Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures

Abstract

Background: Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation.

Methods: The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure.

Results: Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797-8.864), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877-6.138), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047-3.362), P = 0.03 and OR 3.240 (1.786-5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187-3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087-3.518), P = 0.025), copious secretions (OR 4.066 (2.268-7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052-4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100-3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001).

Conclusions: Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies.

Trial registration: ClinicalTrials.gov, NCT 02450669 . Registered on 21 May 2015.

Trial registration: ClinicalTrials.gov NCT02450669.

Keywords: Airway; Extubation; Non-airway, weaning.

Conflict of interest statement

Ethics approval and consent to participate

The appropriate IRB (Comité de Protection des personnes Sud-Mediterranée III) approved the study protocol (code UF: 9242, register: 2013-A01402–43), and, based on the observational design, waived the need for written informed consent. Next of kin were informed of the study, as were patients as soon as their neurologic status was deemed adequate. Written information was delivered to the patient’s next of kin and to the patient when neurologic recovery was deemed appropriate. The study was registered on ClinicalTrials.gov (identifier number NCT 02450669).

Consent for publication

Not applicable.

Competing interests

Pr Jaber reports receiving consulting fees from Drager, Hamilton, Maquet and Fisher & Paykel.

Elie Azoulay has received fees from Gilead Sciences, Alexion, Astellas, MSD and Drager.

Julien Pottecher has received fees from Medtronic, Baxter and Getinge. The authors declare that they have no competing interests.

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Figures

Fig. 1

Flow chart for the study. From December 2013 to May 2015, 1514 extubation procedures were studied in 1453 patients from 26 centers. All extubation procedures were included: 61 patients (4.0%) were intubated twice. The median (interquartile range, IQR) number of intubation procedures included per center was 27 (11–72). The incidence of extubation failure (H48 means during the 48 hours following extubation) was 10.4% (157 of 1514 intubation procedures), with “airway”-failure, non-airway failure and mixed airway and non-airway failure incidences, respectively, of 4.6% (70 of 1514), 5.2% (78 of 1514) and 0.6% (9 of 1514)

Fig. 2

Risk factors in the final model for predicting airway failure, non-airway failure and extubation-failure. BMI, body mass index; SOFA, sequential organ failure assessment. In the final multivariate model constructed with the 1365 extubation procedures and all available data, the main predictors of airway failure were related to patient characteristics and conditions prior to extubation: female gender (OR 2.024 (1.187–3.450), P = 0.010), baseline pathology with coma as a reason for intubation (OR 4.979 (2.797–8.864), P <£0.0001), acute respiratory failure as a reason for intubation (OR 3.395 (1.877–6.138), P < 0.0001), length of ventilation > 8 days (OR 1.956 (1.087–3.518), P = 0.025), copious secretions at the time of extubation (OR 4.066 (2.268–7.292), P < 0.0001) and absence of strong cough before extubation (OR 1.876 (1.047–3.362), P = 0.035). The main predictors of non-airway failure were also related to patient characteristics and conditions prior to extubation: non-obese status (OR 2.153 (1.052–4.408), P = 0.036), baseline pathology with coma as a reason for intubation (OR 2.177 (1.301–3.642), P = 0.003), acute respiratory failure as a reason for intubation (OR 2.067 (1.217–3.510), P = 0.0072), absence of strong cough before extubation (OR 3.240 (1.786–5.879), P = 0.0001) and a SOFA score ≥ 8 (OR 1.848 (1.100–3.105), P = 0.02)