High-Risk Extubation Readiness Testing for Children With Cardiac Critical Illness

Abstract

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.

Keywords: airway extubation; congenital heart defects; extubation failure; extubation readiness test; mechanical ventilation; respiratory therapy; spontaneous breathing trial; ventilator weaning; weaning failure.

Fig. 1.

Flow chart.

Fig. 2.

Control chart for (A) extubation failure, (B) rescue NRS and (C) composite of both over the three phases of study. Solid line indicates event rate; Dashed line = center line (CL) reflects the mean; Dotted lines = upper (UCL) and lower (LCL) control limits is calculated by three times standard deviation above and below the center line, respectively.