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Background: Noninvasive neurally-adjusted ventilatory assist (NIV-NAVA) improves patient-ventilator synchrony and may reduce treatment failure in preterm infants compared with nasal continuous positive airway pressure (NCPAP) and noninvasive positive-pressure ventilation (NIPPV). We conducted a systematic review and meta-analysis to assess the effects of NIV-NAVA in preterm infants with respiratory distress. Methods: Four investigators independently assessed the eligibility of studies in CENTRAL, CINAHL, ClinicalTrials.gov, Embase, MEDLINE, PubMed, and WHO ICTRP databases, and extracted data. The included studies were randomized controlled trials (RCTs) comparing NIV-NAVA with other noninvasive ventilation modalities in preterm infants. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The objective of the meta-analysis was to compare NIV-NAVA vs CPAP/NIPPV as a primary mode post extubation. Results: Five RCTs which examined 279 preterm infants were included. In the subgroup of post-extubation respiratory support, NIV-NAVA decreased treatment failure compared with NCPAP/NIPPV (risk ratio 0.29; 95% confidence interval [0.10, 0.81], 2 RCTs, 96 infants, low certainty of the evidence). NIV-NAVA did not significantly reduce the risk of treatment failure in the subgroup of primary respiratory support (very low certainty of the evidence). There were no significant differences in secondary outcomes with low to very low certainty of evidence. Conclusions: In a small cohort with low certainty of evidence, NIV-NAVA may prevent reintubation in preterm infants. Further large-scale RCTs are needed to determine the effects and safety of NIV-NAVA in preterm infants. [ABSTRACT FROM AUTHOR]

Spontaneous cerebellar hemorrhage (SCH) patients have a low success rate in extubation, but there are currently no guidelines establishing specifically for SCH patients extubation. The study included 68 SCH patients who received mechanical ventilation for more than 24 h, with 39 cases (57.3%) resulting in successful extubation. The multivariate analysis identified four factors significantly associated with extubation success: patient age under 66 years, an Intracerebral Hemorrhage (ICH) score less than 4 points, the presence of tissue shift, and a Glasgow Coma Scale (GCS) score (excluding language) above 6 points at extubation. By simplifying the prediction model, we obtained the Spontaneous Cerebellar Hemorrhage Extubation Success scoring system (SCHES-SCORE). Within the scoring system, 2 points were allocated for a GCS score (excluding language) above 6 at extubation, 1 point each for age under 66 years and an ICH score below 4, while tissue shift was assigned a negative point. A score of Grade A (SCHES-SCORE = 3–4) was found to correlate with a 92.9% success rate for extubation. The area under the receiver operating characteristic curve was 0.923 (95% CI, 0.863 to 0.983). Notably, successful extubation was significantly linked to reduced durations of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay. In conclusion, the scoring system developed for assessing extubation outcomes in SCH patients has the potential to enhance the rate of successful extubation and overall patient outcomes. [ABSTRACT FROM AUTHOR]

Extubation is a crucial step in the weaning process of critically ill mechanically ventilated patients. Some patients may develop postextubation respiratory failure that may lead to the need for re-intubation, which is associated with increased morbidity and mortality. This review comprehensively explores postextubation respiratory support strategies, focusing on the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and noninvasive ventilation (NIV) in reducing re-intubation rates among various patient populations. HFNC improves oxygenation and reduces the work of breathing. However, its effectiveness in preventing re-intubation varies according to the patient's characteristics and the predefined risk for re-intubation. NIV, alternatively, appears to provide substantial advantages in reducing the rates of re-intubation and respiratory failure, especially in patients with obesity and patients with hypercapnia. Therefore, the indiscriminate application of these support strategies without consideration of individual patient characteristics may not improve outcomes, highlighting the need for careful patient selection and tailored therapeutic strategies based on specific risk factors and clinical conditions. By aligning postextubation respiratory support strategies with patient-specific needs, we may improve the success rates of extubation, enhance overall recovery, and reduce the burden of reintubations in the intensive care setting. [ABSTRACT FROM AUTHOR]

Study Design: Submental intubation is and underutilized alternative to traditional techniques of intubation. Complications associated can indeed deter surgeons and anesthesiologist from performing it. Surgeons may opt for submental intubation if they believe that its advantages outweigh the potential risks of the procedure. Identifying the reasons of complications and implementing of proper strategies to address them can help mitigate risks. Objective: This study aims to compare and analyze the complications experienced during and after submental intubation to comment on its safety, efficacy. Revisiting literature, will help us to comment on diagnosis in trauma and associated perioperative and intraoperative complication with it. It will also help us deduce most preferred way of performing submental intubation and various methods to manage complications. Methods: Submental intubation in patients experiencing craniofacial trauma was reviewed retrospectively for 9 years from January 2015 to August 2023. Common diagnosis sites were analyzed for perioperative and postoperative complications. Results: It was found that there were no much complications faced perioperatively and also notes methods used for management of complications. Most commonly encountered postoperative complication was scar. Literature of past years was reviewed, during process we also came out with novel method for safe extubation for which we have got copyright from Government of India. Conclusions: Submental intubation is a safe and efficient intraoperative airway management technique for patients with craniomaxillofacial injuries when there is concurrent facial trauma. This study findings would underscore the safety and efficacy of SEI, making it a promising unparalleled method of airway management worth considering. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion To evaluate the safety and tolerance of elective extubations in preterm newborns (PNB) during skin‐to‐skin care (SSC) compared to those performed in an incubator.Retrospective observational study including 142 extubations in 93 PNB with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g performed during the first 2 months of life. Safety, tolerance and extubation success at 72 h were assessed.The median GA was 25.4 weeks in the SSC group versus 26.6 weeks in the incubator group (p = 0.002). The median BW was 700 grams and 880 grams, respectively (p = 0.001). In total, 60 extubations (42.3%) were performed during SSC in 42 PNB and 82 in incubator in 69 PNB. No incidents related to extubation during SSC were recorded. The extubation success rate was 80% in SSC versus 79.3% in incubator (p = 0.915). Most failures occurred between 3 and 24 h after extubation. There were no observed differences in heart rate or FiO2 variations between the groups, nor in the need to escalate respiratory support at 24 h after extubation (SSC 15% vs. incubator 12.2%, p = 0.628).Extubation during SSC is a feasible, safe and well‐tolerated practice, while allowing PNB to experience the benefits from SSC. [ABSTRACT FROM AUTHOR]

Background: Common causes of air leakage around an endotracheal tube include insufficient endotracheal tube cuff inflation and damage to the cuff, while damage to the pilot balloon or pilot balloon tubing is relatively rare. Case presentation: A 74-year-old female with vertebral osteomyelitis was scheduled for an extreme lateral interbody fusion followed posterior fixation. A fiber-optic light was utilized as part of the surgical illuminator. A sudden decrease in tidal volume and airway pressure was noted intraoperatively. We suspected leakage around the endotracheal tube cuff; however, no decrease in cuff pressure was detected. Despite the normal cuff pressure, we decided to inject a small amount of air which led to a significant increase in the cuff pressure. Upon careful inspection of the endotracheal tube, we discovered that the pilot balloon tubing was damaged as a result of thermal energy emitted by the fiber-optic light, which had ignited the surgical drape. The pilot balloon tubing was partially severed in which the section proximal to the endotracheal tube cuff was burned and punctured, causing the cuff leak. Meanwhile, the section proximal to the pilot balloon had melted and occluded the lumen, resulting in a falsely normal cuff pressure reading followed by an elevated cuff pressure when a small amount of air was injected into the pilot balloon during troubleshooting. Appropriate ventilation was resumed after extubation and re-intubation with a new endotracheal tube. Conclusions: We experienced an endotracheal tube cuff leakage caused by a damaged pilot balloon tubing due to thermal energy of the fiber-optic light. Our case report emphasizes the importance of suspecting damage to the endotracheal tube cuff and inflation system despite a normal cuff pressure reading, given that the measurement may be falsely elevated depending on the specific location of the damage. In addition, all operating personnel should be familiarized with safety warnings and cautions related to handling. [ABSTRACT FROM AUTHOR]

Background: Post‐extubation dysphagia (PED) is a common post‐extubation complication that may lead to serious problems, such as malnutrition and longer hospital and intensive care unit (ICU) stays. Aim: To explore factors associated with the readiness for oral intake in post‐extubated critically ill adult patients. Study Design: This prospective observational study involved 125 extubated patients. Readiness for oral intake was assessed using the Gugging Swallowing Screen (GUSS), and regression analysis was used to determine its predictors. Results: The median age of the participants was 40.0 years, and 51.2% were female. The median GUSS score was 12.0 (possible range, 0–20), and 35.2% of the studied patients had severe dysphagia (scored 0–9). Bivariate regression analysis showed that older age, male, higher APACHE II score, body mass index (BMI) ≥30, smoking history, longer ICU stay, muscle relaxants use, large‐bore endotracheal and orogastric tubes and frequent intubation attempts were associated with lower GUSS score (p‐value <.05). Multivariate regression analysis showed that age, BMI and smoking history predicted 37.2% of the variability in the GUSS score (F = 23.865, p‐value <.001). Adding the ICU length of stay, muscle relaxants use, size of the endotracheal tube, size of the orogastric tube and frequency of intubation attempts to the regression model raised the predictability to 86.0% (F = 88.809, p‐value <.001). Conclusions: More than one‐third of extubated patients have severe PED with a high risk of aspiration. Several modifiable factors, such as muscle relaxant use and endotracheal and orogastric tube size, predict post‐extubation readiness for oral intake. Relevance to Clinical Practice: Using endotracheal and orogastric tubes of appropriate sizes, careful assessment of patients with a high risk for difficult intubation, and minimal use of muscle relaxants may help increase patients' readiness for post‐extubation oral intake. [ABSTRACT FROM AUTHOR]

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]

Background: Post‐extubation dysphagia deserves attention because it places patients at risk following extubation, especially critically ill patients in intensive care unit. However, there are limited studies of post‐extubation dysphagia in the early stages after extubation. Aim: To investigate the incidence and factors associated with post‐extubation dysphagia among patients in intensive care unit within 24 h of extubation. Study Design: A prospective descriptive study was carried out with 173 adult patients in intensive care unit with tracheal extubation at a tertiary hospital in Guangzhou, China. The Gugging Swallowing Screen was used to evaluate the swallowing function of patients 1, 4 and 24 h after extubation. Demographic and clinical data were retrieved from medical records. Results: The incidence of post‐extubation dysphagia in patients within 1, 4 and 24 h after extubation was 86.71% (n = 150), 63.01% (n = 109) and 43.35% (n = 75), respectively. The risk factors included older age (OR = 1.057, 95%CI [1.039, 1.072], p <.001), cardiovascular disease (OR = 0.098, 95%CI [0.082, 0.127], p =.012), thyroid dysfunction (OR = 5.042, 95%CI [1.527, 13.684], p <.001), non‐post‐operative admission (OR = 3.186, 95%CI [1.142, 14.422], p =.036), mechanical ventilation duration >48 h (OR = 3.558, 95%CI [1.217, 10.385], p =.020), intubation duration >24 h (OR = 0.533, 95%CI [0.278, 0.898], p =.048) and intubation model size ≤7 (OR = 0.327, 95%CI [0.158, 0.788], p <.01). Conclusions: This study revealed a high incidence of post‐extubation dysphagia in critical patients in the 24 h after extubation, with the incidence decreasing over time. Screening of early post‐extubation dysphagia after extubation is needed, but the specific evaluation time point requires further investigation. Patients with older age, cerebrovascular disease, thyroid dysfunction, post‐operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time have a higher risk of the occurrence of post‐extubation dysphagia. Relevance to Clinical Practice: The incidence of post‐extubation dysphagia is very high in the early stage. Within 24 h after extubation, the patient's swallowing function should be actively evaluated, and the occurrence of aspiration should be vigilant. Patients with older age, cerebrovascular disease, thyroid dysfunction, post‐operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time should receive more attention. [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: Postoperative sore throat, dry throat, and difficulty swallowing are frequently reported complications following general anesthesia, imposing discomfort and challenges to patients during their recovery. Objective: The aim of this study was to determine the effect of cold vapor application for 15 minutes at 0, 2, and 6 hours after extubation on sore throat, dry throat, and difficulty swallowing. Methods: This was a randomized controlled experimental study. The research was carried out with 64 patients who underwent cholecystectomy in the operating room and general surgery clinic of a state hospital between December 2016 and August 2017. Research data were collected using the American Society of Anesthesiologists classification, Mallampati scoring, patient identification form, intraoperative patient evaluation form, Ramsey Sedation Scale, Numerical Rating Scale, dry throat and difficulty swallowing evaluation form, and cuff pressure gauge. Results: It was found that cold vapor application at the 0th, 2nd, and 6th hours postoperatively had no effect on sore throat and swallowing difficulty. Mean dry throat scores of the patients in the intervention group at the second and sixth hours were significantly lower than those in the control group. At the 24th hour, there was no statistically significant difference between the mean scores of sore throat, swallowing difficulty, and dry throat in the intervention and control groups. Conclusion: According to the results of this study, it was found that cold vapor application in the early postoperative period had no effect on sore throat and swallowing difficulty but reduced throat dryness at the second and sixth hours. Implications for Nursing: In the early postoperative period, cold vapor can be applied to relieve hoarseness due to extubation. [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: This study aims to evaluate the predictive value of bedside ultrasound evaluation of diaphragmatic dynamics in determining successful extubation outcomes for patients eligible for weaning. Methods: This prospective observational study was conducted on patients who were mechanically ventilated and ready for weaning during the spontaneous breathing trial (SBT). The diaphragm contraction and motion-related parameters of patients such as end inspiratory diaphragm thickness (DT-insp), end respiratory diaphragm thickness (DT-exp), diaphragm thickening fraction (DTF), diaphragmatic thickening fraction rapid shallow breathing index (DTF-RSBI), diaphragmatic excursion (DE), diaphragmatic excursion rapid shallow breathing index (DE-RSBI) were recorded and the association with failure in ventilatory extubation was analyzed. A receiver operating characteristic (ROC) curve was conducted to analyze the prediction of successful weaning. Results: Out of 95 patients, 14 (14.74%) died, and 68 (71.58%) were successfully extubated. There were significant differences between the two groups in all parameters except DT-exp. The results indicated that duration of mechanical ventilation (OR = 0.850, 95% CI: 0.770– 0.938, P = 0.001), DTF (OR = 1.214, 95% CI: 1.108– 1.330, P = 0.000), DTF-RSBI (OR = 0.917, 95% CI: 0.880– 0.954, P = 0.000), DE (OR = 127.02, 95% CI: 15.004– 1075.291, P = 0.000), DE-RSBI (OR = 0.752, 95% CI: 0.657– 0.861, P = 0.000) had predictive value for weaning. DTF and DE had a high sensitivity of 91.18%, 100%, respectively. Whereas, duration of mechanical ventilation, DTF-RSBI, DE-RSBI showed a high specificity of 81.48,85.19%, 81.48%. Considering all the above factors, the sensitivity was 88.24% and the specificity was 88.89%. Conclusion: Bedside ultrasound assessment of diaphragmatic parameters enables the detection of diaphragmatic dysfunction, thus proving valuable in predicting extubation success and facilitating a favorable weaning outcome. [ABSTRACT FROM AUTHOR]

Aims/Background Perioperative respiratory adverse events (PRAEs) are common in pediatric anesthesia, especially in otolaryngology procedures. In this randomized controlled trial, we investigated the impact of administering propofol before extubation on PRAEs in pediatric patients undergoing tonsillectomy and adenoidectomy. Methods We enrolled children aged 3 to 8 years old, of American Society of Anesthesiologists (ASA) classes I to III, scheduled for tonsillectomy, and randomly divided them into propofol and control groups. The subjects in the propofol group received multiple small doses of propofol (0.5 mg/kg per dose, total 1–2 mg/kg) until the patient resumed regular spontaneous breathing and exhibited no bodily movements. The subjects in the control group received 0.15 mL/kg of saline. The primary outcome was the rate of PRAEs, such as laryngospasm, bronchospasm, breath-holding spell, severe coughing, desaturation, and airway obstruction, post-extubation. The secondary outcomes were the extubation time, pre-extubation Richmond Agitation-Sedation Scale (RASS) score, end-tidal sevoflurane concentration at extubation, incidence of postoperative agitation, time to consciousness, and Face, Legs, Activity, Cry, and Consolability (FLACC) pain score in the recovery room. Results were reported with risk ratios (RR) and their 95% confidence intervals (CI), as well as the p-values indicating statistical significance. Results A total of 239 patients were included, including 119 in the propofol group and 120 in the control group. Our findings indicated no significant difference in the rate of PRAEs between the two groups (5.9% vs 10.8%, RR: 0.54, 95% CI: 0.23 to 1.31, p = 0.17). However, the propofol group showed a notable decrease in moderate to severe coughs (13.4% vs 60.0%, RR: 0.22, 95% CI: 0.14 to 0.36, p < 0.001) and postoperative agitation (4.2% vs 60.8%, RR: 0.07, 95% CI: 0.03 to 0.17, p < 0.001). Conclusion This trial demonstrated that while administering repeated small doses of propofol before extubation does not significantly reduce respiratory adverse events in children undergoing tonsillectomy and adenoidectomy, it does significantly reduce the incidence of severe coughing, improving postoperative recovery and clinical outcomes. Moreover, propofol helps reduce postoperative agitation, enhancing the safety and effectiveness of postoperative care, and maintaining its valuable clinical role in postoperative management. Clinical Trial Registration ClinicalTrials.gov (NCT05769842). [ABSTRACT FROM AUTHOR]

Delirium is an acute, global cognitive disorder syndrome, also known as acute brain syndrome, characterized by disturbance of attention and awareness and fluctuation of symptoms. Its incidence is high among critically ill patients. Once patients develop delirium, it increases the risk of unplanned extubation, prolongs hospital stay, increases the risk of nosocomial infection, postintensive care syndrome-cognitive impairment, and even death. Therefore, it is of great importance to understand how delirium occurs and to reduce the incidence of delirium in critically ill patients. This paper reviews the potential pathophysiological mechanisms of delirium in critically ill patients, with the aim of better understanding its pathophysiological processes, guiding the formulation of effective prevention and treatment strategies, providing a basis for clinical medication. [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: Although the incidence of postoperative atelectasis could be reduced using lung recruitment manoeuvres, it remains high. We hypothesised that intraoperative visual lung recruitment guided by trans-oesophageal lung ultrasound would be more effective than the conventional method for managing postoperative atelectasis. Methods: In this randomised, controlled, prospective study, 84 patients undergoing thoracoscopic lobectomy were recruited from Affiliated Chengdu Fifth People's Hospital (teaching hospital) in China. Patients were grouped into trans-oesophageal lung ultrasound-guided (Group G, n = 42) and control (Group C, n = 42) groups. Methods: Lung recruitment was performed after anaesthesia induction, before chest closure and before the endotracheal tube extubation. In Group C, recruitment pressure was controlled at 30 cm H2O for 10 s (performed thrice); in Group G, the pressure was controlled at 30 cm H2O (performed thrice), and the tidal volume did not exceed 20 ml kg−1 until no atelectasis was detected by trans-oesophageal ultrasound. The primary outcome was lung ultrasound scores measured at the post anaesthesia care unit 30 min after extubation. The secondary outcomes included the oxygenation index (30 min after extubation) and the incidence of atelectasis (30 min after extubation and 3 days after surgery). Results: The final analysis included 79 patients. The lung ultrasound score was significantly higher in the control group than in the ultrasound-guided group 30 min after extubation (Group C vs. Group G, 8.6 ± 2.6 vs. 6.5 ± 2.0, P < 0.001). No significant difference in the oxygenation indexes 30 min after extubation was observed between the groups (P = 0.074); however, the incidence of atelectasis 30 min after extubation significantly differed between the two groups (Group C vs. Group G, 57% vs. 33%, P = 0.031). The incidence of atelectasis 3 days after surgery did not significantly differ between the two groups (Group C vs. Group G, 45% vs. 28%, P = 0.122). Conclusions: Lung recruitment guided by trans-oesophageal lung ultrasound can reduce lung ultrasound scores and the incidence of atelectasis at the post anaesthesia care unit 30 min after extubation. However, it does not significantly reduce the incidence of atelectasis 3 days after surgery. Trial registration: Registration number: ChiCTR2200062509. Registered on 10 /8/ 2022. [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: 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]

Objective: In our investigation, we aimed to assess the efficacy of employing lidocaine spray application around endotracheal tube cuff (ETTC) prior to intubation, alongside and the use of intracuff lidocaine application following intubation. Our primary objective encompassed an examination of the resultant effects on the cardiovascular and respiratory systems leading up to the extubation phase. Methods: Two hundred patients scheduled for gynecologic operations, with an ASA physical status of I or II and aged between 18 and 65 years, undergoing general anesthesia lasting over one hour, were recruited for the study. Patients were allocated into four groups. Group I involved the inflation of the endotracheal tube cuff with air following intubation. In Group II, 10% lidocaine was sprayed around the ETTC prior to intubation. Group III entailed the inflation of the ETTC with 2% lidocaine after intubation. Lastly, Group IV received both the pre-intubation application of 10% lidocaine spray around the ETTC and the inflation of the cuff with 2% lidocaine following intubation. Cardiovascular parameters in the early post-extubation period and occurrences of postoperative sore throat, cough, and hoarseness up to 48 hours post-operation were documented for analysis. Results: Increases were observed at cardiovasvular system parameters after extubation in all groups continued for 5 or 15 minutes. Postoperative data for sore throat, cough and hoarseness were smilar in all groups. Conclusion: The study revealed that the administration of 10% lidocaine spray around the ETTC, as well as the use of 2% lidocaine within the cuff alone or in combination, did not result in a reduction of cardiovascular system responses during the early post-extubation period. However, these interventions did lead to a decrease in postoperative respiratory system side effects, albeit not providing complete prevention of such occurrences. [ABSTRACT FROM AUTHOR]

Background: Complications of pancreatitis can lead to admission to the intensive care unit (ICU) with invasive mechanical ventilation. Reducing the duration of mechanical ventilation is challenging for critical care practitioners. Respiratory muscle weakness hinders the weaning process, thereby increasing the duration of mechanical ventilation and hindering pulmonary rehabilitation. Methods: We evaluated the effect of transcutaneous neuromodulation on predictors of extubation failure. The patient was a 51-year-old male with a history of type 2 diabetes, obesity (body mass index=35), and regular alcohol consumption of 40 g/day. The patient was admitted to ICU with a diagnosis of severe acute pancreatitis and multi-organ failure. Maximum inspiratory pressure (MIP), airway occlusion pressure at 100 ms (P0.1), rapid shallow breathing index (RSBI), and diaphragmatic thickening fraction (DTf) were measured. Results: The results demonstrated an improvement in all the parameters. Show an increase in MIP from -18 cmH2O to -37 cmH2O and a reduction in P0.1 from -5.7 cmH2O to -3.1 cmH2O. RSBI decreased from 107 to 72, and DTf increased from 20% to 35%. The patient was extubated successfully and discharged to the ward after a 28-day ICU stay. Conclusions: The application of transcutaneous neuromodulation led to an improvement in the predictive parameters of extubation failure in patients with severe acute pancreatitis, which was ultimately confirmed by ventilatory support not being required after extubation. Transcutaneous neuromodulation application helps improve respiratory parameters and systemic improvement of the patient until he is released from ICU. Transcutaneous neuromodulation should be used in combination with other physiotherapy techniques and should be included in a comprehensive rehabilitation protocol rather than as an isolated therapy. [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]

Purpose: This study aims to describe the experiences of critically ill elderly patients (CIEPs) who were treated using the high-flow nasal cannula (HFNC) after extubation. Design/methodology/approach: A descriptive phenomenological approach was conducted to interview eleven CIEPs using face-to-face semi-unstructured interviews. Participants were selected through purposive sampling. Data were analyzed using Giorgi's method. Findings: Experiences of CIEPs included their fears of failure, getting comfortable and uncomfortable, as well as asking for assistance. Fears of failure were described as involving worsening symptoms related to their diseases and failure of HFNC leading to the need for reintubation. While receiving HFNC, their breathing was comfortable, and they were free from intubation. However, they were uncomfortable because of the sensation of burning in the nasal passages. Additionally, they asked for assistance from nurses in managing their symptoms, and the alarms of HFNC oxygen therapy devices resulted in fears of HFNC failure. Originality/value: The paper indicates that CIEPs experienced physical and psychological impacts from HFNC oxygen therapy (e.g. burning sensation in the nose and fear of failure). Although they had comfortable breathing, being uncomfortable also occurred. Therefore, health-care professionals should support what CIEPs need and develop a program or guidelines for managing the complications of HFNC – neither burning noses nor psychological issues enhance the comfort of CIEPs – by considering age-related changes. [ABSTRACT FROM AUTHOR]

Objective: Heat stroke is a life-threatening condition that is characterized by body temperatures above 40 °C and central nervous system dysfunction. Immediate cooling is imperative to prevent irreversible cellular damage and improve patient outcomes. Here, we report two cases of heat stroke that highlight the use of a novel cooling suit (CarbonCool®) as a rapid cooling intervention administered in the prehospital setting, primarily focusing on patients with classic heat stroke. Methods: This study was a retrospective review of two cases involving older patients with severe classic heat stroke, wherein CarbonCool® was used. The device was deployed at the scene of the incidents, throughout transport, and into the emergency department setting, allowing for continuous cooling and medical intervention as needed. The effectiveness of the cooling device was assessed based on the rate of temperature reduction and overall clinical outcomes of the patients. Results: In both cases, CarbonCool® facilitated a rapid reduction in body temperature, aligning with the crucial requirement of immediate cooling for the management of heat stroke. The first case involved a comatose 90-year-old woman whose body temperature decreased from 42.0 to 35.8 °C within 60 min. The second case involved a comatose 70-year-old man who experienced a decrease in body temperature from 41.2 to 36.6 °C over 196 min. CarbonCool® allowed for the execution of concurrent resuscitative procedures and was compatible with various imaging modalities (including computed tomographic scan), allowing for continuous application from the scene to the intensive care unit. Moreover, both patients showed marked improvements in consciousness and were stabilized without the need for more invasive cooling procedures that are typically employed in hospital settings for such cases. Both patients were discharged without any disabilities. Conclusion: We present an innovative approach to prehospital care for patients with heat stroke through the use of CarbonCool®, highlighting its efficacy for rapid cooling and its potential impact on patient outcomes. However, further studies are warranted to fully confirm the efficacy of the system. [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]

Introduction: Recently, some centers have used extubation during extracorporeal membrane oxygenation (ECMO) to eliminate barotrauma and volutrauma as a lung rest strategy. This study aims to demonstrate the use of extubation during ECMO in children. Methods: This retrospective study was conducted from January 1, 2015, to April 1, 2023, in our pediatric intensive care unit. Results: In this study, we presented six cases that were extubated during ECMO support. In addition, we followed 130 pediatric patients on ECMO in the same period. Two patients were primarily diagnosed with cardiomyopathy, one with myocarditis, two with congenital heart defect, and one with necrotizing pneumonia. The median age of patients was 99 (interquartile range 25-75) (16.5-192) months, and all were male. Venoarterial ECMO was connected to 4 patients, and venovenous ECMO was connected to 2 patients. Six patients were extubated during ECMO on the 5th, 12th, 3rd, 4th, 3rd and 14th days of their treatment, respectively. While the patients were extubated, three of them were supported by biphasic positive airway pressure, one was supported by nasal continuous positive airway pressure, and two were provided with supplementary oxygen. Three patients were extubated under ECMO and discharged. Conclusion: The risk of mechanical ventilation related complications such as volutrauma and barotrauma could minimized in patients extubated under ECMO. In addition, sedatives, analgesics, and muscle relaxant related complications such as delirium, muscle weakness, or prolonged ventilation could reduced via awake ECMO.

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.

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:

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.

• Difficult weaning is common in the ICU and is associated with increased consumption of hospital resources and worse outcome. Protocolized weaning in this setting might improve patient-centred outcomes. • An SBT duration of either 30 min or 120 min is equally effective when used for the first weaning attempt. However, the optimal duration of SBT for patients who failed the first attempt is not known. • SL-SBT trial compared 30 min and 120 min of SBT using pressure support of 6 cm of H 2 O for difficult-to-wean patients and showed that the success rate of extubation is similar with both approaches. The optimal duration of spontaneous breath trial (SBT) for patients with difficult extubation from mechanical ventilation is unknown. This study compared extubation success with two different durations of SBT in patients who failed their first SBT. This single-center randomized controlled trial included adults on mechanical ventilation who had failed their first SBT. The participants were randomized to receive pressure support ventilation (PSV) for either 30 or 120 min. Our primary outcome was the rate of successful extubation (without reintubation within 48 h). Key secondary outcomes were the length of intensive care unit (ICU) and hospital stay and in-hospital and 90-day mortality. A total of 119 patients (62.2 % male) with a mean age of 53.9 years were randomized to undergo SBT for either 30 min (n = 60) or 120 min (n = 59). Among them, 82.4 % of patients had hypercapnic respiratory failure. The rates of successful extubation were similar with SBT of 30 min and 120 min (58.3 % vs. 59.3 %, respectively; p = 0.91). There were no significant differences between the two groups in terms of the durations of ICU and hospital stay or in-hospital and 90-day mortality. Extubation success and other clinically important outcomes were comparable between short (30 min) and long (120 min) SBT in difficult weaning. A 30-minute SBT may be acceptable in this setting. [ABSTRACT FROM AUTHOR]

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

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.

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]