5.591, 95% CI [2.402–13.015], p <.05). Conclusions: The fluid balance level 24 h before extubation was correlated with the outcome of extubation in mechanically ventilated patients in the ICU. The risk of extubation failure was higher when the fluid balance level was >497.5 mL. Relevance to Clinical Practice: Tracheal intubation is a crucial life support technique for many critically ill patients, and determining the appropriate time for extubation remains a challenge for clinicians. Although there are many reasons for extubation failure, acute pulmonary oedema caused by continuous positive fluid balance and volume overload is one of the main reasons for extubation failure. Therefore, it is very important to study the relationship between fluid balance and extubation outcome to improve the prognosis of patients with invasive mechanical ventilation in ICU. [ABSTRACT FROM AUTHOR]

Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation. Are different methods of conducting SBTs in critically ill patients associated with different risk of reintubation compared with T-tube? We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to January 26, 2024. The surface under the cumulative ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 22 randomized controlled trials were included, for a total of 6,196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and pressure support ventilation without positive end-expiratory pressure, with 2,135 and 2,101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared with T-tube was high-flow oxygen (HFO) (risk ratio, 0.23; 95% credibility interval, 0.09-0.51; moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%; SUCRA, 96.42), followed by CPAP (11.8%; SUCRA, 76.75). In this study, HFO SBT was associated with a lower risk of reintubation compared with other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBTs and potential clinical heterogeneity related to cointerventions. Further trials should be performed to confirm the results on larger cohorts of patients and to assess specific subgroups. PROSPERO; No.: CRD42023449264; URL: https://www.crd.york.ac.uk/prospero/ [Display omitted] [ABSTRACT FROM AUTHOR]

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: Practice on fasting prior to extubation in critically ill patients is variable. Efficacy of fasting in reducing gastric volume has not been well established. The primary objective of this study was to assess the effect of 4 h of fasting on prevalence of empty stomach using gastric ultrasonography in critically ill subjects who are fasted for extubation. The secondary objectives were to evaluate the change in gastric volumes during 4 h of fasting and to determine factors associated with empty stomach after fasting. METHODS: This was a single-center, prospective, observational study on adult ICU subjects who were enterally fed for at least 6 h continuously and mechanically ventilated. Gastric ultrasound was performed immediately prior to commencement of fasting, after 4 h of fasting, and after nasogastric (NG) aspiration after 4 h of fasting. An empty stomach was defined as a gastric volume ≤ 1.5 mL/kg. RESULTS: Forty subjects were recruited, and 38 (95%) had images suitable for analysis. The prevalence of empty stomach increased after 4 h of fasting (25 [65.8%] vs 31 [81.6%], P = .041) and after 4 h of fasting with NG aspiration (25 [65.8%] vs 34 [89.5%], P = .008). There was a significant difference in median (interquartile range) gastric volume per body weight between before fasting and 4 h after fasting (1.0 [0.5-1.8] mL/kg vs 0.4 [0.2-1.0] mL/kg, P < .001). No patient factors were associated with higher prevalence of empty stomach after 4 h of fasting. CONCLUSIONS: Most mechanically ventilated subjects had empty stomachs prior to fasting for extubation. Fasting for 4 h further increased the prevalence of empty stomach at extubation to > 80%. [ABSTRACT FROM AUTHOR]

Background: Extubation failure is a crucial issue for acute respiratory distress syndrome (ARDS). Ultrasound of the lung and diaphragm is individually valuable for predicting extubation outcomes. We aimed to determine whether combined lung and diaphragmatic ultrasound could improve the accuracy of predicting the extubation of ARDS patients. Methods: This was a prospective cohort study of ARDS patients who were ready for extubation. The lung ultrasound score (LUS), diaphragmatic displacement (DD), diaphragm thickening fraction (DTF), and diaphragmatic-rapid shallow breathing index (D-RSBI) were measured at the end of the spontaneous breathing trial. The primary outcome was extubation success. Logistic regression was used to combine these indicators, and the predictive performance of the single and combined indicators was evaluated through receiver operating characteristic (ROC) curves, the Hosmer–Lemeshow Ĉ‐test, and the Brier score. Multivariate logistic regression was used to determine the association between combined ultrasound indicators and extubation success. Results: This study enrolled 132 eligible patients from January 2019 to December 2022. A total of 71% (94/132) of patients were successfully extubated from mechanical ventilation. The combination of LUS and D-RSBI had the largest area under the ROC curves, the lowest Brier score, and the greatest calibration. After formula transformation, LUS + 2.43 × D-RSBI ≤ 14.273 was significantly associated with extubation success in ARDS patients. Conclusions: In ARDS patients receiving mechanical ventilation, the combination of LUS and D-RSBI was more accurate than a single parameter alone in predicting extubation outcomes. This combined approach could help refine extubation protocols in critical care. Clinical trial registration This study is registered online with the Chinese Clinical Trial Registry (ChiCTR), http://www.chictr.org.cn, ChiCTR1800019340 (Registration time: 2018/11/06). [ABSTRACT FROM AUTHOR]

Background: The success and failure of extubation of patients with acute respiratory failure is a very important issue for clinicians, and the failure of the ventilator often leads to possible complications, which in turn leads to a lot of doubts about the medical treatment in the minds of the people, so in order to increase the success of extubation success of the doctors to prevent the possible complications, the present study compared different time series algorithms and different activation functions for the training and prediction of extubation success or failure models. Methods: This study compared different time series algorithms and different activation functions for training and predicting the success or failure of the extubation model. Results: The results of this study using four validation methods show that the GRU model and Tanh's model have a better predictive model for predicting the success or failure of the extubation and better predictive result of 94.44% can be obtained using Holdout cross-validation validation method. Conclusion: This study proposes a prediction method using GRU on the topic of extubation, and it can provide the doctors with the clinical application of extubation to give advice for reference. [ABSTRACT FROM AUTHOR]

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. Clinical Trial Registration: ClinicalTrials.gov; Identifier: NCT03201263. [ABSTRACT FROM AUTHOR]

Aim: The aim of the present study was to assess the diaphragmatic and lung USG to predict the outcome of weaning process. Methods: The proposed study has been conducted on critically ill post-surgical patients on mechanical ventilation aged between 18-65 years, in intensive care unit of Department of Anaesthesiology and CCM, Nehru hospital, B.R.D. Medical College, Gorakhpur, Uttar Pradesh from December 2020 to November 2021. 110 patients were included in the study. Results: There was significant difference observed in failure rate of extubation among different age groups as age increases the rate of failure also increases significantly (p<0.0001). There was no significant difference observed in success rate of extubation across gender (success rate: male vs female: 88.2% vs 86.8%, p=0.839). Failure rate of extubation was significantly higher in those patients who had any comorbidities as compared to those who had no comorbidities. Mean LUS Score on CPAP was significantly lower in success group as compared to failure group. Mean LUS Score after extubation was significantly lower in success group as compared to failure group. Mean DTF on CPAP was significantly higher in success group as compared to failure group. Mean DTF on T piece was significantly higher in success group as compared to failure group. Mean DTF after Extubation was significantly higher in success group as compared to failure group. Likewise, Mean E on CPAP was significantly higher in success group as compared to failure group. Mean E on T piece was significantly higher in success group as compared to failure group. Mean E after extubation was significantly higher in success group as compared to failure group. Conclusion: The weaning outcome can be predicted by LUS score, diaphragmatic thickness fraction (DTF), diaphragmatic excursion (E) in mechanically ventilated patients. A value of LUS score on T-piece ≤10 predicts the successful weaning final outcome. A value of DTF on T-piece ≥31% predicts the successful weaning final outcome. Similarly, a value of E on Tpiece ≥18mm also predicts a successful weaning outcome. Increased rate of weaning failure observed in older age group, patients with co-morbidities and high SOFA score. Also prolonged duration of mechanical ventilation caused failure in weaning. [ABSTRACT FROM AUTHOR]

Background: When the diaphragm moves from its level throughout complete expiration to its level during full inhalation, this movement is referred to as diaphragmatic excursion for short. An evaluation of the value of the diaphragmatic excursion time index & the diaphragmatic rapid shallow breathing index, both of which were evaluated using ultrasonography, in order to forecast the likelihood of successful weaning from mechanical ventilation & extubation. Methods: For the purpose of predicting the probability of effective weaning from mechanical ventilation & extubation, an assessment of the value of the diaphragmatic excursion time index and the diaphragmatic fast shallow breathing index was performed. Both of these indices were analysed using ultrasonography. Results: 99 cases were enrolled in this study, there was not a statistically significant distinction amongst the three categories that were investigatedas regards Ventilator hours till SBT p= 0.577. DETI and DRSBI at 30 minutes were more significant predictors of successful weaning than at the beginning of the SBT. Regarding DETI at 30 min, AUC was 0.965, Cutoff value was 1.3, Sensitivity was 99%and Specificity was 88.2%, while DRSBI at 30 min, AUC was 0.895, Cutoff value was 1.07, Sensitivity was 97.2% & Specificity was 86.5%. Conclusion: When it comes to predicting the result of weaning, comparatively, the diagnostic accuracy of the DETI and DRSBI were better than that of the standard RSBI in supporting clinical decision-making regarding the release of patients from mechanical ventilation. [ABSTRACT FROM AUTHOR]

Noninvasive mechanical ventilation (NIV) may reduce postoperative complications of obesity--associated restrictive pulmonary syndrome. We evaluated the effects of NIV use after extubation in patients undergoing bariatric surgery on acute changes in lung function. A randomized clinical trial was performed with patients in the immediate postoperative period of bariatric surgery. The intervention group used NIV for 1 hour after arrival at the post-anesthesia recovery room, the control group received standard care. Pulmonary function assessment was performed preoperatively, immediately after surgery and 1 hour after arrival in the recovery room. Statistical analysis was performed using the Generalized Estimation Equations test and Bonferroni's post-hoc test. The significance level adopted was 0.05. A total of 46 individuals were evaluated, of which 31 were able to perform spirometry in the pre and immediate postoperative period. The sample consisted of 25 women, mean age of 42.55 ± 10.39 years and mean Body Mass Index of 50.82 ± 10.20. Preoperative spirometry showed that most patients had mild restrictive disorders (46.7% versus 43.8%) or no respiratory disorder (40% versus 31.3%). In the post-extubation evaluation, most patients had severe restrictive disorder (66.7% versus 53.8%), after one hour in the recovery room, 64.3% versus 60% of patients had severe restriction and 21.4% versus 20% severe obstruction. It was concluded that the use of prophylactic NIV did not improve pulmonary function in the immediate postoperative period. [ABSTRACT FROM AUTHOR]

Preterm infants born before 34 weeks of gestation often face respiratory challenges and may require resuscitation with an endotracheal tube and ventilator support. Unplanned extubation is a common problem for such infants, affecting their care and outcomes. This quasi-experimental study compared the incidence of unplanned extubation, stability of vital signs and oxygen saturation between a control group (n = 24) receiving routine care in a neonatal intensive care unit and an experimental group (n = 24) receiving routine care along with the use of the Endotracheal Tube Adjustable Stabilizing Set, developed by the researchers. The latter set comprises an endotracheal tube-holding cap, head-locked pillows, and an oxygen meter. Data were analyzed using descriptive statistics, t-tests, chi-square tests, and Fisher's exact tests. Results show that the control group had an average tracheal tube insertion time of 78.94 hours, while the experimental group had an average of 39.35 hours. The incidence of unplanned extubation was 33.33% (8 cases) in the control group and 4.17% (1 case) in the experimental group. The unplanned extubation rate per 100 ventilator days was 4.41 times in the experimental group, significantly less than in the control group (23.84 times). The experimental group also exhibited significantly more time spent on vital signs and oxygen saturation within normal limits than the control group. In conclusion, using the Endotracheal Tube Adjustable Stabilizing Set in neonatal care can improve patient outcomes by reducing the incidence of unplanned extubation and stabilizing vital signs. This set has passed patentability evaluation for product design and enhances neonatal care by stabilizing endotracheal tubes, reducing slippage, and helping nurses provide more effective care. However, further testing in different settings with larger sample sizes and an equal average tracheal tube insertion time between the two groups is recommended to validate these findings. [ABSTRACT FROM AUTHOR]

Background: To discuss whether decreasing the pressure of endotracheal tube cuff slowly with a constant speed can decrease the incidence of coughing during extubation. Methods: Ninety patients undergoing elective noncardiac surgery under general anesthesia with endotracheal intubation were randomly divided into two groups: group P, the pilot balloon was connected to a syringe and an aneroid manometer through a three-way stopcock, respectively, and the decrease of cuff pressure was controlled at 3 cmH2O/s during deflating before extubation; group C, the pressure in endotracheal tube cuff was decreased suddenly with a syringe extracting the air from the cuff rapidly at once exactly before extubation. The incidence of coughing during extubation period was recorded. Mean arterial pressure (MAP) and heart rate (HR) were recorded before general anesthesia induction (T0), just before cuff deflation (T1), immediately after deflation (T2), at 1 min (T3), 3 min (T4), and 5 min after extubation (T5). The occurrence of adverse reactions was also recorded. Results: The initiation of coughing during extubation period occurs at immediately the time of balloon deflation. Compared with group C, the incidence of coughing was significantly decreased (P = 0.001), MAP and HR were significantly decreased at T2-T4 and T2-T5, respectively (P < 0.05 for all), and the incidence of pharyngolaryngeal discomfort after extubation was significantly reduced (P = 0.021) in group P. Conclusions: Decreasing the pressure of endotracheal tube cuff slowly with a constant speed can significantly reduce the incidence of coughing during extubating period, stabilize hemodynamics, and reduce the incidence of adverse reactions. [ABSTRACT FROM AUTHOR]

Background: This study aims to compare the topical administration of bupivacaine hydrochloride and lidocaine hydrochloride with epinephrine in alleviating post-tonsillectomy pain. Post-tonsillectomy pain has remained a challenge to both patient and doctors, and local anaesthetic agents applied to the tonsillar fossae post-operatively look promising. Methods: One hundred and twenty ASA I or II children aged 2–15 years of consenting parents undergoing adenoidectomy and/or tonsillectomy were enrolled in the study. This was a randomized double-blind study in which the children were allocated into either of two groups to receive 5 ml of 0.125% bupivacaine or equal volume of lidocaine plus 1:200,000 adrenaline-soaked swab applied directly on the tonsillar floor within the fossae and/or nasopharynx after haemostasis was secured for 5 min before discontinuation of anaesthesia. Results: Patients in the bupivacaine group had better extubating condition (p = 0.0001). There was no difference in the time to eye opening in both groups (p-value 0.316). Patients in the lidocaine group had a time to first analgesic request between 1 and 6 h, whereas in the bupivacaine group, about 25 patients (44% of the group) had a time to first analgesic request that exceeded 6 h (6–10 h). The only complication recorded in both groups following oral feeds was vomiting, and there was no difference in both groups (p = 0.968). Overall parental satisfaction was better with bupivacaine group (p = 0.00001). Conclusion: Topical application of bupivacaine was associated with better extubation conditions and parental satisfaction when compared to topical lidocaine plus adrenaline while both demonstrated similar time to eye opening, analgesic request, haemodynamic parameters and incidence of complications. [ABSTRACT FROM AUTHOR]

Introduction: Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. Materials and methods: This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value. Results: Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure. Conclusions: In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings. [ABSTRACT FROM AUTHOR]

Background: Postoperative time to extubation plays a role in prognosis after heart valve surgery; however, its exact impact has not been clarified. This study compared the postoperative outcomes of minimally invasive surgery and conventional sternotomy, focusing on early extubation and factors influencing prolonged mechanical ventilation. Methods: Data from 744 patients who underwent heart valve surgery at the Zhejiang Provincial People's Hospital between August 2019 and June 2022 were retrospectively analyzed. The outcomes in patients who underwent conventional median sternotomy (MS) and minimally invasive (MI) video-assisted thoracoscopic surgery were compared using inverse probability of treatment weighting (IPTW) and Kaplan–Meier curves. Clinical data, including surgical data, postoperative cardiac function, postoperative complications, and intensive care monitoring data, were analyzed. Results: After propensity score matching and IPTW, 196 cases of conventional MS were compared with 196 cases of MI video-assisted thoracoscopic surgery. Compared to patients in the conventional MS group, those in the MI video-assisted thoracoscopic surgery group in the matched cohort had a higher early postoperative extubation rate (P < 0.01), reduced incidence of postoperative pleural effusion (P < 0.05), significantly shorter length of stay in the intensive care unit (P < 0.01), shorter overall length of hospital stay (P < 0.01), and lower total cost of hospitalization (P < 0.01). Conclusions: Successful early tracheal extubation is important for the intensive care management of patients after heart valve surgery. The advantages of MI video-assisted thoracoscopic surgery over conventional MS include significant reductions in the duration of use of mechanical ventilation support, reduced length of intensive care unit stay, reduced total length of hospitalization, and a favorable patient recovery rate. [ABSTRACT FROM AUTHOR]

Background: During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound. Methods: Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay). Results: There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes. Conclusion: In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF. Trial registration: ChiCTR2300079284. Registered on December 29, 2023. [ABSTRACT FROM AUTHOR]

Background: To analyze the effects of different anesthesia depths on perioperative heart rate variability and hemodynamics in middle-aged and elderly patients undergoing general anesthesia, and to provide a basis for clinical application. Methods: A total of 111 patients with gastric cancer who were treated with epidural anesthesia combined with general anesthesia were selected as the study subjects, and the patients were randomly divided into group A, group B and group C. The bispectral index (BIS) was maintained by adjusting the infusion speed of anesthetics, the BIS of group A was maintained at 50 ~ 59, the BIS of group B was maintained at 40 ~ 49, and the BIS of group C was maintained at 30 ~ 39. The high-frequency power (HFP), low-frequency power (LFP), total power (TP), mean arterial pressure (MAP), heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP) were measured before anesthesia induction (T1), immediately after intubation (T2), 3 min after intubation (T3), and 6 min after extubation (T4). The cognitive function of the patients was evaluated before and 48 h after surgery. Results: The HFP, LFP/HFP, TP, HR, DBP and SBP between the three groups at T1 ~ T3 are significantly difference from each other (P < 0.05). There were significant differences in spontaneous breathing recovery time, eye opening time and extubation time among group A, B and C groups, and group B had the lowest spontaneous breathing recovery time, eye opening time and extubation time (P < 0.05). There was no significant difference in the incidence of adverse reactions during anesthesia between the three groups. The cognitive function score of group B was significantly higher than that of group A and group C (P < 0.05). Conclusions: BIS maintenance of 40 ~ 49 has little effect on perioperative heart rate variability and hemodynamics in middle-aged and elderly patients undergoing general anesthesia, which is helpful for postoperative recovery. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR). METHODS: A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation. RESULTS: We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator. CONCLUSIONS: Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns. [ABSTRACT FROM AUTHOR]

Aim: To analyse the evidence of non‐invasive neurally adjusted ventilatory assist (NIV‐NAVA) in preterm neonates compared to nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV). Methods: We performed a systematic review and meta‐analysis of randomised controlled trials and included studies where NIV‐NAVA was analysed in preterm (<37 gestational weeks) born neonates. Our main outcomes were the need for endotracheal intubation, the need for surfactant therapy, and reintubation rates. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Results: A total of five studies were included. The endotracheal intubation rate was 25% in the NIV‐NAVA group and 26% in the nCPAP group (RR 0.91, CI: 0.56–1.48). The respective rates for surfactant therapy were 30% and 35% (RR 0.85, CI: 0.56–1.29). The reintubation rate in neonates previously invasively ventilated was 8% in the NIV‐NAVA group and 29% in the nCPAP/NIPPV group (RR 0.29, 95%CI: 0.10–0.81). Evidence certainty was rated as low for all outcomes. Conclusions: NIV‐NAVA as the primary respiratory support did not reduce the need for endotracheal intubation or surfactant therapy. NIV‐NAVA seemed to reduce the reintubation rate after extubation in pre‐term neonates. [ABSTRACT FROM AUTHOR]

Background: Post-extubation dysphagia occurs in 3% to 62% of adults who have received invasive mechanical ventilation in an intensive care unit (ICU). A stepwise approach to identify dysphagia includes a routine swallow screening in patients who are recently extubated followed by a formal assessment by a Speech and Language Pathologist (SLP), in the event of a failed swallow screen, has been suggested. This quality improvement project aimed to implement and evaluate a new post-extubation swallow screening process. Methods: Using the Model for Improvement framework, a new process that included the Yale Swallow Protocol (YSP) was developed, implemented, and evaluated between July and December 2022 in a 20-bed tertiary ICU. All patients with at least four hours post-extubation were included in the project. Process development included a literature review and feedback from ICU educators, nurses, physicians, SLPs, and Registered Dietitians (RDs). Education was provided to critical care nurses prior to implementation. Data on patient characteristics, process indicators, and outcomes were collected between September and December 2022 to evaluate the project implementation. Descriptive statistics were used to describe the data and bivariate analyses were used to compare data between patients who passed and failed the YSP. Results: Fifty-four patients were extubated and evaluated using the new swallow screening process. Post-extubation dysphagia was diagnosed by an SLP in 30.0% of patients. Dysphagia was diagnosed in 90.0% of patients who failed, compared with 8.6% of patients who passed the YSP (P<0.001). Conclusion: A swallow screening process using the YSP was successfully adopted in a tertiary ICU. [ABSTRACT FROM AUTHOR]

BACKGROUND: A protocolized extubation readiness test (ERT), including a spontaneous breathing trial (SBT), is recommended for patients who are intubated. This quality-improvement project aimed to improve peri-extubation outcomes by using a high-risk ERT protocol in intubated cardiac patients in addition to a standard-risk protocol. METHODS: After baseline data collection, we implemented a standard-risk ERT protocol (pressure support plus PEEP), followed by a high-risk ERT protocol (PEEP alone) in cardiac subjects who were intubated. The primary outcome, a composite of extubation failure and rescue noninvasive respiratory support, was compared between phases. Ventilator duration and use of postextubation respiratory support were balancing measures. RESULTS: A total of 213 cardiac subjects who were intubated were studied, with extubation failure and rescue noninvasive respiratory support occurring in 10 of 213 (4.7%) and 8 of 213 (3.8%), respectively. We observed a reduction in the composite outcome among the 3 consecutive phases (5/29 [17.2%], 10/110 [9.1%] vs 3/74 [4.1%]; P = .10), but this did not reach statistical significance. In the logistic regression model when adjusting for admission type, the high-risk ERT protocol was associated with a significant reduction of the composite outcome (adjusted odds ratio 0.20, 95% CI 0.04-0.091; P = .037), whereas the standard-risk ERT protocol was not (adjusted odds ratio 0.48, 95% CI 0.15-1.53; P = .21). This was not accompanied by a longer ventilator duration (2.0 [1.0, 3.0], 2.0 [1.0-4.0], vs adjusted odds ratio 2.0 [95% [1.0-6.0]; P = .99) or an increased use of planned noninvasive respiratory support (10/29 [35.5%], 35/110 [31.8%], vs 25/74 [33.8%]; P > .99). CONCLUSIONS: In this quality-improvement project, a high-risk ERT protocol was implemented with improvement in peri-extubation outcomes among cardiac subjects. [ABSTRACT FROM AUTHOR]

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Abstract Background Extubation failure is a crucial issue for acute respiratory distress syndrome (ARDS). Ultrasound of the lung and diaphragm is individually valuable for predicting extubation outcomes. We aimed to determine whether combined lung and diaphragmatic ultrasound could improve the accuracy of predicting the extubation of ARDS patients. Methods This was a prospective cohort study of ARDS patients who were ready for extubation. The lung ultrasound score (LUS), diaphragmatic displacement (DD), diaphragm thickening fraction (DTF), and diaphragmatic-rapid shallow breathing index (D-RSBI) were measured at the end of the spontaneous breathing trial. The primary outcome was extubation success. Logistic regression was used to combine these indicators, and the predictive performance of the single and combined indicators was evaluated through receiver operating characteristic (ROC) curves, the Hosmer–Lemeshow Ĉ‐test, and the Brier score. Multivariate logistic regression was used to determine the association between combined ultrasound indicators and extubation success. Results This study enrolled 132 eligible patients from January 2019 to December 2022. A total of 71% (94/132) of patients were successfully extubated from mechanical ventilation. The combination of LUS and D-RSBI had the largest area under the ROC curves, the lowest Brier score, and the greatest calibration. After formula transformation, LUS + 2.43 × D-RSBI ≤ 14.273 was significantly associated with extubation success in ARDS patients. Conclusions In ARDS patients receiving mechanical ventilation, the combination of LUS and D-RSBI was more accurate than a single parameter alone in predicting extubation outcomes. This combined approach could help refine extubation protocols in critical care. Clinical trial registration This study is registered online with the Chinese Clinical Trial Registry (ChiCTR), http://www.chictr.org.cn , ChiCTR1800019340 (Registration time: 2018/11/06).

Abstract 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. Clinical Trial Registration: ClinicalTrials.gov; Identifier: NCT03201263.

Abstract Background To discuss whether decreasing the pressure of endotracheal tube cuff slowly with a constant speed can decrease the incidence of coughing during extubation. Methods Ninety patients undergoing elective noncardiac surgery under general anesthesia with endotracheal intubation were randomly divided into two groups: group P, the pilot balloon was connected to a syringe and an aneroid manometer through a three-way stopcock, respectively, and the decrease of cuff pressure was controlled at 3 cmH2O/s during deflating before extubation; group C, the pressure in endotracheal tube cuff was decreased suddenly with a syringe extracting the air from the cuff rapidly at once exactly before extubation. The incidence of coughing during extubation period was recorded. Mean arterial pressure (MAP) and heart rate (HR) were recorded before general anesthesia induction (T0), just before cuff deflation (T1), immediately after deflation (T2), at 1 min (T3), 3 min (T4), and 5 min after extubation (T5). The occurrence of adverse reactions was also recorded. Results The initiation of coughing during extubation period occurs at immediately the time of balloon deflation. Compared with group C, the incidence of coughing was significantly decreased (P = 0.001), MAP and HR were significantly decreased at T2-T4 and T2-T5, respectively (P

Abstract Background Postoperative time to extubation plays a role in prognosis after heart valve surgery; however, its exact impact has not been clarified. This study compared the postoperative outcomes of minimally invasive surgery and conventional sternotomy, focusing on early extubation and factors influencing prolonged mechanical ventilation. Methods Data from 744 patients who underwent heart valve surgery at the Zhejiang Provincial People’s Hospital between August 2019 and June 2022 were retrospectively analyzed. The outcomes in patients who underwent conventional median sternotomy (MS) and minimally invasive (MI) video-assisted thoracoscopic surgery were compared using inverse probability of treatment weighting (IPTW) and Kaplan–Meier curves. Clinical data, including surgical data, postoperative cardiac function, postoperative complications, and intensive care monitoring data, were analyzed. Results After propensity score matching and IPTW, 196 cases of conventional MS were compared with 196 cases of MI video-assisted thoracoscopic surgery. Compared to patients in the conventional MS group, those in the MI video-assisted thoracoscopic surgery group in the matched cohort had a higher early postoperative extubation rate (P

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 reducing EFs.

Abstract Background The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed to predict extubation outcomes. However, few studies focused on the predicting value of E/Ea and DE at different positions during a spontaneous breathing trial (SBT), as well as the effects of △E/Ea and △DE (changes in E/Ea and DE during a SBT). Methods This study was a reanalysis of the data of 60 difficult-to-wean patients in a previous study published in 2017. All eligible participants were organized into respiratory failure (RF) group and extubation success (ES) group within 48 h after extubation, or re-intubation (RI) group and non-intubation (NI) group within 1 week after extubation. The risk factors for respiratory failure and re-intubation including E/Ea and △E/Ea, DE and △DE at different positions were analyzed by multivariate logistic regression, respectively. The receiver operating characteristic (ROC) curves of E/Ea (septal, lateral, average) and DE (right, left, average) were compared with each other, respectively. Results Of the 60 patients, 29 cases developed respiratory failure within 48 h, and 14 of those cases required re-intubation within 1 week. Multivariate logistic regression showed that E/Ea were all associated with respiratory failure, while only DE (right) and DE (average) after SBT were related to re-intubation. There were no statistic differences among the ROC curves of E/Ea at different positions, nor between the ROC curves of DE. No statistical differences were shown in △E/Ea between RF and ES groups, while △DE (average) was remarkably higher in NI group than that in RI group. However, multivariate logistic regression analysis showed that △DE (average) was not associated with re-intubation. Conclusions E/Ea at different positions during a SBT could predict postextubation respiratory failure with no statistical differences among them. Likewise, only DE (right) and DE (average) after SBT might predict re-intubation with no statistical differences between each other.

Abstract Background In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation. Methods This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization. Discussion We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients. Trial registration The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d’Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

Abstract Purpose We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. Methods This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. Results Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71–0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. Conclusion PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.

Diaphragm dysfunction (DD) is diagnosed in 60% patients 24 hours after intubation. Diaphragm ultrasound (DU) facilitates non-invasive assessment of excursion and thickness of the diaphragm throughout the breathing cycle. Sonographically measured excursion and thickening fraction (TF) of the diaphragm show moderate correlation with reference methods for diaphragm dysfunction detection. Both increase and decrease in diaphragm thickness in mechanically ventilated patients are associated with prolonged mechanical ventilation. TF exceeding 25% increases probability of successful weaning. Maintaining TF within 15–40 % might shorten the duration of mechanical ventilation.

Abstract Background Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke. Methods This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (

Background: The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed to predict extubation outcomes. However, few studies focused on the predicting value of E/Ea and DE at different positions during a spontaneous breathing trial (SBT), as well as the effects of △E/Ea and △DE (changes in E/Ea and DE during a SBT). Methods: This study was a reanalysis of the data of 60 difficult-to-wean patients in a previous study published in 2017. All eligible participants were organized into respiratory failure (RF) group and extubation success (ES) group within 48 h after extubation, or re-intubation (RI) group and non-intubation (NI) group within 1 week after extubation. The risk factors for respiratory failure and re-intubation including E/Ea and △E/Ea, DE and △DE at different positions were analyzed by multivariate logistic regression, respectively. The receiver operating characteristic (ROC) curves of E/Ea (septal, lateral, average) and DE (right, left, average) were compared with each other, respectively. Results: Of the 60 patients, 29 cases developed respiratory failure within 48 h, and 14 of those cases required re-intubation within 1 week. Multivariate logistic regression showed that E/Ea were all associated with respiratory failure, while only DE (right) and DE (average) after SBT were related to re-intubation. There were no statistic differences among the ROC curves of E/Ea at different positions, nor between the ROC curves of DE. No statistical differences were shown in △E/Ea between RF and ES groups, while △DE (average) was remarkably higher in NI group than that in RI group. However, multivariate logistic regression analysis showed that △DE (average) was not associated with re-intubation. Conclusions: E/Ea at different positions during a SBT could predict postextubation respiratory failure with no statistical differences among them. Likewise, only DE (right) and DE (average) after SBT might predict re-intubation with no statistical differences between each other. [ABSTRACT FROM AUTHOR]

Background: This study aims to comprehend the levels of dry mouth and thirst in patients after general anesthesia, and to identify the factors influencing them. Methods: The study included all patients transferred to the Post Anesthesia Care Unit (PACU) at the Second Affiliated Hospital of Dalian Medical University between August 2021 and November 2021 after undergoing general anesthesia. A thirst numeric rating scale was utilized to conduct surveys, enabling the assessment of thirst incidence and intensity. Statistical analysis was performed to explore patient thirst levels and the associated factors. Results: The study revealed a thirst incidence rate of 50.8%. Among the thirst intensity ratings, 71.4% of patients experienced mild thirst, 23.0% reported moderate thirst, and 5.6% expressed severe thirst. Single-factor statistical analysis of potential risk factors among the enrolled cases indicated that gender, history of coronary heart disease, surgical duration, intraoperative fluid volume, intraoperative blood loss, intraoperative urine output, and different surgical departments were linked to post-anesthetic thirst in patients undergoing general anesthesia. Multifactorial Logistic regression analysis highlighted age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume as independent risk factors for post-anesthetic thirst in patients undergoing general anesthesia. Moreover, age, gender, history of coronary heart disease, and intraoperative fluid volume were also identified as risk factors for varying degrees of thirst. Conclusion: The incidence and intensity of post-anesthetic thirst after general anesthesia are relatively high. Their occurrence is closely associated with age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume. [ABSTRACT FROM AUTHOR]

Background: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). Methods: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.clinicaltrials.gov (https://clinicaltrials.gov/) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18–80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. Results: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. Conclusions: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area. [ABSTRACT FROM AUTHOR]

Background and aims: Extubation after an elective intubation for GA depends on patients preoperative status, the intraoperative course and expected post operative recovery. Increased cardiovascular instability during anaesthesia and abnormal cardiovascular responses to intubation and extubation have been described in patients with diabetic autonomic neuropathy. Aim: To assess the effectiveness of esmolol on blocking the hemodynamic response to extubation in diabetic and non-diabetic patients. Methodology: It is a comparative, randomized, prospective, observational study. A total of 42 patients of ASA grade 1 and 2 of either sex, aged 30 to 80 years, scheduled for elective surgeries under General Anaesthesia (GA) were randomly allocated into two groups of 21 each – Group A- Non-Diabetic, Esmolol received 1.5mg/kg IV 2 minutes before extubation Group B- Diabetic, Esmolol received 1.5mg/kg IV 2 minutes before extubation. Heart rate (HR), Systolic arterial pressure (SAP), Diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were recorded 1 minute before IV administration, during extubation at 1, 3, 5, and 10 minutes after extubation. Data analysis done using standard statistical tests and SPSS for windows software. Results: HR and BP values of the diabetic esmolol group were significantly lower as compared to the nondiabetic esmolol group. In group 1, HR at administration of drug, at extubation after 1,5 and 10 minutes was higher. In group 1, SAP at administration of drug, extubation after 1,3, 5 minutes was higher. DAP was higher in group 1. MAP was not statistically significant between two groups. Conclusion: Use of esmolol 1.5mg/kg dose 2 minutes before extubation is effective in diabetic and non-diabetic patients in preventing tachycardia and hypertension without any serious side effects. [ABSTRACT FROM AUTHOR]

Despite neweffective medications, patients with spinal muscular atrophy types 1-3 can continue to have inadequate cough flows to prevent episodes of acute respiratory failure. Ventilator unweanable intubated patients are thought to require tracheostomy tubes. As a result, potentially beneficial medications may be discontinued and patients die despite receiving these medications. Three cases are presented of medically treated, physically strengthening children, with spinal muscular atrophy type 1. All three subsequently died or underwent tracheotomy. However, there is no evidence of extubation attempts to noninvasive ventilatory support settings or optimal mechanical insufflation-exsufflation despite this option being described to be over 98% successful for extubating unweanable medically untreated children with spinal muscular atrophy 1. [ABSTRACT FROM AUTHOR]

Background: Palliative extubation (PE) is the cessation of mechanical ventilation (MV) during terminal illness. Although PE is widely practiced in many countries, it remains illegal in others. Attitudes toward PE of patients at the highest risk for MV were scarcely explored before. Objective: To assess the attitudes of patients with advanced chronic illnesses (ACI) toward PE and other end-of-life decisions in a country where PE is illegal. Design: A prospective observational study using questionnaire-based interviews. Setting/Subjects: Patients with ACI hospitalized between 2021 and 2022 in a large tertiary center. Attitudes toward PE and mechanical ventilation were evaluated. Predictors for favoring/opposing PE were analyzed using multivariate logistical regression models. Results: A total of 152 (40% female, 75 ± 11 years) patients were included. The most common ACIs were advanced heart failure (32%), metastatic malignancy (32%), and chronic obstructive pulmonary disease (22%). Around 132 patients (87%) supported the legalization of PE, and their main reason was to avoid pain and suffering (87%). Legalization of PE would change the decision to avoid mechanical intubation in 34% of the cases. Most patients thought that the decision to perform PE should be made by the patient's physician and primary caregiver collaboratively (64%). Religious observance was an independent predictor for opposing PE (adjusted odds ratio 0.18; 95% confidence interval 0.06–0.59; p < 0.01), whereas the type of ACI was not. Conclusion: Most admitted patients with ACIs support the legalization of PE. Such policy change could have major impact on patients' end-of-life preferences. At-risk patients should be the focus of future studies in this area. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the association between the pre-extubation sum of eye and motor components of the Glasgow Coma Score (GCS-EM) and odds of extubation failure in patients with acute brain injury being liberated from mechanical ventilation. DESIGN: Secondary analysis of a prospective, multicenter observational study (ClinicalTrials.gov identifier NCT03400904). SETTING: Sixty-three hospital sites worldwide, with patient recruitment from January 2018 to November 2020. PATIENTS: One thousand one hundred fifty-two critically ill patients with acute brain injury, with a median age of 54 years, of whom 783 (68.0%) were male, 559 (48.5%) had traumatic brain injury, and 905 (78.6%) had a GCS-EM greater than 8 before extubation (scores range from 2 to 10). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: GCS-EM was computed in intubated patients on the day of extubation. The main outcome was extubation failure, defined as unplanned reintubation within 5 days of extubation. Analyses used multilevel logistic regression with adjustment for patient characteristics and a random intercept for hospital site. In the primary analysis, GCS-EM was not associated with extubation failure (odds ratio, 1.07 per additional point; 95% CI, 0.87-1.31). Findings were consistent in sensitivity analyses that: 1) used different adjustment covariates, 2) included a verbal estimate to derive an overall GCS, 3) accounted for missing data, 4) considered a 2-day time interval to define extubation failure, 5) accounted for competing risks, and 6) used a propensity score-based model. There was no association between GCS-EM and extubation outcome in sub-groups defined by brain injury diagnosis or age. CONCLUSIONS: In this large, contemporary, multicenter cohort of patients with acute brain injury, we found no association between the GCS-EM and odds of extubation failure. However, few patients had a pre-extubation GCS-EM less than or equal to 8, and the possibility of a true prognostic association in patients with low scores is not excluded. [ABSTRACT FROM AUTHOR]

Objective Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) were the new modes of noninvasive ventilation. This study's aim was to clarify as to which of the nHFOV and sNIPPV modes was superior in preventing postextubation failure or reintubation in neonates. Study Design An open-label parallel randomized study was performed. Extubated preterm and term neonates were randomly allocated into nHFOV or sNIPPV modes; the reintubation rate was evaluated within 7 days after extubation between the two modes. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. The sample calculation was 1,050 neonates; however, this trial was stopped early as enrollment was too slow. Results From July 2020 to June 2022, 202 neonates were assessed for eligibility and 69 neonates were excluded. Finally, 133 neonates were randomly allocated to the study interventions (nHFOV = 67, sNIPPV = 66). The median gestational age and birth weight were 33 (30–37) weeks and 1,910 (1,355–2,836) g, respectively. The reintubation rate within 7 days did not significantly differ between the groups (nHFOV [5/67, 7%] vs. sNIPPV [4/66, 6%]); risk difference [95% confidence interval] = 0.01 [−0.08 to 0.11]; p = 0.99), including preterm (nHFOV [4/55, 7%] vs. sNIPPV [3/44, 7%]) and very preterm (nHFOV [3/25, 12%] vs. sNIPPV [3/25, 12%]) neonates. Conclusion After neonatal extubation, there was no significant difference of reintubation rates within 7 days between nHFOV and sNIPPV. This trial has been registered in the ClinicalTrials.gov database (https://clinicaltrials.gov/ct2/show/NCT04323397). First posted registration on March 26, 2020. Key Points There was no significant difference of reintubation rates between nHFOV and sNIPPV. During nHFOV support, one neonate developed pneumomediastinum. During sNIPPV support, one neonate developed pulmonary hemorrhage. [ABSTRACT FROM AUTHOR]

Objective Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) yield a lower partial pressure of carbon dioxide (pCO 2) after extubation than nasal continuous positive airway pressure. Our aim was to clarify which of the two was superior. Study Design We performed a crossover randomized study to evaluate pCO 2 level among 102 participants from July 2020 to June 2022. Intubated preterm and term neonates with arterial lines were randomly allocated to nHFOV–sNIPPV or sNIPPV–nHFOV sequences; their pCO 2 levels were measured after 2 hours in each mode. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. Results The mean gestational age (nHFOV–sNIPPV, 32.8 vs. sNIPPV–nHFOV, 33.5 weeks) and median birth weight (1,850 vs. 1,930 g) did not differ between the sequences. The mean ± standard deviation pCO 2 level after nHFOV (38.7 ± 8.8 mm Hg) was significantly higher than that after sNIPPV (36.8 ± 10.2 mm Hg; mean difference: 1.9 mm Hg; 95% confidence interval: 0.3–3.4 mm Hg; treatment effect [ p = 0.007] but no sequence [ p = 0.92], period [ p = 0.53], or carryover [ p = 0.94] effects). However, the difference in pCO 2 level between the sequences was not statistically significant in the subgroup analyses of preterm and very preterm neonates. Conclusion After neonatal extubation, the sNIPPV mode was associated with a lower pCO 2 level than the nHFOV mode with no significant difference in preterm and very preterm neonates. Key Points Full noninvasive ventilation support is suggested in neonatal ventilation. pCO 2 level in sNIPPV was lower than in nHFOV. No differences in pCO 2 levels were observed in either preterm or very preterm neonates. [ABSTRACT FROM AUTHOR]

Emergence and extubation are critical transitional phases in the perioperative period. Evidence has shown that complications occur more at extubation than intubation and induction. A comprehensive understanding of the various factors influencing emergence and extubation, potential complications, essential steps and different techniques employed can maximize patient outcomes and satisfaction. Vigilant monitoring and assessment of the patient's readiness for extubation are required at emergence. Reasons for delay and delirium in emergence must be screened and investigated so that corresponding treatment can be pursued. Haemodynamic stability, continued oxygen delivery, adequate analgesia and anti-emesis are the general objectives. Extubation is an elective procedure with the potential for unanticipated challenges and mortalities. Should extubation be determined appropriate, individualized planning and methodical preparation must precede the performance of extubation to avoid complications and failures. Risk stratification, airway assessment and optimization of physiological parameters are some of the necessary processes. Different extubation techniques are selected and performed to address specific physiological consequences and airway concerns. Guidelines and systematic approaches regarding emergence and extubation should be followed. [ABSTRACT FROM AUTHOR]

This article discusses a 62-year-old woman who has a long term diagnoses of Rheumatoid Arthritis, and had frequent hospitalization for recurrent pneumonia. In the current hospitalization, she suffered from severe pneumonia complicated with respiratory failure, and received endotracheal intubation with mechanical ventilator use. After treatment, she was extubated and high-flow nasal cannula was applied afterwards for avoiding re-intubation. Data was collected from October 19th to November 3rd, 2020, through direct care, observations, physical assessments, conversation and chart reviews, and comprehensive assessments of the physical, psychological, social and spiritual aspects were implemented. Three health problems were identified: ineffective respiratory patterns, impaired skin integrity and anxiety. During the intensive care period, the writer established a healthy nurse-patient relationship, leading the patient to perform lung rehabilitation for improving respiratory pattern. Also, observing and listening to the patient with positive feedback minimized her anxiety. Meanwhile, using cross-team cooperation to draw up caring strategies. Owing to individualized nursing intervention, the patient successfully weaned from the mechanical ventilator. The writer hopes this nursing experience could assist nurses in taking care of these types of patients in the future. [ABSTRACT FROM AUTHOR]

This article describes the caring experience of a male patient with oral cancer who was admitted to the intensive care unit due to massive bleeding after endotracheal tube placement. The care period was from May 7th to May 10th, 2022. Data was collected through communication via writing, observation, physical assessment, and medical record review. The patient's health problems were identified as ineffective airway clearance, anxiety, and sleep disturbance by using Kolcaba's Theory of Comfort as an evaluation framework. Chest physiotherapy, pulmonary rehabilitation exercises, and teaching of deep breathing and coughing were provided to improve respiratory clearance function. In addition, music therapy and adjustment of the sleep environment were provided to improve the patient's overall comfort. Finally, the patient's extubation was successful and they were transfer out of the ICU. We suggested that the Theory of Comfort can be used more extensively as an assessment tool in the future to evaluate the physiological, psychological, social-cultural, and environmental factors that affect patients and promote a balance and comfort in their physical and mental health. [ABSTRACT FROM AUTHOR]

In patients with intubation, the endotracheal tube oppresses the throat for a long time, causing laryngeal ulcers or paralysis of the recurrent laryngeal nerve, resulting in reduced swallowing efficiency. After extubation, evaluation of swallowing and oral rehabilitation exercises should be performed as soon as possible to strengthen swallowing muscle strength and reflex, so as to achieve safe eating. Based on the analysis of the current practices, it was established that the completeness of swallowing care performed by nursing staff in extubated patients is 34.3%. Contributing reasons include: the nursing staff's swallowing care cognition is 55%; the in-hospital evaluation form is not applicable; the swallowing care process is incomplete; there is no swallowing care guide and unified assessment tool for patients after extubation. In order to improve current practice, the following steps were taken: revising the swallowing training evaluation form and swallowing care flow chart; the production of swallowing assessment kits and oral rehabilitation exercise videos covering the five steps of swallowing care; and holding educational courses on swallowing care. After the implementation of the project, the completeness of swallowing care performed by nursing staff increased from 34.3% to 92.3%. The cognitive accuracy increased from 55% to 95.3%, thus reaching the project goal to maintain patient safety and improve nursing quality. [ABSTRACT FROM AUTHOR]

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Purpose: We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70). Method: Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence. Result: Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15–0.82, p = 0.015 and OR 0.07; CI 0.01–0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge. Conclusion: Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge. [ABSTRACT FROM AUTHOR]

Background and Objectives: Extubation success in ICU patients is crucial for reducing ventilator-associated complications, morbidity, and mortality. The Rapid Shallow Breathing Index (RSBI) is a widely used predictor for weaning from mechanical ventilation. This study aims to determine the predictive value of serial RSBI measurements on extubation success in ICU patients on mechanical ventilation. Materials and Methods: This prospective observational study was conducted on 86 ICU patients at Hitit University between February 2024 and July 2024. Patients were divided into successful and unsuccessful extubation groups. RSBI values were compared between these groups. Results: This study included 86 patients (32 females, 54 males) with a mean age of 54.51 ± 12.1 years. Extubation was successful in 53 patients and unsuccessful in 33. There was no significant difference in age and intubation duration between the groups (p = 0.246, p = 0.210). Significant differences were found in RSBI-1a and RSBI-2 values (p = 0.013, p = 0.011). The median RSBI-2a was 80 in the successful group and 92 in the unsuccessful group (p = 0.001). The ΔRSBI was higher in the unsuccessful group (p = 0.022). ROC analysis identified optimal cut-off values: RSBI-2a ≤ 72 (AUC 0.715) and ΔRSBI ≤ −3 (AUC 0.648). RSBI-2a ≤ 72 increased the likelihood of successful extubation by 10.8 times, while ΔRSBI ≤ −3 increased it by 3.4 times. Using both criteria together increased the likelihood by 28.48 times. Conclusions: Serial RSBI measurement can be an effective tool for predicting extubation success in patients on IMV. These findings suggest that serially measured RSBI may serve as a potential indicator for extubation readiness. [ABSTRACT FROM AUTHOR]

Introduction: Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. Objectives: To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non‐invasive respiratory support modes. Material & methods: We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. Results: This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. Conclusions: NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted. [ABSTRACT FROM AUTHOR]

Objective Dexamethasone has been associated with early extubation and shorter duration of mechanical ventilation in preterm infants. High doses or prolonged courses of dexamethasone may be associated with poor neurodevelopmental outcomes. Study Design This is an observational cohort study assessing the efficacy of a low-dose short dexamethasone course combined with postextubation bubble continuous positive airway pressure (bCPAP) strategy on rates of successful extubation and reduction of the duration of invasive mechanical ventilation in extremely preterm infants. We compared the short-term outcomes of implementing such strategy on a group of infants with birth weight <750 g to a historical cohort. Results Among infants intubated for at least 10 days, median time to extubation from starting the dexamethasone course was 2 days (interquartile range: 1–3). Total duration of intubation was significantly shorter in infants who received dexamethasone compared with the control groups (21 ± 6 vs. 30 ± 10 days, p = 0.03), and although statistically nonsignificant, duration to wean to 21% bCPAP was shorter compared with the control group (48 ± 13 vs. 74 ± 29 days, p = 0.06). Conclusion A low-dose short dexamethasone course combined with postextubation bCPAP intervention may be associated with successful early extubation and shorter duration of mechanical ventilation. Key Points Noninvasive strategies may not succeed in infants < 750 g birth weight. Bubble CPAP has been shown to be associated with reduced complications including chronic lung disease. Postnatal dexamethasone therapy may succeed in conjunction with bubble CPAP to reduce reintubation. [ABSTRACT FROM AUTHOR]