Voluntary Is Better Than Involuntary Cough Peak Flow for Predicting Re-Intubation After Scheduled Extubation in Cooperative Subjects

Abstract

BACKGROUND:

In this study, we compared the predictive accuracy of voluntary cough peak flow (V-CPF) and involuntary cough peak flow (IV-CPF) for re-intubation in mechanically ventilated subjects.

METHODS:

Endotracheally intubated patients who passed a spontaneous breathing trial and assessment of readiness for extubation were enrolled. Before extubation, V-CPF and IV-CPF were measured. Re-intubation was recorded at 72 h after extubation.

RESULTS:

A total of 115 extubations in 106 cooperative subjects (including 9 subjects with second extubation) and 5 extubations in 5 uncooperative subjects were recorded. At 72 h, 20 (17.4%) and 1 (25%) instances of re-intubation occurred in cooperative and uncooperative subjects, respectively. In cooperative subjects, those who had been successfully extubated had higher V-CPF than re-intubated subjects (81.3 ± 41.4 vs 51.3 ± 31.7, P = .003). However, rates were not significantly different with IV-CPF (70.9 ± 39.8 vs 55.7 ± 37.9, P = .121). Areas under the curve of the receiver operating characteristic in V-CPF and IV-CPF were 0.743 ± 0.057 and 0.632 ± 0.069 (P < .001 and P = .058, respectively, compared with area under the curve = 0.5). V-CPF had higher predictive accuracy for re-intubation than IV-CPF (P = .034). In subjects with a lower quartile and third quartile V-CPF (≤ 43.2 L/min and 43.2–68.4 L/min, respectively), V-CPF was similar to IV-CPF. However, in second quartile and upper quartile V-CPF (68.4–99.0 L/min and > 99.0 L/min, respectively), V-CPF was higher than IV-CPF (82.1 ± 9.6 vs 66.6 ± 19.5 L/min, P < .001; 135.5 ± 29.8 vs 116.2 ± 38.2 L/min, P = .006, respectively). Overall, V-CPF was higher than IV-CPF (76.0 ± 41.4 vs 68.2 ± 39.7, P = .003). In uncooperative subjects, the IV-CPF was higher than V-CPF (40.2 ± 10.2 vs 79.2 ± 29.0, P = .042).

CONCLUSIONS:

V-CPF is noninvasive. It is much more accurate than IV-CPF as a predictor of re-intubation in cooperative patients because the IV-CPF may underestimate cough strength in patients with high V-CPF. However, it is unclear which is optimal for use in uncooperative patients.

Keywords

cough peak flow spontaneous breathing trial extubation re-intubation tracheotomy

Get full access to this article

View all access options for this article.

References

MacIntyre

, Cook

, Ely

Jr , Epstein

, Fink

, Heffner

, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest, 2001; 120(6 Suppl):375S–395S.

Boles

, Bion

, Connors

, Herridge

, Marsh

, Melot

, et al. Weaning from mechanical ventilation. Eur Respir J, 2007; 29(5):1033–1056.

Macintyre

. Evidence-based assessments in the ventilator discontinuation process. Respir Care, 2012; 57(10):1611–1618.

El Solh

, Bhat

, Gunen

, Berbary

. Extubation failure in the elderly. Respir Med, 2004; 98(7):661–668.

Navalesi

, Frigerio

, Moretti

, Sommariva

, Vesconi

, Baiardi

, Levati

. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med, 2008; 36(11):2986–2992.

Solsona

, Diaz

, Vazquez

, Pilar Gracia

, Zapatero

, Marrugat

. A pilot study of a new test to predict extubation failure. Crit Care, 2009; 13(2):R56.

Liu

, Wei

, Li

, Lu

, Wang

, Zhang

, Cao

. A decision-tree model for predicting extubation outcome in elderly patients after a successful spontaneous breathing trial. Anesth Analg, 2010; 111(5):1211–1218.

Hayashi

, Gazzotti

, Vidotto

, Jardim

. Incidence, indication and complications of postoperative reintubation after elective intracranial surgery. Sao Paulo Med J, 2013; 131(3):158–165.

Epstein

, Ciubotaru

. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med, 1998; 158(2):489–493.

10.

Rothaar

, Epstein

. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opinion Crit Care, 2003; 9(1):59–66.

11.

Menon

, Joffe

, Deem

, Yanez

, Grabinsky

, Dagal

, et al. Occurrence and complications of tracheal reintubation in critically ill adults. Respir Care, 2012; 57(10):1555–1563.

12.

Smina

, Salam

, Khamiees

, Gada

, Amoateng-Adjepong

, Manthous

. Cough peak flows and extubation outcomes. Chest, 2003; 124(1):262–268.

13.

Beuret

, Roux

, Auclair

, Nourdine

, Kaaki

, Carton

. Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med, 2009; 35(6):1090–1093.

14.

Salam

, Tilluckdharry

, Amoateng-Adjepong

, Manthous

. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med, 2004; 30(7):1334–1339.

15.

Gao

, Qin

. [A study of cough peak expiratory flow in predicting extubation outcome]. Chinese Crit Care Med (Zhongguo Weizhongbing Jijiuyixue), 2009; 21(7):390–393.

16.

, Chen

, Yang

, Su

, Perng

, et al. Involuntary cough strength and extubation outcomes for patients in an ICU. Chest, 2010; 137(4):777–782.

17.

Duan

, Guo

, Han

, Tang

, Xu

, et al. Dual-mode weaning strategy for difficult-weaning tracheotomy patients: a feasibility study. Anesth Analg, 2012; 115(3):597–604.

18.

Hanley

, McNeil

. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology, 1983; 148(3):839–843.

19.

Youden

. Index for rating diagnostic tests. Cancer, 1950; 3(1):32–35.

20.

Mokhlesi

, Tulaimat

, Gluckman

, Wang

, Evans

, Corbridge

. Predicting extubation failure after successful completion of a spontaneous breathing trial. Respir Care, 2007; 52(12):1710–1717.

21.

Khamiees

, Raju

, DeGirolamo

, Amoateng-Adjepong

, Manthous

. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest, 2001; 120(4):1262–1270.

22.

Lee

, Cotterill-Jones

, Eccles

. Voluntary control of cough. Pulm Pharmacol Ther, 2002; 15(3):317–320.

23.

Magni

, Chellini

, Lavorini

, Fontana

, Widdicombe

. Voluntary and reflex cough: similarities and differences. Pulm Pharmacol Ther, 2011; 24(3):308–311.

24.

Widdicombe

, Addington

, Fontana

, Stephens

. Voluntary and reflex cough and the expiration reflex; implications for aspiration after stroke. Pulm Pharmacol Ther, 2011; 24(3):312–317.

25.

Widdicombe

, Singh

. Physiological and pathophysiological down-regulation of cough. Respir Physiology Neurobiol, 2006; 150(2-3):105–117.

26.

Hutchings

, Eccles

, Smith

, Jawad

. Voluntary cough suppression as an indication of symptom severity in upper respiratory tract infections. Eur Respir J, 1993; 6(10):1449–1454.

27.

Ackerman

. The effect of saline lavage prior to suctioning. Am J Crit Care, 1993; 2(4):326–330.

28.

Ackerman

, Mick

. Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. Am J Crit Care, 1998; 7(4):261–266.

29.

Hagler

, Traver

. Endotracheal saline and suction catheters: sources of lower airway contamination. Am J Crit Care, 1994; 3(6):444–447.

30.

Kinloch

. Instillation of normal saline during endotracheal suctioning: effects on mixed venous oxygen saturation. Am J Crit Care, 1999; 8(4):231–240; quiz 241-232.

31.

Sellares

, Ferrer

, Cano

, Loureiro

, Valencia

, Torres

. Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU. Intensive Care Med, 2011; 37(5):775–784.