What's New in Critical Illness and Injury Science? Extubation Failure Predictors for 2016.

Dear Editor,

In last years, extubation failure rates range from 10% to 20%.[1] It has been proved in a Spanish large trial that extubation outcome is not influenced by breathing tests: spontaneous breathing trials with T–tube or pressure support ventilation.[2] Another previous study showed that prolonged mechanical ventilation and cough strength, but not Intensive Care Unit (ICU)-acquired paresis, were independently associated with extubation failure.[3] ICU–acquired paresis may happen in around 25% of patients after 7 days of mechanical ventilation. Cough strength is more important than a peripheral weakness for extubation outcome, and extubation should not be delayed in patients with an adequate cough even if there is peripheral paresis.[4] In this last study,[4] we have proved that strongest predictors of planned extubation failure were duration of mechanical ventilation longer than 1 week prior to extubation, ineffective cough, and severe systolic left ventricular dysfunction. We proved also that caregivers could predict the course of extubation and reintubation with a low sensitivity, and a majority of patients who failed extubation were not considered at high risk for extubation failure. Integrating the above–mentioned risk factors in the physician's assessment of the risk of extubation failure might avoid some premature extubations and the risks associated with reintubation.[4] The mortality rate in case of reintubation, still be very high; it reaches 43% in a recent work.[5] In another study published in 2006,[6] factors associated with reintubation were: an age > 65 years, chronic pulmonary or heart disease. Some new factors tested to predict extubation failure. Recently, the prediction of the patient of his own extubation can be also considered.[7] The study presented here aimed to assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). It showed that the FOUR score is superior to the GCS in the prediction of successful extubation in the general ICU population. Nevertheless, the sample of the study, as mentioned by the authors, is too small. Thus, the reliability of these results is questionable even if this study is original with an accurate research question. In addition, the time of measuring GCS score and FOUR score had not been done before any sedation and had not been measured at other times. The neurologic causes of extubation failure usually arise during ICU hospitalization and not at the beginning especially “around” extubation. To conclude, we believe that the decision to extubate still be a critical moment with multiple factors and mainly: cough, secretions, cardiopulmonary status, and caregiver's prediction. However, easily identified at–risk patients for extubation failure may benefit from noninvasive ventilation.[8]