Reintubation as an Outcome Predictor in Trauma Patients

doi:10.1378/chest.110.6.1577

Chest

Volume 110, Issue 6, December 1996, Pages 1577-1580

https://doi.org/10.1378/chest.110.6.1577 Get rights and content

Study objective

Determine reintubation rate, identify its cause, and detail adverse outcomes from reintubation.

Design

Retrospective review of extubation failures in the trauma ICU.

Setting

University hospital and regional trauma center.

Patients

Four hundred five patients arriving intubated or requiring intubation during hospitalization after 2,516 traumatic injury admissions over 18 months.

Interventions

None.

Results

Reintubation incidence was 7% (27 times per 405 patients). Comparative mortality of the reintubated group (2/24=8%) is similar to overall trauma center mortality (224/2516=6.5%), but less than the cohort of patients admitted to the hospital intubated (63/405=16%). Reintubated patients had an increased frequency of stridor than reported previously (33%), and an increased tracheostomy rate (62% vs 30%). Stridor was not predictable from injury severity score, Glasgow coma score, age, sex, length of intubation, or place of intubation. Pulmonary complications (atelectasis, tracheobronchitis, pneumonia) developed in half of reintubated patients; stridorous patients did not have an increased rate of pulmonary complications.

Conclusion

Reintubation in trauma ICU patients does not predict poor outcome.

Section snippets

Materials and Methods

We performed a retrospective case review of the experience at the Southern New Jersey Regional Trauma Center from October 1992 to March 1994. The Southern New Jersey Regional Trauma Center has a catchment area of nearly 2 million people. Data were obtained from review of the patients' hospital records, the Trauma Registry, and minutes of the Quality Assurance Committee of the Division of Trauma, where reintubation is a mandatory review filter.

Patients admitted to the trauma ICU who required

Results

During the study period, 2,516 patients were admitted to the trauma center. Blunt mechanisms (motor vehicle crashes, falls, etc) were most frequent cause for hospital admission. There were 405 patients who were intubated or arrived intubated.

Twenty-four patients were reintubated 27 times for 19 planned, 5 self-extubations, and 3 unplanned extubations (Table 2). All patients were intubated orotracheally. There were 8 women and 16 men, with a mean age of 37 years (range, 14 to 80 years). Mean

Discussion

Prediction of outcome has always been a goal of medicine. Recently, economic forces, ethical concerns, and resource allocation have spurred mathematically complex prognostic formulas. Efforts to simplify prognostic determination have focused on simple characteristics or events that can be detected easily. The need for additional ventilatory support or airway protection after initial discontinuation of such support has been proposed to be a simple identifier of mortality risk in critically ill

Conclusion

Reintubation in the traumatized ICU patient is not a predictor of mortality; reintubation implies the need for prolonged airway protection and/or ventilatory support and leads to tracheostomy. Aggressive termination of ventilatory support would be possible in the trauma patient as opposed to the medical ICU or surgical ICU patient, as there is little adverse outcome from reintubation when required.

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Reintubation as a predictor of mortality [abstract]
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There are more references available in the full text version of this article.

Cited by (62)

Rocuronium is associated with an increased risk of reintubation in patients with soft tissue infections
2016, Journal of Clinical Anesthesia
To determine risk factors associated with reintubations in adult patients with soft tissue infections.
A retrospective case-control design.
Operating room and postoperative recovery area.
There were 39 patients who presented for surgical intervention of their soft tissue infection and 222 controls having general surgery who were matched for age, sex, and body mass index. All patients were older than the age of 18 years and mostly American Society of Anesthesiologists physical status of III to IV and presented to our level 1 trauma center.
Reintubation within 2 hours after planned extubation.
The following data were collected: reintubation rates, train of four ratio, reversal agents, age, sex, creatinine, smoking history, transfusion requirements, Sequential Organ Failure Assessment score, hemoglobin, and lactate.
The use of rocuronium was independently associated with increased odds of reintubation. Patients with a higher train of four ratio were more likely to be reintubated and less likely to be reversed as compared to those with a lower train of four ratio.
Soft tissue patients who have received rocuronium are at increased risk for reintubation, particularly those with renal failure. In addition, this article supports the use of neuromuscular blockade reversals, even in patients with a strong train of four ratio.
Risk factors associated with post-extubation stridor in the trauma intensive care unit
2016, American Journal of Surgery
Citation Excerpt :
Additionally, although there are articles describing absence of cuff leak as a reliable indicator of PES,5 there is some evidence that cuff leaks do not predict PES.6,13,19 Furthermore, our extubation failure rate is comparable with previously reported rates in the trauma literature ranging from 4% to 9%,12,14,20 and thus, lack of such a test does not seem to have an effect on extubation failure in our patients. Further prospective trials are needed to better describe risk factors for PES as the cause of extubation failure in a trauma population.
Post-extubation stridor is an uncommon complication in medical intensive care units (ICUs) but has not been well studied in trauma patients. We sought to determine the incidence of reintubation due to stridor in trauma patients and describe associated risk factors.
A retrospective review of all intubated trauma patients was performed. Data collected included presence of stridor, demographic data, and details of intubation and extubation.
Of all trauma patients reintubated, 31% were for stridor. Although female gender, age less than 18, blunt mechanism, and duration of intubation 5 days or more were associated with reintubation for stridor, endotracheal tube diameter was not. Mortality was not increased with reintubation.
Trauma ICU patients are reintubated for stridor at a higher rate than medical ICU patients. Age, gender, blunt mechanism, and duration of intubation are risk factors for this complication.
Variation in tracheal reintubations among patients undergoing cardiac surgery across washington state hospitals
2015, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
It also was found that patients requiring reintubation had nearly 3-fold higher 30-day mortality than patients who were not reintubated postoperatively. This was consistent with previous studies observing higher hospital mortality, increased length of ICU and hospital stay, and prolonged mechanical ventilation in patients requiring reintubation during hospitalization.1–4,17–25 It was unclear if the worse outcome observed in reintubated patients was related to complications associated with reintubation itself,6 to higher patient morbidity, or a combination of both.
The objectives of this study were to examine the variation in reintubations across Washington state hospitals that perform cardiac surgery, and explore hospital and patient characteristics associated with variation in reintubation.
Retrospective cohort study.
All nonfederal hospitals performing cardiac surgery in Washington state.
A total of 15,103 patients undergoing coronary artery bypass grafting or valvular surgery between January 1, 2008 and September 30, 2011.
None.
Patient and hospital characteristics were compared between hospitals that had a reintubation frequency≥5% or<5%. Multivariate logistic regression was used to compare the odds of reintubation across the hospitals. The authors tested for heterogeneity of odds of reintubation across hospitals by performing a likelihood ratio test on the hospital factor. After adjusting for patient-level characteristics and procedure type, significant heterogeneity in reintubations across hospitals was present (p = 0.005). This exploratory analyses suggested that hospitals with lower reintubations were more likely to have more acute care days and teaching intensive care units (ICU).
After accounting for patient and procedure characteristics, significant heterogeneity in the relative odds of requiring reintubation was present across 16 nonfederal hospitals performing cardiac surgery in Washington state. The findings suggested that greater hospital volume and ICU teaching status were associated with fewer reintubations.
Risk factors for reintubation in the post-anaesthetic care unit: A casecontrol study
2012, British Journal of Anaesthesia
Risk factors for reintubation in post-anaesthetic care units related to anaesthetic processes have not previously been reported. Our goal was to identify risk factors for reintubation in general surgical patients.
A time-matched, case–control study was conducted on anaesthetic patients between 2001 and 2011. One hundred and sixty-four reintubated patients were compared with 656 randomly selected controls.
Independent risk factors for reintubation were age <1 yr vs age 30–49 yr [odds ratio (OR)=16.4, 95% confidence interval (CI)=5.7–47.7], chronic pulmonary disease (OR=2.1, CI=1.1–4.0), preoperative hypoalbuminaemia (OR=4.9, CI=2.4–10), creatinine clearance <24 vs >60 (OR=4.1, CI=1.2–13.4), emergency case (OR=1.8, CI=1.0–3.1), operative time >3 vs <1 h (OR=3.0, CI=1.5–6.2), airway surgery (OR=32.2, CI=13.6–76), head and neck surgery (OR=3.4, CI=1.8–6.2), cardiac surgery (OR=3.8, CI=1.1–13.4), thoracic surgery (OR=6.3, CI=1.9–21.2), cardiac catheterization (OR=2.5, CI=1.1–5.5), ASA physical status III (OR=3.8, CI=1.4–10), and the use of certain types of neuromuscular blocking agent (P<0.001).
Age <1 yr, chronic pulmonary disease, preoperative hypoalbuminaemia, and renal insufficiency were patient factors for reintubation. Emergency case, head and neck, cardiothoracic and airway surgery, and operative time >3 h were operative factors, while certain neuromuscular blocking agents and ASA physical status III were anaesthetic factors for reintubation.
Involuntary cough strength and extubation outcomes for patients in an ICU
2010, Chest
Removing the artificial airway is the last step in the mechanical ventilation withdrawal process. In order to assess cough effectiveness, a critical component of this process, we evaluated the involuntary cough peak flow (CPFi) to predict the extubation outcome for patients weaned from mechanical ventilation in ICUs.
One hundred fifty patients were weaned from ventilators, passed a spontaneous breathing trial (SBT), and were judged by their physician to be ready for extubation in the Tri-Service General Hospital ICUs from February 2003 to July 2003. CPFi was induced by 2 mL of normal saline solution at the end of inspiration and measured using a hand-held respiratory mechanics monitor. All patients were then extubated.
Of 150 enrolled patients for this study, 118 (78.7%) had successful extubation and 32 (21.3%) failed. In the univariate analysis, there were higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 vs 18.5, P = .018), less negative maximum inspiratory pressure (−45.0 vs −39.0, P = .010), lower cough peak flows (CPFs) (74.0 vs 42.0 L/min, P < .001), longer postextubation hospital stays (15.0 vs 31.5 days, P < .001), and longer postextubation ICU stays (1.0 vs 9.5 days, P < .001) in the extubation failures compared with the extubation successes. In the multivariate analysis, we found that a higher APACHE II score and a lower CPF were related to increasing risk of extubation failure (odds ratio [OR] = 1.13; 95% CI, 1.03-1.25; and OR = 0.95; 95% CI, 0.93-0.98, respectively). The receiver operator characteristic curve cutoff point for CPF was 58.5 L/min, with a sensitivity of 78.8% and specificity of 78.1%.
CPFi as an indication of cough reflex has the potential to predict successful extubation in patients who pass an SBT.
A 2-minute pre-extubation protocol for ventilated intensive care unit patients
2008, American Journal of Surgery
Citation Excerpt :
This translates to an additional $1,500 in hospital costs for each additional ventilated day, and even more when ventilator-associated pneumonias or other complications supervene.5,25 These findings are similar to those reported by previous studies.26,27 The mortality rate in this study was 5.6% (12 of 213 patients).
Clinicians often are challenged with safely predicting the optimal time of extubation for ventilated patients. Commonly used weaning parameters have poor positive predictive value for successful extubation.
A total of 213 intubated patients in our 20-bed surgical intensive care unit were enrolled in a trial to test a prospective, observational, 2-minute extubation protocol (TMEP). Daily measurements were obtained on all intubated patients who met criteria, which included adequate oxygenation, systolic blood pressure, heart rate, hemoglobin, Glasgow Coma Score greater than 10t, absence of significant metabolic/respiratory acidosis, and absence of therapeutic or neurologic paralysis. During TMEP, endotracheally intubated patients were physically disconnected from the ventilator for a 2-minute period of observation while spontaneously breathing room air. Patients were extubated if they tolerated the trial without clinically significant desaturation or alteration of vital signs or mental status.
The TMEP reliably predicted successful extubations in 203 of 213 patients (95.3%). Patients who required reintubation had a longer intensive care unit stay and a longer hospital stay.
TMEP is a simple and reliable method of predicting successful extubation.

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: revision accepted June 14.

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Chest

Clinical Investigations in Critical CareReintubation as an Outcome Predictor in Trauma Patients

Study objective

Design

Setting

Patients

Interventions

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Chest

Am J Med

A comparison of four methods of weaning patients from mechanical ventilation

N Engl J Med

Quality improvement

Incidence of morbidity of extubation failure in surgical intensive care unit patients

Crit Care Med

Reintubation as a predictor of mortality [abstract]

J Trauma

Clinical Investigations in Critical Care
Reintubation as an Outcome Predictor in Trauma Patients