Khemani et al identified risk factors for extubation failure in pediatric patients. These can help to identify a pediatric patient who may benefit from more aggressive management. The authors are from Children's Hospital Los Angeles, University of Southern California, Med-E Link (Amsterdam) and King's College London.
Patient selection: pediatric on ventilatory support, from > 37 weeks gestation to 18 years
Outcome: failure of extubation with reintubation within 48 hours
Risk factors for extubation failure prior to extubation:
(1) maximum airway pressure during airway occlusion prior to extubation (aPiMax) <= 30 cm H2O (indicates impaired respiratory system strength)
(2) longer period of ventilation
(3) higher preextubation positive end-expiratory pressure
(4) shorter height
(5) acute neurologic disease
Risk factors for extubation failure after extubation:
(1) upper airway obstruction after extubation
(2) increased respiratory effort after extubation (based on pressure rate product, pressure time product, tension time index).
(3) postextubation phase angle (degree of relative synchrony between the ribcage and abdominal movement, obtained from respiratory inductance plethysmography
pressure rate product =
= (peak to trough change in esophageal pressure during inspiration) * (respiratory rate)
The risk of reintubation was increased if
(1) The pressure rate product at 5 minutes postextubation > 500 AND aPiMax low.
(2) The pressure rate product at 5 minutes postextubation > 1000 AND aPiMax normal.
