8 APRIL - JUNE 2023ELDERCARE REVIEWViraj LakdawalaBy David Vines, Chairperson, Rush University Medical CenterOnce the underlying reason for mechanical ventilation has sufficiently resolved, patients are provided a spontaneous breathing trial (SBT) with no or a low level of positive pressure support. If patients can maintain stable vital signs without developing distress for 30 to 120 minutes, they are usually considered ready for extubation failure. Unfortunately, ten to twenty percent of these patients fail extubation requiring reintubation and mechanical ventilation. In addition, mortality rates in reintubated patients have been reported at 26 to 50 percent compared to 3-12 percent in patients that remain extubated.Multiple indices and predictors have been studied to identify patients at risk of extubation failure so interventions can be provided after extubation to prevent reintubation. Some of these potential risk factors include patients older than 65 years of age, diagnosed with a chronic cardiorespiratory disease or pneumonia, rapid shallow breathing index (frequency/tidal volume) of 105, higher APACHE II scores, positive fluid balance, arterial oxygen to inspired oxygen ratio (P/F ratio) of less than 200, Glasgow coma scale score less than 8, copious secretions, absent or weak cough, peak expiratory flow less than 60 L/min, hemoglobin less than 10 g/dl, increased B-type natriuretic peptide during the SBT and prolonged weaning. The number or combination of these factors to predict extubation failure is unknown. Post extubation monitoring of these patients to detect signs of respiratory distress can allow for the application of therapies to prevent extubation failure. The issue is that the medical staff has to observe these patients closely, which can be difficult when caring for multiple patients.To identify patients at risk of respiratory failure and allocate therapy based on clinical findings, the Respiratory Assessment and Allocation of Therapy (RAAT) tool was created. The first or second RAAT score of 10 or greater predicted the need for PPV ventilation with a sensitivity and specificity of approximately 0.80. More importantly, once therapy was allocated and RAAT scores decreased, PPV was not needed. A drawback to this system is that every patient admitted to the unit or extubated needs to be scored on USING TECHNOLOGY TO IMPROVE PATIENTS OUTCOMES IN CRITICAL CONDITIONSDavid VinesIn My Opinion
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