ICU计划性拔管后采取不同床头抬高角度对低氧血症发生率的影响:一项前瞻性随机对照研究

Background Children with OSAS are prone to various airway complications during tracheal extubation after tonsillectomy and adenoidectomy due to oropharyngeal secretions and oozing blood. However, few studies have examined the effect of position on airway complications after tracheal extubation in children with OSAS. The aim of this study was to investigate the appropriate position for extubation in children with OASA. Methods A total of 459 children aged 3–14 years with OSAS who underwent tonsillectomy and adenoidectomy were recruited for this study. All children were treated with the same surgical approach and standard anesthesia methods of induction of anesthesia, tracheal intubation and maintenance of anesthesia. At the end of surgery, the children were delivered to the post anesthesia care unit and randomly divided into three groups: Group A: Head-high 0° in lateral position; Group B: Head-high 15° in lateral position; Group C: Head-high 30° in lateral position. The main outcomes of this study were the pulse oxygen saturation (SpO_2) and the Sedation-Agitation Scale (SAS) scores of the children after extubation, the outflow of oral-nasal secretions and the respiratory complications. Secondary outcomes were blood pressure, heart rate, end-respiratory carbon dioxide, respiratory rate, and post-operative awakening time of the children in three groups. Results Data from a total of 423 children were statistically analyzed, 141 in Group A, 142 in Group B, and 140 in Group C. The main results showed a significant decrease in choking response after extubation in Group B (46.5%) and Group C (40.7%) compared to Group A (60.3%) ( P  < 0.05). The SAS score for postoperative agitation was higher in Group A (4.6 $$\pm$$ ± 0.9) than in Group B (4.4 $$\pm$$ ± 0.7) and Group C (4.3 $$\pm$$ ± 0.6) ( P  < 0.05). Also the SpO_2 after extubation was higher in Group B (97.2%) and Group C (97.1%) than in Group A (95.8%) ( P  < 0.05). In contrast, there was no difference in the occurrence of respiratory complication and postoperative agitation in children between Group B and Group C (all P  > 0.05). In addition, there was no difference in the amount of oral-nasal secretions among the children in the three groups (all P  > 0.05). Conclusion The head-high 15° lateral position and head-high 30° lateral position can reduce the incidence of airway complications and agitation and provide safe and comfortable extubation conditions for children during the peri-extubation period after tonsillectomy and adenoidectomy, which has certain clinical guidance value. Trial registration Registration Number: NO.ChiCTR2200055835(20,01,2022) https://www.chictr.org.cn

The ramped position is often used during endotracheal intubation to improve oxygenation, improve laryngeal views, and reduce airway complications. We sought to compare the impact of ramp angle and bed height on intubation outcomes during simulated endotracheal intubation.

Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.

BackgroundRespiratory support following postoperative extubation is of major importance to prevent hypoxemia and subsequent respiratory failure and reintubation. High-flow nasal cannula oxygen (HFNC) delivers a flow-dependent positive airway pressure and improves oxygenation by increasing end-expiratory lung volume. Whether application of HFNC may have therapeutic advantages over conventional oxygen therapy for respiratory support in the early postextubation surgical period remains to be established.Methods/designThe Optiflow for prevention of post-extubation hypoxemia after abdominal surgery (OPERA) trial is an investigator-initiated multicenter randomized controlled two-arm trial with assessor-blinded outcome assessment, randomizing 220 patients with intermediate to high risk of pulmonary complications after abdominal surgery to receive HFNC or conventional oxygen therapy following extubation, stratified by the presence of epidural analgesia and center. The primary outcome measure is the percentage of patients with postoperative hypoxemia one hour after tracheal extubation. Secondary outcome measures are postoperative pulmonary complications, need for noninvasive ventilation and intubation for respiratory failure.DiscussionThe OPERA trial is the first randomized controlled study powered to investigate whether early application of HFNC following extubation after abdominal surgery prevents against postoperative hypoxemia and pulmonary complications.Trial registrationClinicalTrials.gov Identifier: NCT01887015

… Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway … of extubation failure and are frequently associated with difficult airway management. Extubation …

Background/Aims: Post-extubation respiratory failure (PERF) is associated with poor clinica l outcomes. High-f low nasa l cannula (HF NC) ox ygen therapy has been used in patients with respiratory failure, but the clinical benefit in patients with PERF remains unclear. The aim of this study was to evaluate the clinical efficacy of HFNC compared to noninvasive ventilation (NIV) in patients with PERF. Methods: A historic retrospective cohort analysis was performed in 28 beds in the medical Intensive Care Unit (ICU) at a single medical center in South Korea. In total, 73 patients with PERF were enrolled: 39 patients who underwent NIV from April 2007 to March 2009 and 34 patients who received HFNC from April 2009 to May 2011. Results: The rate of avoidance of reintubation was not different between the HFNC group (79.4%) and NIV group (66.7%, p = 0.22). All patients with HFNC tolerated the device, whereas five of those with NIV did not tolerate treatment (p = 0.057). The mean duration of ICU stay was significantly shorter in the HFNC group than in the NIV group (13.4 days vs. 20.6 days, p = 0.015). There was no difference in ICU or in-hospital mortality rate. Conclusions: HFNC is likely to be as effective as, and better tolerated than, NIV for treatment of PERF.

… All subjects were evaluated with the head of the bed angled between 20 and 40 of elevation… predicted extubation success more often in patients intubated for respiratory failure (hypoxic …

… a decline in sleep quality. This study, based on a breathing zone captured during sleep, introduced … a comfortable oxygen-rich environment for better sleep, and facilitates a more evenly …

… , the head of the patient's bed was positioned at a 45-degree angle. The initial ventilator … cleared or that were associated with acidosis, hypoxemia, or changes in mental status. The final …

No study has evaluated the inspiratory effort in patients with obesity immediately after extubation according to the noninvasive ventilatory support used. We aimed to determine, in critically ill patients with morbid obesity, whether Non Invasive Ventilation applied with facial mask with Pressure Support above Positive End-Expiratory Pressure (PSV-PEEP) may reduce patient inspiratory efforts to a greater extent than Continuous Positive Airway Pressure (CPAP) after extubation. We conducted a post-hoc analysis based on data from a physiological study involving consecutive patients with morbid obesity prior to extubation. Flow, airway, esophageal, and gastric pressure signals were then recorded 20 min after extubation under three distinct conditions: (1) standard oxygen, (2) CPAP and (3) PSV-PEEP. Inspiratory efforts were assessed by calculation of the trans-diaphragmatic pressure (Pdi) and work-of-breathing (WOB). Fifteen patients with mean body mass index of 45 kg/m2 (± 8 kg/m2) were enrolled. WOB and Swing Pdi were lower with PSV-PEEP than with CPAP and standard oxygen respectively 5.3 [3.6–6.0] vs 8.4 [7.4–10.0] and 14.9 [11.1–22.1] J/min (p < 0.001), and 5.9 [4.0–7.8] vs 11.4 [10.1–13.1] and 19.6 [18.5–23.6] cmH2O (p < 0.001). We also observed a significant decrease of respiratory rate (RR) and RR/VT (tidal volume) ratio with the use of PSV-PEEP (24.4 [21.9–27.7] breaths/min and 65.7 [45.1–78.5] min/mL, respectively), and with the use of CPAP (24.6 [24.1–34.5] breaths/min and 75.3 [57.2–108.0] min/mL), compared with standard oxygen (29.0 [24.2–34.9] breaths/min and 81.1 [73.5–108.9] min/mL), p < 0.05. In critically ill post extubation patients with morbid obesity, both PSV-PEEP and CPAP reduced the inspiratory effort indexes including inspiratory work-of-breathing, traducing an unload of inspiratory muscles. This effect was more important when PSV-PEEP was used in comparison to CPAP, suggesting a more pronounced effect of inspiratory muscle unloading.

… Forty-one had hypoxemic ARF, 52 had hypercapnic ARF, 22 … -five percent of the patients developed ARF after extubation. … ARF and in those with hypoxemic ARF in whom the clinical …

… a fasting period of 6 h after extubation). To minimize the risk … head of the bed was kept elevated at a L 45 angle. Patients … , and the prevention of hypoxemia together result in a recovery …

BACKGROUND We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. METHODS In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. RESULTS A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups. CONCLUSIONS In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. CLINICAL TRIAL REGISTRATION NCT04566419.

Background/Aims Both diaphragmatic excursion and change in muscle thickening are measured using ultrasonography (US) to assess diaphragm function and mechanical ventilation weaning outcomes. However, which parameter can better predict successful extubation remains to be determined. The aim of this study was to compare the clinical utility of these two diaphragmatic parameters to predict extubation success. Methods This study included patients subjected to extubation trial in the medical or surgical intensive care unit of a university-affiliated hospital from May 2015 through February 2016. Diaphragm excursion and percent of thickening change (Δtdi%) were measured using US within 24 hours before extubation. Results Sixty patients were included, and 78.3% (47/60) of these patients were successfully extubated, whereas 21.7% (13/60) were not. The median degree of excursion was greater in patients with extubation success than in those with extubation failure (1.65 cm vs. 0.8 cm, p < 0.001). Patients with extubation success had a greater Δtdi% than those with extubation failure (42.1% vs. 22.5%, p = 0.03). The areas under the receiver operating curve for excursion and Δtdi% were 0.836 (95% confidence interval [CI], 0.717 to 0.919) and 0.698 (95% CI, 0.566 to 0.810), respectively (p = 0.017). Conclusions Diaphragm excursion seems more accurate than a change in the diaphragm thickness to predict extubation success.

OBJECTIVES: To investigate the effect of 90 lateral positioning on oxygenation, respiratory mechanics, and hemodynamics in ventilated intensive care patients. METHODS: Thirty-four …

BackgroundPredicting whether an obese critically ill patient can be successfully extubated may be specially challenging. Several weaning tests have been described but no physiological study has evaluated the weaning test that would best reflect the post-extubation inspiratory effort.MethodsThis was a physiological randomized crossover study in a medical and surgical single-center Intensive Care Unit, in patients with body mass index (BMI) >35 kg/m2 who were mechanically ventilated for more than 24 h and underwent a weaning test. After randomization, 17 patients were explored using five settings : pressure support ventilation (PSV) 7 and positive end-expiratory pressure (PEEP) 7 cmH2O; PSV 0 and PEEP 7cmH2O; PSV 7 and PEEP 0 cmH2O; PSV 0 and PEEP 0 cmH2O; and a T piece, and after extubation. To further minimize interaction between each setting, a period of baseline ventilation was performed between each step of the study. We hypothesized that the post-extubation work of breathing (WOB) would be similar to the T-tube WOB.ResultsRespiratory variables and esophageal and gastric pressure were recorded. Inspiratory muscle effort was calculated as the esophageal and trans-diaphragmatic pressure time products and WOB. Sixteen obese patients (BMI 44 kg/m2 ± 8) were included and successfully extubated. Post-extubation inspiratory effort, calculated by WOB, was 1.56 J/L ± 0.50, not statistically different from the T piece (1.57 J/L ± 0.56) or PSV 0 and PEEP 0 cmH2O (1.58 J/L ± 0.57), whatever the index of inspiratory effort. The three tests that maintained pressure support statistically underestimated post-extubation inspiratory effort (WOB 0.69 J/L ± 0.31, 1.15 J/L ± 0.39 and 1.09 J/L ± 0.49, respectively, p < 0.001). Respiratory mechanics and arterial blood gases did not differ between the five tests and the post-extubation condition.ConclusionsIn obese patients, inspiratory effort measured during weaning tests with either a T-piece or a PSV 0 and PEEP 0 was not different to post-extubation inspiratory effort. In contrast, weaning tests with positive pressure overestimated post-extubation inspiratory effort.Trial registrationClinical trial.gov (reference NCT01616901), 2012, June 4th

OBJECTIVES: To determine the outcomes of noninvasive ventilation (NIV) and the factors associated with NIV failure in patients with acute hypoxemic respiratory failure (AHRF). METHODS: This was a prospective observational study and all patients with AHRF requiring NIV over a one-and-a-half-year period were enrolled in the study. We recorded the etiology of AHRF and prospectively collected the data for heart rate, respiratory rate, arterial blood gases (pH, PaO2 , PaCO2 ) at baseline, 1 hour, and 4 hours. The patients were further classified into 2 groups, based on the etiology of AHRF: either acute lung injury/acute respiratory distress syndrome [ALI/ARDS], or AHRF due to other causes. The primary outcome was the need for endotracheal intubation during the ICU stay. RESULTS: During the study period, 287 patients were admitted in the ICU, and of these 40 (13.9%) (21 ALI/ARDS, 19 AHRF due to other causes; 16 male, 24 female patients; mean ± SD age 43.2 ± 20.6 years) patients with AHRF were initiated on NIV. The baseline characteristics were similar in the 2 groups. After 1 hour there was a significant decrease in respiratory rate and heart rate, with increase in pH and PaO2 ; however, there was no difference in improvement of clinical and blood-gas parameters between the 2 groups. The NIV failures, the mean ICU and hospital stay, and the hospital mortality were similar in the 2 groups. In the univariate logistic regression model the only factor associated with NIV failure was the baseline ratio of PaO2 to fraction of inspired oxygen (PaO2 /FIO2 ) (odds ratio 0.97, 95% confidence interval 0.95-0.99). CONCLUSIONS: NIV should be judiciously used in patients with AHRF. A low baseline PaO2 /FIO2 ratio was associated with NIV failure.

IntroductionA semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.MethodsA systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure.ResultsThree trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes.ConclusionsAlthough the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.

Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions are needed.

… elevation of head of bed for patients under mechanical ventilation and the factors related to such elevation … Daily hours in which patients remained with the head of the bed elevated (≥…

… Intended for healthcare professionals … Head-of-bed elevation (HOBE) has been shown to assist in reducing respiratory complications associated with mechanical ventilation; however, …

… target elevation in the treatment group was not achieved, the average head of bed elevation … Indeed, the current mean bed head elevation at the author’s institution was found to be 25 …

BACKGROUND Elevating the head of bed (HOB) to 30° to 45° is an evidence-based recommendation to prevent ventilator-associated pneumonia (VAP). However, the available scientific data are inconclusive regarding the optimal degree of HOB elevation which is safe and effective for mechanically ventilated patients. AIMS AND OBJECTIVES To investigate the impact a of semirecumbent position at 30° and 45°on the development of VAP as compared with aHOB elevation to <30°. METHODS A 5-day, single centre, prospective, randomized, controlled, parallel group, three-arm study was conducted in adult patients on mechanical ventilation staying in the intensive care unit. Patients were randomly placed in <30°, 30°, or 45° HOB elevation position on the day of intubation and followed up for 5 days. They were assessed in terms of the development of microbiologically confirmed VAP (by the culture of endotracheal aspirate) over the study period. RESULTS Sixty patients (20 in each arm) completed the study. VAP occurred in 55%, 25%, and 20% of patients in the HOB elevation to <30°, 30°, and 45°study arms, respectively. The frequency of VAP was significantly lower in the 45° compared with the <30° study arm (P = .022); there were no significant differences between the <30° and 30° as well as the 45° and 30° study groups. Unlike the frequency of VAP, the timing of the VAP (early or late) was not dependent on the degree of HOB elevation (P = .703). CONCLUSIONS Keeping the mechanically ventilated patients in a semirecumbent position as close to 45°as possible should be the goal to prevent the development of VAP. The backrest elevation <30° should be avoided unless medically indicated. RELEVANCE TO CLINICAL PRACTICE The study results reaffirm the crucial role of patient positioning, an essential nursing care intervention, in preventing VAP. Intensive care nurses can contribute to improving the VAP rates and outcomes by placing and keeping the patients in the correct position.

… Management of the ventilator and extubation were performed by the multidisciplinary team … Patients were expected to have a higher percentage of pepsin-positive oral secretions with …

… Data collection included head of bed elevation (electronic measurement on bed frame), … In addition, it would be expected that patients in the NSICU would, on average, have higher …

BackgroundThe “National Surgical Quality Improvement Program” (NSQIP) is a nationally validated, risk-adjusted database tracking surgical outcomes. NSQIP has been demonstrated to decrease complications, expenses, and mortality. In the study institution, a high rate of nosocomial pneumonia (PNEU) and prolonged ventilator days ≥48 hours (V48) was observed on the surgical service.MethodsThe hospital studied is a 500 bed university-affiliated teaching hospital performing approximately 20,000 surgical operations per year. A multidisciplinary team was formed and a series of interventions were implemented to address high pneumonia rates and prolonged intubation. Specific interventions included enforcement of protocols and adherence to the Institute for Healthcare Improvement (IHI) ventilator bundles, including head of bed elevation, sedation holidays, extubate when ready, and early nutrition. NSQIP collected pre-operative through 30-day postoperative data prospectively on 1,081 surgical patients in the intensive care unit from January 1, 2010 – July 31, 2012. The variables pneumonia and V48 undergo logistic regression and risk adjusted results of observed versus expected are calculated. Mean and confidence intervals are represented in caterpillar charts and bar graphs. Statistical analysis was via Fisher exact t-test.ResultsProgressive improvements were observed over a two-year period via three semiannual reports (SAR). Corrective measures showed a decrease in V48 with an observed to expected odds ratio (O: E) improving from 1.5 to 1.04, or 1.9% ( 7/368 patients) July 31, 2011 to 1.11% (12/1080 patients) July 31, 2012 respectively. Similarly, pneumonia rates decreased 1.36% (5/368 patients) July 31, 2011 to 1.2% ( 13/1081 patients) July 31, 2012 with O: E = 1.4 and 1.25 respectively. Statistical significance was achieved (p < .05).ConclusionGiven an estimated annual volume of 20,000 cases per year with a cost of $22,097 per episode of pneumonia and $27,654 per episode of prolonged intubation greater than 48 hours; a projected 32 avoided episodes of pneumonia and 160 avoided episodes of V48 could be realized with potential savings exceeding $5,000,000.

Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of “Institute for Healthcare Improvement Ventilator Bundle”, i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the “IHI Ventilator Bundle” combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle’s compliance should be the gold standard combination.

Background: The low acceptance rate of continuous positive airway pressure therapy in postoperative patients with untreated obstructive sleep apnea (OSA) indicates the necessity for development of an alternative postoperative airway management strategy. The authors considered whether the combination of high-flow nasal cannula and upper-body elevation could improve postoperative OSA. Methods: This nonblinded randomized crossover study performed at a single university hospital investigated the effect on a modified apnea hypopnea index, based exclusively on the airflow signal without arterial oxygen saturation criteria (flow-based apnea hypopnea index, primary outcome), of high-flow nasal cannula (20 l · min–1 with 40% oxygen concentration) with and without upper-body elevation in patients with moderate to severe OSA. Preoperative sleep studies were performed at home (control, no head-of-bed elevation) and in hospital (30-degree head-of-bed elevation). On the first and second postoperative nights, high-flow nasal cannula was applied with or without 30-degree head-of-bed elevation, assigned in random order to 23 eligible participants. Results: Twenty-two of the 23 (96%) accepted high-flow nasal cannula. Four participants resigned from the study. Control flow-based apnea hypopnea index (mean ± SD, 60 ± 12 events · h–1; n = 19) was reduced by 15 (95% CI, 6 to 30) events · h–1 with head-of-bed elevation alone (P = 0.002), 10.9 (95% CI, 1 to 21) events · h–1 with high-flow nasal cannula alone (P = 0.028), and 23 (95% CI, 13 to 32) events · h–1 with combined head-of-bed elevation and high-flow nasal cannula (P < 0.001). Compared to sole high-flow nasal cannula, additional intervention with head-of-bed elevation significantly decreased flow-based apnea hypopnea index by 12 events · h–1 (95% CI, 2 to 21; P = 0.022). High-flow nasal cannula, alone or in combination with head-of-bed elevation, also improved overnight oxygenation. No harmful events were observed. Conclusions: The combination of high-flow nasal cannula and upper-body elevation reduced OSA severity and nocturnal hypoxemia, suggesting a role for it as an alternate postoperative airway management strategy. The authors evaluated the role of high-flow nasal cannula (20 l/min with 40% oxygen concentration) with or without 30-degree head-of-bed elevation in patients with moderate to severe obstructive sleep apnea (OSA), all of whom had perioperative sleep studies evaluated by the modified apnea hypopnea index, based exclusively on the airflow signal without arterial oxygen saturation criteria. Both high-flow nasal cannula and head-of-bed elevation, independently, improved OSA significantly with an additive effect when combined. The combination of high-flow nasal cannula and upper-body elevation may be considered as an alternative postoperative airway management strategy where continuous positive airway pressure, a standard of care, is refused or is unsuitable.

Studies have shown that a ventilator associated pneumonia (VAP) bundle significantly decreases VAP rates. In this study, we evaluated existing knowledge, practices, and adherence of nurses and infection control preventionists (ICP) to the VAP bundles of care in the intensive care unit (ICU) by using qualitative and quantitative tools. Of 60 participants (56 nurses and 4 ICPs), mean knowledge score regarding specific evidence-based VAP guidelines was 5 (range 3–8) out of 10 points. Self-reported adherence to the VAP bundle ranged from 38.5 to 100%, with perfect compliance to head of bed elevation, and poorest compliance with readiness to extubate. Overall VAP median bundle compliance was 84.6%. Knowledge regarding specific components of VAP prevention is lacking. Formal training and interactive educational sessions should be performed regularly to assess the competency of key personnel regarding the VAP bundle, especially in the context of rapid nurse turnover. Incentives for retention of nurses should also be considered, so that knowledge of hospital specific initiatives such as the VAP bundles of care can be cultivated over time.

INTRODUCTION This review aimed at investigating the impact of bundle components on the prevention of ventilator-associated pneumonia (VAP) in adults and the elderly. METHODOLOGY The databases consulted were PubMed, EBSCO, and Scielo. The terms Bundle and Pneumonia were searched in combination. The original articles were selected in Spanish and English; published between January 2008 and December 2017. After eliminating the duplicate papers, an analysis of the titles and the abstracts was performed in order to select the assessed articles. A total of 18 articles were included in this review that were evaluated according to the following criteria: research reference, country of data collection, type of study, characteristics of the studied patients, analysis and intervention performed, bundle items investigated and their results, and research outcome. RESULTS Four bundle items were presented in all the investigated papers. 61% of those works were considered from seven to eight bundle items. Daily evaluation of sedation interruption and daily assessment for verifying extubation condition, head-of-bed elevation at 30 degrees, cuff pressure monitoring, coagulation prophylaxis, and oral hygiene were the most reported bundle items. One study described the increased mortality of patients under mechanical ventilation when omitted the bundle items of oral hygiene and stress ulcer prophylaxis. Head-of-bed elevation at 30 degrees was the item reported in 100% of the studied papers. CONCLUSIONS Existing research demonstrated that VAP reduction occurred when bundle items were performed for adults and the elderly. Four works showed the relevance of team education as a central approach to the event reduction related to the ventilator.

… These include combinations of the following: head-of-bed elevation to … parameters related to extubation as described below. … Fox 11 has proposed a goal of complete elimination of VAP …

Ventilator-associated pneumonia (VAP) is a potentially preventable iatrogenic illness that may develop following mechanical ventilation. A bundle for the prevention of VAP consists of different measures which may vary between institutions, and may include: elevation of the head of the bed, oral care with chlorhexidine, subglottic suctioning, daily assessment for extubation and the need for proton-pump inhibitors, use of closed suction systems, and maintaining endotracheal cuff pressure at 25 cmH2O. Our aim was to determine the efficacy of a VAP prevention bundle, consisting of the above-mentioned measures, by evaluating the incidence of VAP before (no-VAP-B group) and after (VAP-B group) the introduction of the bundle. We retrospectively evaluated the data for patients who were mechanically ventilated with an endotracheal tube, in the period between 1 September and 31 December 2014 (no-VAP-B group, n = 55, 54.5% males, mean age 67.8 ± 14.5 years) and between 1 January to 30 April 2015 (VAP-B group, n = 74, 62.1% males, mean age 64.8 ± 13.7 years). There were no statistically significant differences between no-VAP-B and VAP-B groups in demographic data, intensive care unit (ICU) mortality, hospital mortality, duration of ICU treatment, and duration of mechanical ventilation. No significant differences in the rates of VAP and early VAP (onset ≤7 days after intubation) were found between no-VAP-B and VAP-B groups (41.8% versus 25.7%, p = 0.06 and 10.9% versus 12.2%, p > 0.99, respectively). However, a significant decrease in the late VAP (onset >8 days after intubation) was found in VAP-B group compared to no-VAP-B group (13.5% versus 30.9%, p = 0.027). Overall, our results support the use of VAP prevention bundle in clinical practice.

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center. A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June 2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30- 45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable Development Goals.

Simple, no cost, and effective

High-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared. After evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53–1.06] and 0.92 [0.67–1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32–0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61–1.08] and 1.02 [0.53–1.97]; moderate and very low certainty, respectively). NPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation. PROSPERO (registration number: CRD42020139112, 01/21/2020).

The process of successfully weaning patients from invasive mechanical ventilation is a great challenge for all healthcare providers working in critical care. Despite several recent advances in the care of intensive care patients, failed extubation remains a significant problem that may result in poor patient outcomes. A lack of consensus in many areas regarding clinical approach to extubation and the peri-extubation period exists, and the numerous strategies described in this review add to the complexity of the decision faced by the clinicians involved. The process of weaning and timing of extubation may be improved by implementation of a consistent multidisciplinary approach to weaning, with a number of easily identifiable risk factors available to support clinical decision making. There are also many known risk factors that can be used to predict the likelihood of extubation failure; whilst these factors may not be easily modifiable, they do allow the identification of patients at a high risk of extubation failure who may require more detailed care and planning post extubation. Finally, a number of strategies, including non-invasive ventilation and high flow nasal oxygen therapy, are available to support carefully selected groups in the post extubation period. Evidence is emerging linking these adjuncts to a reduction in the risk of extubation failure. This article will discuss these risk factors and the evidence supporting their use in this challenging patient group.

… as inspiratory stridor leading to hypoxaemia and in severe cases post-… post extubation can be a direct consequence of the surgical procedure or associated with patient positioning (…

Background Tracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler’s position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery. Methods We enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler’s ( n  = 70) or supine ( n  = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU. Results In comparison with the supine position, the semi-Fowler’s position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P  = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P  = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P  < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P  = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P  = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference. Conclusion Tracheal extubation in the semi-Fowler’s position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position. Trial registration Chinese Clinical Trial Registry, ChiCTR1900025566 . Registered on 1st September 2019.

This review explores relevant definitions, epidemiology, management, and potential future research directions in the extubation of the challenging/difficult airway. It provides guidance on identifying patients at risk and how to approach these clinical scenarios. Based on recent literature, including large-scale audits and closed claims analysis, it is increasingly recognized that extubation of the difficult airway is a situation at risk of severe adverse events. Some strategies to manage the extubation of the challenging/difficult airway have been described. Extubating the challenging/difficult airway is a high-risk situation. However, it is fundamental to keep in mind that intended extubation is always an elective procedure. As such, it is imperative to adhere to principles of careful patient and context assessment, planning, and execution only when optimal conditions have been secured.

Background Standard high-flow nasal cannula (HFNC) is a respiratory support device widely used to manage post-extubation hypoxemic acute respiratory failure (hARF) due to greater comfort, oxygenation, alveolar recruitment, humidification, and reduction of dead space, as compared to conventional oxygen therapy. On the contrary, the effects of the new asymmetrical HFNC interface (Optiflow® Duet system (Fisher & Paykel, Healthcare, Auckland, New Zealand) is still under discussion. Our aim is investigating whether the use of asymmetrical HFNC interface presents any relevant difference, compared with the standard configuration, on lung aeration (as assessed by end-expiratory lung impedance (EELI) measured by electrical impedance tomography (EIT)), diaphragm ultrasound thickening fraction (TFdi) and excursion (DE), ventilatory efficiency (estimated by corrected minute ventilation (MV)), gas exchange, dyspnea, and comfort. Methods Pilot physiological crossover randomized controlled study enrolling 20 adults admitted to the Intensive Care unit, invasively ventilated for at least 24 h, and developing post-extubation hARF, i.e., PaO_2/set FiO_2 < 300 mmHg during Venturi mask (VM) within 120 min after extubation. Each HFNC configuration was applied in a randomized 60 min sequence at a flow rate of 60 L/min. Results Global EELI, TFdi, DE, ventilatory efficiency, gas exchange and dyspnea were not significantly different, while comfort was greater during asymmetrical HFNC support, as compared to standard interface (10 [7–10] and 8 [7–9], p-value 0.044). Conclusions In post-extubation hARF, the use of the asymmetrical HFNC, as compared to standard HFNC interface, slightly improved patient comfort without affecting lung aeration, diaphragm activity, ventilatory efficiency, dyspnea and gas exchange. Clinical trial number ClinicalTrial.gov. Registration number: NCT05838326 (01/05/2023). New & noteworthy The asymmetrical high-flow nasal cannula oxygen therapy (Optiflow® Duet system (Fisher & Paykel, Healthcare, Auckland, New Zealand) provides greater comfort as compared to standard interface; while their performance in term of lung aeration, diaphragm activity, ventilatory efficiency, dyspnea, and gas exchange is similar.

… extubation process, while the post-extubation care is aimed at … The causes of early postoperative hypoxia are multiple and … with head up, but lateral positioning and head down is still …

Background High-flow nasal cannula (HFNC) oxygen therapy has shown potential benefits in improving oxygenation in perioperative settings. However, its role in preventing early postoperative hypoxemia after extubation under deep sedation during laparoscopic surgery remains unclear. Methods This single-center randomized controlled trial enrolled 120 patients undergoing elective laparoscopic surgery. After extubation under deep sedation, patients were randomized to receive either HFNC or NC until discharge from the post-anesthesia care unit (PACU). Extubation under deep sedation was performed during emergence after discontinuation of anesthetic agents, when patients had regained spontaneous respiration but had not yet fully recovered consciousness, according to predefined clinical and bispectral index criteria.The primary outcome was hypoxemia, defined as peripheral oxygen saturation (SpO₂) < 90% for > 60 s between extubation and PACU discharge. Secondary outcomes included arterial partial pressure of oxygen/inspired oxygen fraction (PaO₂/FiO₂), arterial partial pressure of carbon dioxide (PaCO₂), heart rate, mean arterial pressure, and perioperative complications. Parameters were measured at six time points: before anesthesia (T0), immediately after extubation (T1), and at 5 (T2), 15 (T3), 30 (T4) minutes post-extubation, and at PACU discharge (T5). Results Hypoxemia occurred in 24/60 (40%) NC patients and 12/60 (20%) HFNC patients (P = 0.028). Of those, mask-assisted positive pressure ventilation was needed in 11/24 NC and 2/12 HFNC patients (P = 0.026); jaw thrust was performed in 13/24 and 10/12, respectively. At T2 and T3, PaO₂/FiO₂ was higher (T2: 333.0 ± 34.6 vs. 286.3 ± 41.7; T3: 345.9 ± 34.5 vs. 303.2 ± 40.3 mmHg; both P < 0.001) and PaCO₂ lower (T2: 42.2 ± 4.2 vs. 48.8 ± 3.8; T3: 39.6 ± 3.7 vs. 45.3 ± 3.6 mmHg; both P < 0.001) in the HFNC group. No differences were found in PACU stay or other complications. Conclusions HFNC oxygen therapy after extubation under deep sedation significantly reduces hypoxemia and improves early respiratory function versus NC, with comparable safety. Trial registration Chinese Clinical Trial Registry (ChiCTR2500107249, August 7, 2025).

Objective To identify, evaluate, and synthesize the best available evidence regarding the perioperative management of hypoxemia, providing a comprehensive clinical reference for healthcare professionals. Methods Following the “6S” evidence-based resource pyramid model, a systematic search was performed across international and domestic databases and professional society websites. The search encompassed clinical decision support tools, guidelines, evidence summaries, systematic reviews, expert consensuses, and randomized controlled trials (RCTs) published from database inception through November 2025. Two researchers independently performed quality assessment and evidence extraction for the included literature. Results Twenty articles were included, comprising 2 clinical decisions, 1 guideline, 1 expert consensus, 10 systematic reviews, and 6 RCTs. A total of 38 pieces of evidence were synthesized across eight key dimensions: initial assessment and management, oxygenation monitoring and target-directed management, risk assessment for high-risk populations, intraoperative etiology and ventilation management, selection of non-invasive respiratory support, perioperative high-flow nasal cannula (HFNC) therapy, nursing management in the PACU, and comprehensive interventions (including positioning and pharmacotherapy). Conclusion This study summarizes the best evidence for the nursing management of perioperative hypoxemia, covering the entire process from risk assessment and intraoperative intervention to PACU care. These findings provide a standardized, evidence-based framework for healthcare professionals. When implementing these strategies, clinical context and individual patient characteristics should be considered to standardize hypoxemia management, reduce the risk of perioperative complications, and optimize patient outcomes.

… the extubation techniques and positioning of the patient used … The onset of hypoxia can be delayed by first breathing 100% … the incidence of post extubation respiratory complications …

Objectives This review aimed to summarize the recent literature on positive-pressure extubation. Design A scoping review was conducted under the framework of the Joanna Briggs Institute. Data sources Web of Science, PubMed, Ovid, Cumulative Index to Nursing & Allied Health, EBSCO, Cochrane Library, Wan Fang Data, China National Knowledge Infrastructure, and China Biology Medicine databases were searched for studies on adults and children. Study selection All articles describing the use of positive-pressure extubation were considered eligible for inclusion. The exclusion criteria were articles not available in English or Chinese, and those without full text available. Data extraction and synthesis The database searches identified 8,381 articles, 15 of which could be included in this review, with an aggregated patient number of 1,544. Vital signs, including mean arterial pressure, heart rate, R-R interval, and SpO2 before and after extubation; blood gas analysis indexes, including pH, oxygen saturation, PaO2, and PaCO2 before and after extubation; and incidence of respiratory complications, including bronchospasm, laryngeal edema, aspiration atelectasis, hypoxemia, and hypercapnia, were reported in the included studies. Results The majority of these studies reported that the positive-pressure extubation technique can maintain stable vital signs and blood gas analysis indices as well as prevent complications during the peri-extubation period. Conclusions The positive-pressure extubation technique has a safety performance similar to that of the traditional negative-pressure extubation technique and may lead to better clinical outcomes, including stable vital signs, arterial blood gas analysis, and a lower incidence of respiratory complications.

Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate–severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research. Awake prone positioning of patients with acute hypoxaemic respiratory failure reduces invasive ventilation risk in patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours https://bit.ly/3ZbLNCp

BACKGROUND: Previous studies suggest that prone position could improve oxygenation and prevent lung injury. Whether prone position can improve post-extubation clinical outcomes in infants undergoing cardiac surgery is unknown. The aim of our study was to investigate the effects of prone position in preventing extubation failure in noninvasively ventilated infants after cardiac surgery. METHODS: Ninety-six infants who were weaned to nasal CPAP after congenital cardiac surgery were randomly divided into 2 groups: the prone position group (n = 48) and the supine position group (n = 48). Primary outcomes measured were extubation failure rate within 48 h of extubation and arterial blood gas values within 6 h of a mandatory prone positioning session. Secondary outcomes included nasal trauma, pressure ulcers, pneumothorax, gastroesophageal reflux, abdominal distention, in-hospital mortality, postoperative nasal CPAP duration, and hospital length of stay. RESULTS: Compared with the supine position group, the prone position group had fewer extubation failure infants (2.0% vs 14.5%, P = .02). Arterial blood gas values after 6 h after a mandatory prone positioning session showed that the PaO2 and PaO2/FIO2 in the prone position group were significantly higher than those in the supine position group (PaO2 93.3 ± 8.5 vs 82.5 ± 9.1 , P < .05; PaO2/FIO2 255.8 ± 23.6 vs 235.8 ± 20.7, P < .05). Moreover, nasal CPAP duration and total hospital length of stay in the prone position group were significantly shorter than those in the supine position group (P < .05). CONCLUSIONS: In infants supported with nasal CPAP following cardiac surgery, prone positioning improved postextubation oxygenation, helped reduced extubation failure, and reduced the duration of nasal CPAP ventilation and total hospital length of stay.

Background Prophylactic high-flow nasal cannula (HFNC) oxygen therapy can decrease the risk of extubation failure. It is frequently used in the postextubation phase alone or in combination with noninvasive ventilation. However, its physiological effects in this setting have not been thoroughly investigated. The aim of this study was to determine comprehensively the effects of HFNC applied after extubation on respiratory effort, diaphragm activity, gas exchange, ventilation distribution, and cardiovascular biomarkers. Methods This was a prospective randomized crossover physiological study in critically ill patients comparing 1 h of HFNC versus 1 h of standard oxygen after extubation. The main inclusion criteria were mechanical ventilation for at least 48 h due to acute respiratory failure, and extubation after a successful spontaneous breathing trial (SBT). We measured respiratory effort through esophageal/transdiaphragmatic pressures, and diaphragm electrical activity (ΔEAdi). Lung volumes and ventilation distribution were estimated by electrical impedance tomography. Arterial and central venous blood gases were analyzed, as well as cardiac stress biomarkers. Results We enrolled 22 patients (age 59 ± 17 years; 9 women) who had been intubated for 8 ± 6 days before extubation. Respiratory effort was significantly lower with HFNC than with standard oxygen therapy, as evidenced by esophageal pressure swings (5.3 [4.2–7.1] vs. 7.2 [5.6–10.3] cmH_2O; p  < 0.001), pressure–time product (85 [67–140] vs. 156 [114–238] cmH_2O*s/min; p  < 0.001) and ΔEAdi (10 [7–13] vs. 14 [9–16] µV; p  = 0.022). In addition, HFNC induced increases in end-expiratory lung volume and PaO_2/FiO_2 ratio, decreases in respiratory rate and ventilatory ratio, while no changes were observed in systemic hemodynamics, Troponin T, or in amino-terminal pro-B-type natriuretic peptide. Conclusions Prophylactic application of HFNC after extubation provides substantial respiratory support and unloads respiratory muscles. Trial registration January 15, 2021. NCT04711759.

IntroductionNoninvasive ventilation (NIV), as a weaning-facilitating strategy in predominantly chronic obstructive pulmonary disease (COPD) mechanically ventilated patients, is associated with reduced ventilator-associated pneumonia, total duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay, and mortality. However, this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be elucidated. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask (OM) in patients with acute respiratory failure (ARF).MethodsA randomized, prospective, controlled, unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period. Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure, after following the ICU weaning protocol. Patients were randomized immediately before elective extubation, being randomly allocated to one of the study groups: NIV or OM. We compared both groups regarding gas exchange 15 minutes, 2 hours, and 24 hours after extubation, reintubation rate after 48 hours, duration of mechanical ventilation, ICU length of stay, and hospital mortality.ResultsForty patients were randomized to receive NIV (20 patients) or OM (20 patients) after the following extubation criteria were met: pressure support (PSV) of 7 cm H2O, positive end-expiratory pressure (PEEP) of 5 cm H2O, oxygen inspiratory fraction (FiO2) ≤ 40%, arterial oxygen saturation (SaO2) ≥ 90%, and ratio of respiratory rate and tidal volume in liters (f/TV) < 105. Comparing the 20 patients (NIV) with the 18 patients (OM) that finished the study 48 hours after extubation, the rate of reintubation in NIV group was 5% and 39% in OM group (P = 0.016). Relative risk for reintubation was 0.13 (CI = 0.017 to 0.946). Absolute risk reduction for reintubation showed a decrease of 33.9%, and analysis of the number needed to treat was three. No difference was found in the length of ICU stay (P = 0.681). Hospital mortality was zero in NIV group and 22.2% in OM group (P = 0.041).ConclusionsIn this study population, NIV prevented 48 hours reintubation if applied immediately after elective extubation in patients with more than 3 days of ARF when compared with the OM group.Trial Registration numberISRCTN: 41524441.

Background High-flow nasal cannula (HFNC) oxygen therapy is being increasingly used to prevent post-extubation hypoxemic respiratory failure and reintubation. However, evidence to support the use of HFNC in chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure after extubation is limited. This study was conducted to test if HFNC is non-inferior to non-invasive ventilation (NIV) in preventing post-extubation treatment failure in COPD patients previously intubated for hypercapnic respiratory failure. Methods COPD patients with hypercapnic respiratory failure who were already receiving invasive ventilation were randomized to HFNC or NIV at extubation at two large tertiary academic teaching hospitals. The primary endpoint was treatment failure, defined as either resumption of invasive ventilation or switching to the other study treatment modality (NIV for patients in the NFNC group or vice versa). Results Ninety-six patients were randomly assigned to the HFNC group or NIV group. After secondary exclusion, 44 patients in the HFNC group and 42 patients in the NIV group were included in the analysis. The treatment failure rate in the HFNC group was 22.7% and 28.6% in the NIV group—risk difference of − 5.8% (95% CI, − 23.8–12.4%, p  = 0.535), which was significantly lower than the non-inferior margin of 9%. Analysis of the causes of treatment failure showed that treatment intolerance in the HFNC group was significantly lower than that in the NIV group, with a risk difference of − 50.0% (95% CI, − 74.6 to − 12.9%, p  = 0.015). One hour after extubation, the mean respiratory rates of both groups were faster than their baseline levels before extubation ( p  < 0.050). Twenty-four hours after extubation, the respiratory rate of the HFNC group had returned to baseline, but the NIV group was still higher than the baseline. Forty-eight hours after extubation, the respiratory rates of both groups were not significantly different from the baseline. The average number of daily airway care interventions in the NIV group was 7 (5–9.3), which was significantly higher than 6 (4–7) times in the HFNC group ( p  = 0.006). The comfort score and incidence of nasal and facial skin breakdown of the HFNC group was also significantly better than that of the NIV group [7 (6–8) vs 5 (4–7), P  < 0.001] and [0 vs 9.6%, p  = 0.027], respectively. Conclusion Among COPD patients with severe hypercapnic respiratory failure who received invasive ventilation, the use of HFNC after extubation did not result in increased rates of treatment failure compared with NIV. HFNC also had better tolerance and comfort than NIV. Trial registration chictr.org ( ChiCTR1800018530 ). Registered on 22 September 2018, http://www.chictr.org.cn/usercenter.aspx

RATIONALE When compared to VenturiMask after extubation, high-flow nasal oxygen provides physiological advantages. OBJECTIVE To establish whether high-flow oxygen prevents endotracheal re-intubation in hypoxemic patients after extubation, as compared to VenturiMask. METHODS In this multicentre randomized trial, 494 patients exhibiting PaO2:FiO2 ratio≤300 mmHg after extubation were randomly assigned to receive high-flow or VenturiMask oxygen, with the possibility to apply rescue noninvasive ventilation before re-intubation. High-flow use in VenturiMask group was not permitted. MEASUREMENTS AND MAIN RESULTS The primary outcome was the rate of re-intubation within 72 hours according to predefined criteria, which were validated a posteriori by an independent adjudication committee. Main secondary outcomes included re-intubation rate at 28 days and the need for rescue noninvasive ventilation according to predefined criteria. After intubation criteria validation (n=492 patients), 32 patients (13%) in the high-flow group and 27 patients (11%) in the VenturiMask group required re-intubation at 72 hours (unadjusted odds ratio 1.26 [95%CI 0.70-2.26], p=0.49). At 28 days, the rate of re-intubation was 21% in the high-flow group and 23% in the VenturiMask group (adjusted hazard ratio 0.89 [95%CI 0.60-1.31], p=0.55). The need for rescue noninvasive ventilation was significantly lower in the high-flow group than in the VenturiMask group: at 72 hours, 8% vs. 17%, adjusted hazard ratio 0.39 [95%CI 0.22- 0.71], p=0.002; at 28 days, 12% vs. 21%, adjusted hazard ratio 0.52 [95%CI 0.32-0.83], p=0.007. CONCLUSIONS Re-intubation rate did not significantly differ between patients treated with VenturiMask or high-flow oxygen after extubation. High-flow oxygen yielded to less frequent use of rescue noninvasive ventilation. Clinical trial registration available at www. CLINICALTRIALS gov, ID: NCT02107183.

Background: The α2-adrenoreceptor agonist, dexmedetomidine, provides excellent sedation with minimal cardiovascular instability or respiratory depression and may be a useful adjunct to facilitate smooth tracheal extubation. Materials and Methods: Fifty American Society of Anesthesiologists grade I-II patients, aged 20-45 years, scheduled for elective general surgical, urological and gynecological surgeries were studied after randomization into two groups. Group A and B, received an intravenous infusion of dexmedetomidine 0.75 mcg/kg or placebo respectively, over 15 minutes before anticipated time of end of surgery, in a double blind manner. Anesthesia techniques were standardized. Heart rate, systolic, diastolic, mean arterial pressures were recorded while starting injection, at 1, 3, 5, 10, 15 minutes after starting injection, during extubation, at 1, 3, 5 minutes after extubation, and thereafter every 5 minutes for 30 minutes. Quality of extubation was evaluated on a 5 point scale and postoperative sedation on a 6 point scale. Any event of laryngospasm, bronchospasm, desaturation, respiratory depression, vomiting, hypotension, undue sedation was noted. Results: Heart rate, systolic, diastolic, mean arterial pressures were significantly higher in group B (P < 0.05). Extubation quality score of majority of patients was 2 in group A and 3 in group B. Sedation score of most patients was 3 in group A and 2 in group B. Bradycardia and hypotension incidences were higher in group A. One patient in group A, two patients in group B had vomiting. No patient had any other side effects. Conclusion: Dexmedetomidine 0.75 mcg/kg administered 15 minutes before extubation, stabilizes hemodynamics and facilitates smooth extubation.

Background Two extubation methods are commonly used in the intensive care unit (ICU): the traditional method with endotracheal suctioning and the positive-pressure method without suctioning. Better physiological outcomes were found in lab studies using the latter, as the air passing between the endotracheal tube and the larynx pushes out the collected subglottic secretions, which can be suctioned. Methods 70 mechanically ventilated patients in a tertiary ICU were randomised into 2 groups of 35 patients each. At the end of the spontaneous breathing trial (SBT), the positive pressure extubation (PPE) group was given a pressure support of 15 cm H2O and a positive end expiratory pressure of 10 cm H2O for 5 minutes while the other group (traditional extubation – TE) was extubated directly. We compared the lung ultrasound scores (LUS), chest X-ray findings, alveolar arterial oxygen gradient changes, adverse clinical events, ICU-free days and reintubation rates between the two groups. Results Median LUS at the end of the SBT was similar between the two groups. However, the median post-extubation LUS at 30 minutes, 6 hours, 24 hours in the PPE group [5 (4–8) (P = 0.04), 5 (3–8) (P = 0.02), 4 (3–7) (P = 0.02), respectively] were significantly lower compared to the TE group [6 (6–8), 6 (5–7.5), 6 (5–7.5), respectively]. There was a persistent lowering of the scores even at the end of 24 hours in the PPE group, while the percentage of patients without adverse clinical events was significantly higher (80% vs. 57.14%, P = 0.04). Conclusions The study shows that positive pressure extubation is a safe procedure which improves aeration and reduces adverse events.

… supplemental oxygen via nasal cannula if necessary to maintain an oxygen saturation measured … measured before and 2 and 4 h after extubation, where arterial blood gas analysis was …

IntroductionWeaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol.MethodPatients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed.ResultsSeventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay.ConclusionInclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.

OBJECTIVE To compare extubation failure rate with two ranges of nasal continuous positive airway pressure (NCPAP) in oxygen dependent preterm infants. STUDY DESIGN Preterm infants of birth weight 500-1000 g and gestational age 23-30 weeks, extubated for the first time during the first 6 weeks while requiring fraction of inspired oxygen ≥ 0.25, were randomly assigned to a NCPAP range of 4-6 (low NCPAP) or 7-9 (high NCPAP) cmH2O. RESULTS Infants were randomized to low (n = 47) or high NCPAP (n = 46) at day 16.3 ± 14.7 and 15.5 ± 12.4, respectively. Rates of extubation failure per criteria (24% vs 43%, P = .04, OR and 95% CI: 0.39 [0.16-0.96]) and re-intubation (17% vs 38%, P = .023, 0.33 [0.016-0.85]) within 96 hours were significantly lower in the high- compared with the low NCPAP group. This was mainly due to a strikingly lower failure rate in the 500-750 g birth weight strata. Duration of ventilation, bronchopulmonary dysplasia, or severe bronchopulmonary dysplasia did not differ significantly. No infant developed pneumothorax during 96 hours post-extubation. CONCLUSIONS Extubation failure in preterm infants with residual lung disease was lower with NCPAP range of 7-9 compared with 4-6 cmH2O. These findings suggest the need for higher distending pressure post-extubation in the more immature infants who are still oxygen dependent.

BACKGROUND: Two orotracheal extubation techniques are described in the literature: the traditional technique and the positive-pressure technique. Although prior studies reported better clinical outcomes with the positive-pressure extubation technique, its superiority has not been extensively studied yet. This study was to determine whether the positive-pressure orotracheal extubation technique, compared with the traditional orotracheal extubation technique, reduces the incidence of major postextubation complications (up to 60 min) in critically ill adult subjects. METHODS: This was a multi-center randomized clinical trial. Subjects age > 18 y, requiring invasive mechanical ventilation through an endotracheal tube, who met the orotracheal extubation criteria were included and randomized to traditional extubation group (removing the endotracheal tube by applying continuous endotracheal suctioning during the entire procedure) or positive-pressure group (application of pressure support mode at 15/10 cm H2O during cuff deflation and extubation). The primary measure was postextubation major complications, defined as the clinical evidence of at least one of the following: desaturation, upper-airway obstruction, or vomiting. RESULTS: A total of 725 subjects was randomly assigned to the traditional extubation group (n = 358) and positive-pressure group (n = 367). Seventeen subjects were eliminated and not included in the per-protocol analysis. Of 708 subjects, 185 (26.1%) developed at least one major complication. The incidence was 27.8% (96/345) in the traditional group compared with 24.5% (89/363) in the positive-pressure group. No statistically significant differences were observed between the 2 groups (absolute risk 3% [95 CI −3 to 10]; relative risk, 0.88 [95 CI 0.69−1.13], P = .32). CONCLUSIONS: Despite the trend toward the positive-pressure group, no statistically significant differences were observed. Our findings agree with the literature in that positive-pressure extubation is a safe procedure; therefore, both techniques may be used during extubation in critically ill adult patients.

Purpose: Till date, the benefit of using noninvasive ventilation (NIV) routinely after extubation to prevent reintubation has been conflicting. We aim to demonstrate the effect of targeted-volume NIV for the prevention of reintubation and extubation failure after planned extubation in medical intensive care unit (ICU) patients. Study Design: This was a prospective, randomized controlled study. Materials and Methods: Patients on invasive mechanical ventilation for more than 48 hrs for acute respiratory failure, who were ready for extubation, were randomized into targeted-volume NIV (intervention group) or oxygen mask (controlled group) immediately after extubation and continuously for 24 hrs. Results: A total of 58 patients were enrolled in this study. The targeted-volume NIV group was observed to have a trend toward lower reintubation rate within 48 hrs compared to oxygen mask group (0% vs. 17.2%; P = 0.052). Extubation failure rate within 48 hrs was significantly lower in targeted-volume NIV group compared to oxygen mask group (0% vs. 41.38%; P < 0.001). There was a trend toward lower ICU length of stay (6[5] days vs. 10[8] days (median interquartile range [IQR]); P = 0.053) as well as shorter hospital length of stay after extubation (10[19] days vs. 18[15] days (median [IQR]); P = 0.059). There were no differences in the incidence of ventilator-associated pneumonia (VAP)/hospital-acquired pneumonia (HAP) (6.90% vs. 20.69%;P = 0.253) and 28 day-mortality (13.79% vs. 20.69%; P = 0.487). Conclusions: Our study is the first study to demonstrate the benefit of application of targeted-volume NIV immediately after extubation in reducing extubation failure rate. There was a trend toward lowering reintubation rate and shorter ICU length of stay and hospital length of stay after extubation in mixed medical ICU patients.

Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post‐extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A–a) DO2] after pediatric laparoscopic surgery.

… as 2 or more additional RCTs compared to each of the other meta-analyses. In addition to focusing on the use of HFNC after extubation and including a larger number of RCTs, other …

Awake extubation is deemed a generally safe option for tracheal extubation in low-risk patients, while anesthetized, or“deep” extubation is often considered best suited to seasoned providers due to its perceived hazards. However, inadequate data exists about the relative safety of deep and awake extubations in the adult population. Adult patients (n=220) with favorable airways undergoing elective surgeries under general tracheal anesthesia were enrolled prospectively. Following a standardized volatile anesthetic regimen, patients were randomized to undergo deep or awake tracheal extubation. The primary outcome was the occurrence of at least one airway or respiratory complication. Secondary outcomes included airway interventions, hemodynamic parameters, severe emergence agitation, and sore throat severity. Pre-extubation, awake extubations exhibited an increased rate of any airway and respiratory complications (risk ratio [RR] – 5.1; 95% confidence interval [CI] – 2.8-9.5; p<.001), attributable to greater incidences of cough (RR – 6.8; 95% CI – 3.2-14.3, p>.001) and hypoxemia (RR – 3.6; 95% CI – 1.3-10.6, p=.010). After extubation, a significantly decreased rate of one or more complications occurred in the awake extubation group (RR – 0.7; 95% CI – 0.6-1.0; p=.028). Awake extubations were associated with fewer incidences of airway obstruction (RR – 0.2; 95% CI – 0.1-0.4, p<.001) and apnea (RR – 0.3; 95% CI – 0.1-0.9; p=.025), but higher rates of any severity cough (RR – 2.9; 95% CI – 1.6-5.2; p<.001). Awake extubations required significantly fewer airway interventions after extubation (RR – 0.2; 95% CI – 0.1-0.6; p<.001). No serious adverse events occurred. Deep and awake extubations produce distinct airway and respiratory complication profiles, without either being conclusively safer. The risks posed by each technique during emergence and after extubation should be considered by anesthesia providers when formulating an extubation strategy. This study was retrospectively registered at clinicaltrials.gov (NCT05361850) on April 23, 2022.

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Dear editor, We read with great interest the article of Tongyoo et al. “High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial” published in Annals of Intensive Care [1]. The authors compared high-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) as a ventilatory support in post-extubated sepsis patients seeking a reduction of the reintubation rate using HFNC. A few reservations could be considered. We felt that the study could have followed a more comprehensive approach concerning acute respiratory failure, pulmonary mechanics and physiology of ventilatory management. This is particularly perceptible in front of the absence of data characterizing patients’ neural drive and pulmonary mechanics, namely, airway pressures, airway collapsibility and respiratory system compliance and resistance [2], both prior and after extubation, which could identify a type of patients benefiting from NIV over HFNC and vice versa. Another important factor to assess, is the patient’s psychological state which could be a cause of extubation failure and thereafter alter the adherence to a type of ventilatory support. Secondly, the causes of reintubation presented by the authors could mostly be described as consequences of severe acute respiratory failure (hypoxia, inability to clear secretion, altered mental status, cardiac arrest, etc.), whereas it would have been more adapted to characterize the direct clinical causes of the respiratory failure such as, delirium, neuromuscular disorders, laryngeal edema, airways collapsibility, left heart failure, etc. In our opinion, adapting different means of ventilatory support in accordance to the natural evolution of a disease, or in this particular case, according to the mechanism and severity of the post-extubation acute respiratory failure is more interesting than comparing one technique of ventilatory support to another. NIV is adapted in ARF associated with altered respiratory mechanics while HFNC is adapted to situations at risk of high patient–device interaction generating P-SILI (Patient Self-Inflicted Lung Injury). Perhaps, taking into consideration the previously stated data, identifying a subgroup of patients presenting the same mechanism of post-extubation respiratory failure that would benefit from one technique rather than the other would be feasible and of great value.

… oxygen saturation in patients randomised to positive pressure or suctioning extubation … The primary endpoint was the onset time of arterial hemoglobin oxygen desaturation after …

目的 探讨基于护理敏感指标监测的ICU护理质量管理的应用效果。 方法 安徽中医药大学第一附属医院ICU自2014年7月开始建立护理敏感指标小组，制定科室的护理敏感指标项目并进行筛选，然后进行科室人员的培训并收集数据，将收集的数据与护理质量挂钩，对发生的护理问题进行归因分析，积极调整护理措施，改善科室的护理质量。 结果 2018年每住院病人24 h平均护理时间短于2017年（ P < 0.01）；2016、2017和2018年ICU病人床头抬高率均低于2015年（ P < 0.01），ICU病人口腔清洁度均高于2015年（ P < 0.01）；住院病人身体约束率与胃管非计划性拔管发生均逐年降低（ P < 0.01）；2018年ICU呼吸机相关肺炎发生率高于2017年（ P < 0.01）。 结论 护理敏感指标监测应用于ICU护理管理，能有效改善ICU护理质量。

目的 观察冠脉搭桥术后低氧血症患者早期呼吸训练器治疗的疗效。 方法 2013年2月至2016年9月,冠脉搭桥术后低氧血症患者53例,随机分为对照组(n=25)和观察组(n=28)。两组均进行常规治疗,观察组在此基础上应用呼吸功能训练器进行呼吸功能锻炼。 结果 拔管后3 d,观察组1秒用力呼气容积(FEV 1 )(实测值)和FEV 1 /用力肺活量(FVC)明显高于对照组( t >3.590, P <0.01),氧分压(PaO 2 )水平显著高于对照组( t =5.824, P <0.001);两组FEV 1 (实测值)、FEV 1 (实测值/预计值)和FEV 1 /FVC均较术前降低( F >1.044, P <0.05)。观察组总住院时间短于对照组( t =-2.138, P =0.037)。两组术后1 d PaO 2 水平均较术前及拔管后3 d高( P <0.001)。两组机械通气时间和ICU住院时间无显著性差异( P >0.05)。 结论 早期呼吸训练器肺康复治疗有助于改善冠脉搭桥术后患者肺功能,进而改善氧合状态,缩短住院时间。