Skip to main content

Part of the book series: Yearbook of Intensive Care and Emergency Medicine ((YEARBOOK,volume 2000))

Abstract

There are two elements to liberating a patient from mechanical ventilation. The first element, often termed ‘weaning’, consists of readiness testing and progressive withdrawal. Investigators have focused on when readiness testing can be started [1, 2] and which mode of ventilator support best accelerates the process of progressive withdrawal [3–5]. Ultimately, these efforts result in extubation, the removal of the translaryngeal endotracheal tube. Until recently, extubation received little attention, being perceived as a simple and automatic step at the end of the weaning process. Unfortunately, many investigators combine weaning and extubation failure into a single entity. In reality these are distinct processes with discrete pathophysiological causes and unique outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Ely EW, Baker AM, Dunagan DP, et al (1996) Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335: 1864–1869

    Article  PubMed  CAS  Google Scholar 

  2. Kollef MH, Shapiro SD, Silver P, et al (1997) A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 25: 567–574

    Article  PubMed  CAS  Google Scholar 

  3. Brochard L, Rauss A, Benito S, et al (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 150: 896–903

    Article  PubMed  CAS  Google Scholar 

  4. Esteban A, Frutos F, Tobin MJ, et al (1995) A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 332: 345–350

    Article  PubMed  CAS  Google Scholar 

  5. Esteban A, Alia I, Gordo F, et al (1997) Extubation outcome after spontaneous breathing trials with t-tube or pressure support ventilation. Am J Respir Crit Care Med 156: 459–465

    Article  PubMed  CAS  Google Scholar 

  6. Esteban A, Alia I, Tobin M, et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med 159: 512–518

    Article  PubMed  CAS  Google Scholar 

  7. Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J (1998) Clinical characteristics, respiratory functional parameters, and outcome of two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 158: 1855–1862

    Article  PubMed  CAS  Google Scholar 

  8. Demling RH, Read T, Lind LJ, Flanagan HL (1988) Incidence and morbidity of extubation failure in surgical intensive care patients. Crit Care Med 16: 573–577

    Article  PubMed  CAS  Google Scholar 

  9. Daley B, Garcia-Perez F, Ross S (1996) Reintubation as an outcome predictor in trauma patients. Chest 110: 1577–1580

    Article  PubMed  CAS  Google Scholar 

  10. Capdevila XJ, Perrigault PF, Perey PJ, Roustan JPA, d’Athis F (1995) Occlusion pressure and its ratio to maximum inspiratory pressure are useful predictors for successful extubation following T-piece weaning trial. Chest 108: 482–489

    Article  PubMed  CAS  Google Scholar 

  11. Del Rosario N, Sassoon CS, Chetty KG, Gruer SE, Mahutte CK (1997) Breathing pattern during acute respiratory failure and recovery. Eur Respir J 10: 2560–2565

    Article  PubMed  Google Scholar 

  12. Epstein SK, Ciubotaru RL, Wong JB (1997) Effect of failed extubation on the outcome of mechanical ventilation. Chest 112: 186–192

    Article  PubMed  CAS  Google Scholar 

  13. Rady MY, Ryan T (1999) Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 27: 340–347

    Article  PubMed  CAS  Google Scholar 

  14. Engoren M, Buderer N, Zacharias A, Habib R (1999) Variables predicting reintubation after cardiac surgical procedures. Ann Thorac Surg 67: 661–665

    Article  PubMed  CAS  Google Scholar 

  15. Nathan SD, Ishaaya AM, Koerner SK, Selman MJ (1993) Prediction of minimal pressure support during weaning from mechanical ventilation. Chest 103: 1215–1219

    Article  PubMed  CAS  Google Scholar 

  16. Jones D, Byrne P, Morgan C, Fraser I, Hyland R (1991) Positive end-expiratory pressure vs T-piece extubation after mechanical ventilation. Chest 100: 1655–1659

    Article  PubMed  CAS  Google Scholar 

  17. Saura P, Blanch L, Mestre J, Valles J, Artigas A, Fernandez R (1996) Clinical consequences of the implementation of a weaning protocol. Intensive Care Med 22: 1052–1056

    Article  PubMed  CAS  Google Scholar 

  18. Vassilakopoulos T, Zakynthinos S, Roussos C (1998) The tension-time index and the frequency/ tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. Am J Respir Crit Care Med 158: 378–385

    Article  PubMed  CAS  Google Scholar 

  19. Jubran A, Tobin MJ (1997) Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 155: 906–915

    Article  PubMed  CAS  Google Scholar 

  20. Miller R, Cole R (1996) Association between reduced cuffleak volume and postextubation stridor. Chest 110: 1035–1040

    Article  PubMed  CAS  Google Scholar 

  21. Colice G, Stukel T, Dain B (1989) Laryngeal complications of prolonged intubation. Chest 96: 877–884

    Article  PubMed  CAS  Google Scholar 

  22. Whited R (1984) A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope 94: 367–377

    Article  PubMed  CAS  Google Scholar 

  23. Darmon J-Y, Rauss A, Dreyfuss D, et al (1992) Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. Anesthesiology 77: 245–251

    Article  PubMed  CAS  Google Scholar 

  24. Stauffer JL, Olson DE, Petty TL (1981) Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 70: 65–76

    Article  PubMed  CAS  Google Scholar 

  25. de Larminat V, Montravers P, Dureuil B, Desmonts J-M (1995) Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med 23: 486–490

    Article  PubMed  Google Scholar 

  26. Burgess GE, Cooper JR, Marino RJ, et al (1979) Laryngeal competence after tracheal extubation. Anesthesiology 51: 73–77

    Article  PubMed  Google Scholar 

  27. Bach J, Saporto L (1996) Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. Chest 110: 1566–1571

    Article  PubMed  CAS  Google Scholar 

  28. Lemaire F, Teboul J-L, Cinotti L, et al (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69: 171–179

    Article  PubMed  CAS  Google Scholar 

  29. Epstein SK (1995) Etiology of extubation failure and the predictive value of the rapid shallow breathing index. Am J Respir Crit Care Med 152: 545–549

    Article  PubMed  CAS  Google Scholar 

  30. Epstein SK, Ciubotaru RL (1998) Independent effects of etiology of failure and time to re-intubation on outcome for patients failing extubation. Am J Respir Crit Care Med 158: 489–493

    Article  PubMed  CAS  Google Scholar 

  31. Tahvanainen J, Salmenpera M, Nikki P (1983) Extubation criteria after weaning from intermittent mandatory ventilation and continuous positive airway pressure. Crit Care Med 11: 702–707

    Article  PubMed  CAS  Google Scholar 

  32. Brochard L, Rua F, Lorino H, et al (1991) Inspiratory pressure support compensates for the additional work of breathing caused by the endotracheal tube. Anesthesiology 75: 739–745

    Article  PubMed  CAS  Google Scholar 

  33. Murciano D, Boczkowski J, Lecocguic Y, Milic-Emili J, Patiente R, Aubier M (1988) Tracheal occlusion pressure: a simple index to monitor respiratory muscle fatigue during acute respiratory failure in patients with chronic obstructive pulmonary disease. Ann Intern Med 108: 800–805

    Article  PubMed  CAS  Google Scholar 

  34. Schwartz D, Matthay M, Cohen N (1995) Death and other complications of emergency airway management in critically ill adults. Anesthesiology 82: 367–376

    Article  PubMed  CAS  Google Scholar 

  35. Torres A, Gatell JM, Aznar E, et al (1995) Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 152: 137–141

    Article  PubMed  CAS  Google Scholar 

  36. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94: 281–288

    Article  PubMed  CAS  Google Scholar 

  37. Esteban A, Anzueto A, Alia I, et al (1999) Mortality of patients receiving mechanical ventilation. Am J Respir Crit Care Med 159: A47 (Abst)

    Google Scholar 

  38. DeHaven CB, Kirton OC, Morgan JP, Hart AML, Shatz DV, Civetta JM (1996) Breathing measurement reduces false negative classification of tachypneic preextubation trial failures. Crit Care Med 24: 976–980

    Article  PubMed  CAS  Google Scholar 

  39. Kirton OC, DeHaven CB, Morgan JP, Windsor J, Civetta JM (1995) Elevated imposed work of breathing masquerading as ventilator weaning intolerance. Chest 108: 1021–1025

    Article  PubMed  CAS  Google Scholar 

  40. Yang KL, Tobin MJ (1991) A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 324: 1445–1450

    Article  PubMed  CAS  Google Scholar 

  41. Farias JA, Alia I, Esteban A, Golubicki AN, Olazarri FA (1998) Weaning from mechanical ventilation in pediatric intensive care patients. Intensive Care Med 24: 1070–1075

    Article  PubMed  CAS  Google Scholar 

  42. Krieger BP, Ershowsky PF, Becker DA, Gazeroglu HB (1989) Evaluation of conventional criteria for predicting successful weaning from mechanical ventilatory support in elderly patients. Crit Care Med 17: 858–861

    Article  PubMed  CAS  Google Scholar 

  43. Epstein SK, Ciubotaru RL (1996) Influence of gender and endotracheal tube size on preextubation breathing pattern. Am J Respir Crit Care Med 154: 1647–1652

    Article  PubMed  CAS  Google Scholar 

  44. Lee KH, Hui KP, Chan TB, Tan WC, Lim TK (1994) Rapid shallow breathing (frequency-tidal volume ratio) did not predict extubation outcome. Chest 105: 540–543

    Article  PubMed  CAS  Google Scholar 

  45. Jubran A, Tobin MJ (1994) Use of flow-volume curves in detecting secretions in ventilator-dependent patients. Am J Respir Crit Care Med 150: 766–769

    Article  PubMed  CAS  Google Scholar 

  46. Levy MM, Miyasaki A, Langston D (1995) Work of breathing as a weaning parameter in mechanically ventilated patients. Chest 108: 1018–1020

    Article  PubMed  CAS  Google Scholar 

  47. Hilbert G, Gruson D, Portel L, Vargas F, Gbikipi-Benissan G, Cardinaud J (1998) Airway occlusion pressure at 0.1 s (P0.1) after extubation: an early indicator of postextubation hypercapnic respiratory insufficiency. Intensive Care Med 24: 1277–1282

    Article  PubMed  CAS  Google Scholar 

  48. Meduri GU, Turner RE, Abou-Shala N, Wunderink RG, Tolley E (1996) Noninvasive positive pressure ventilation via face mask: first-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 109: 179–193

    Article  PubMed  CAS  Google Scholar 

  49. Wysocki M, Tric L,WolffM, Millet H, Herman B (1995) Noninvasive pressure support ventilation in patients with acute respiratory failure. A randomized comparison with conventional therapy. Chest 107: 761–768

    Google Scholar 

  50. Hilbert G, Gruson D, Portel L, Gbikpi-Benissan G, Cardinaud J (1998) Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J 11: 1349–1353

    Article  PubMed  CAS  Google Scholar 

  51. Chiang A, Lee K (1995) Use of noninvasive ventilation via nasal mask in patients with respiratory distress after extubation. Chin Med J 56: 94–101

    CAS  Google Scholar 

  52. Jiang J, Kao S, Wang S (1999) Effect of early application of biphasic positive airway pressure on the outcome of extubation in ventilatory weaning. Respirology 4: 161–165

    Article  PubMed  CAS  Google Scholar 

  53. Epstein SK (2000) Endotracheal extubation. Respir Care Clin N Am (in press)

    Google Scholar 

  54. Epstein SK (2000) Extubation failure: prediction and consequences. In: Levy MM, Hill NS (eds) Ventilator management strategies for critical care. Marcel Dekker, New York (in press)

    Google Scholar 

Download references

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2000 Springer-Verlag Berlin Heidelberg

About this paper

Cite this paper

Epstein, S.K. (2000). Extubation Failure. In: Vincent, JL. (eds) Yearbook of Intensive Care and Emergency Medicine 2000. Yearbook of Intensive Care and Emergency Medicine, vol 2000. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-13455-9_27

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-13455-9_27

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-66830-5

  • Online ISBN: 978-3-662-13455-9

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics