BACKGROUND: The ratio (E/Ea) of mitral Doppler inflow velocity to annular tissue Doppler wave velocity by transthoracic echocardiography and diaphragmatic excursion (DE) by diaphragm ultrasound have been confirmed to predict extubation outcomes. However, few studies focused on the predicting value of E/Ea and DE at different positions during a spontaneous breathing trial (SBT), as well as the effects of △E/Ea and △DE (changes in E/Ea and DE during a SBT).
METHODS: This study was a reanalysis of the data of 60 difficult-to-wean patients in a previous study published in 2017. All eligible participants were organized into respiratory failure (RF) group and extubation success (ES) group within 48 h after extubation, or re-intubation (RI) group and non-intubation (NI) group within 1 week after extubation. The risk factors for respiratory failure and re-intubation including E/Ea and △E/Ea, DE and △DE at different positions were analyzed by multivariate logistic regression, respectively. The receiver operating characteristic (ROC) curves of E/Ea (septal, lateral, average) and DE (right, left, average) were compared with each other, respectively.
RESULTS: Of the 60 patients, 29 cases developed respiratory failure within 48 h, and 14 of those cases required re-intubation within 1 week. Multivariate logistic regression showed that E/Ea were all associated with respiratory failure, while only DE (right) and DE (average) after SBT were related to re-intubation. There were no statistic differences among the ROC curves of E/Ea at different positions, nor between the ROC curves of DE. No statistical differences were shown in △E/Ea between RF and ES groups, while △DE (average) was remarkably higher in NI group than that in RI group. However, multivariate logistic regression analysis showed that △DE (average) was not associated with re-intubation.
CONCLUSIONS: E/Ea at different positions during a SBT could predict postextubation respiratory failure with no statistical differences among them. Likewise, only DE (right) and DE (average) after SBT might predict re-intubation with no statistical differences between each other.

OBJECTIVE: To assess the effect of ultrasound-guided bilateral erector spinae plane block (ESPB) on the time to extubation in patients who had undergone cardiac surgery through a midline sternotomy.
METHODS: Randomized controlled trial.
METHODS: Cairo University Hospital and National Heart Institute, Egypt.
METHODS: Patients aged 18 to 70 years who underwent a cardiac surgical procedure through a midline sternotomy.
METHODS: Recruited patients were randomized to receive either preoperative single-shot ultrasound-guided bilateral ESPB or fentanyl infusion.
METHODS: The primary outcome was the time to extubation. Other outcomes included total perioperative fentanyl consumption, pain score using the numerical rating score (NRS), length of intensive care unit (ICU) stay, and incidence of perioperative complications.
RESULTS: Two hundred and nineteen patients were available for final analysis. The mean time to extubation was significantly shorter In the ESPB group compared to the control group (159.5 ± 109.5 minutes vs 303.2 ± 95.9 minutes; mean difference, -143.7 minutes; 95% confidence interval, -171.1 to -116.3 minutes; p = 0.0001). Ultra-fast track (immediate postoperative) extubation was achieved in 23 patients (21.1%) in the ESPB group compared to only 1 patient (0.9%) in the control group. The ICU stay was significantly reduced in the ESPB group compared to the control group (mean, 47.2 ± 13.3 hours vs 78.9 ± 25.2 hours; p = 0.0001). There was a more significant reduction in NRS in the ESPB group compared to the control group for up to 24 hours postoperatively (p = 0.001).
CONCLUSIONS: Among adult patients undergoing cardiac surgery through a midline sternotomy, the extubation time was halved in patients who received single-shot bilateral ESPB compared to patients who received fentanyl infusion.

Pediatric cardiac surgery poses significant challenges in developing countries, where a considerable number of children require intervention for congenital heart disease (CHD). The utilization of endotracheal intubation and anesthesia is pivotal in conducting surgical or angiography procedures on patients with CHD exhibiting diverse anatomical and hemodynamic characteristics. The decision to extubate pediatric patients following cardiac surgery remains a crucial element of postoperative care. This article explores the complexities surrounding extubation decision-making in this population, emphasizing the critical role of surgical, physiological, and postoperative factors. Various preoperative and intraoperative factors influence the timing of extubation. Early extubation is increasingly prevalent, offering benefits like reduced length of stay and minimized drug exposure. Multidisciplinary collaboration and protocol-driven strategies contribute to improved extubation outcomes, emphasizing the need for a comprehensive approach in pediatric cardiac surgery. Future research can focus on the implementation and efficacy of standardized extubation procedures involving collaboration among healthcare experts.

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease.

BACKGROUND: We aimed to determine the epidemiology and outcomes of unplanned extubation (UE), both accidental and self-extubation, in ICU.
METHODS: A multicentre prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, and planned and unplanned extubation were recorded in each center over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes were compared based on the UE mechanism (accidental or self-extubation). Self-extubation outcomes were compared with planned extubation using a propensity-matched population. Finally, risk factors for extubation failure (re-intubation before day 7) were determined following self-extubation.
RESULTS: During the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 605 UE, 88% were self-extubation and 12% were accidental-extubations. The latter had a worse prognosis than self-extubation (34%vs. 8% ICU-mortality, p < 0.001). Self-extubation did not increase mortality compared with planned extubation (8 vs. 11%, p =  0.075). Regardless of the type of extubation, planned or unplanned, extubation failure was independently associated with a poor outcome. Cancer, higher respiratory rate, lower PaO2/FiO2 at the time of extubation, weaning process not-ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation.
CONCLUSIONS: Unplanned extubation, mostly represented by self-extubation, is common in ICU and accounts for 9% of all endotracheal extubations. While accidental extubations are a serious and infrequent adverse event, self-extubation does not increase mortality compared to planned extubation.

Early extubation after pediatric cardiac surgery has come full circle from being practiced in the early days of pediatric cardiac surgery, falling out of favor with opioid-heavy cardiostable anesthesia, and resurfacing again in more recent times as part of enhanced recovery after surgery practice. Early extubation is variably defined, but is mostly accepted as extubation that occurs within 6-8 h from the end of surgery. In recent years, the debate has shifted from early extubation in the intensive care unit to immediate extubation in the operating theatre. In this review, we examined the benefits and pitfalls of early and immediate extubation, factors that influence the success of early extubation, and potential guidelines for practice and implementation.

BACKGROUND: In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation.
METHODS: This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization.
CONCLUSIONS: We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients.
BACKGROUND: The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d\'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

OBJECTIVE: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients.
METHODS: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation.
RESULTS: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation.
CONCLUSIONS: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.

BACKGROUND: Practice on fasting prior to extubation in critically ill patients is variable. Efficacy of fasting in reducing gastric volume has not been well established. The primary objective of this study was to assess the effect of 4 h of fasting on prevalence of empty stomach using gastric ultrasonography in critically ill subjects who are fasted for extubation. The secondary objectives were to evaluate the change in gastric volumes during 4 h of fasting and to determine factors associated with empty stomach after fasting.
METHODS: This was a single-center, prospective, observational study on adult ICU subjects who were enterally fed for at least 6 h continuously and mechanically ventilated. Gastric ultrasound was performed immediately prior to commencement of fasting, after 4 h of fasting, and after nasogastric (NG) aspiration after 4 h of fasting. An empty stomach was defined as a gastric volume ≤ 1.5 mL/kg.
RESULTS: Forty subjects were recruited, and 38 (95%) had images suitable for analysis. The prevalence of empty stomach increased after 4 h of fasting (25 [65.8%] vs 31 [81.6%], P = .041) and after 4 h of fasting with NG aspiration (25 [65.8%] vs 34 [89.5%], P = .008). There was a significant difference in median (interquartile range) gastric volume per body weight between before fasting and 4 h after fasting (1.0 [0.5-1.8] mL/kg vs 0.4 [0.2-1.0] mL/kg, P < .001). No patient factors were associated with higher prevalence of empty stomach after 4 h of fasting.
CONCLUSIONS: Most mechanically ventilated subjects had empty stomachs prior to fasting for extubation. Fasting for 4 h further increased the prevalence of empty stomach at extubation to > 80%.

The incidence of extubation failure varies between 2 and 25% depending on the studied population. Few studies have been conducted in burn victims. To determine the incidence, causes, risk factors and outcome of burned patients after a failed extubation, a retrospective single-center case-control study was conducted over a period of 3 years (January 2018-December 2021). All burned patients aged over 16, ventilated for at least 24 hours and having had at least one extubation attempt were included. Extubation failure was defined as the need for re-intubation within 48 hours. Eighty-eight patients had planned extubation. These patients were divided into 2 groups comparable in terms of age and sex. Failure group: including patients with failed extubation (N= 34) and a success group (N= 64) including patients who succeeded. The incidence of extubation failure was 36.6%. Hypophosphatemia, anemia <8g/dl, duration of mechanical ventilation of 8,5 days and abundant secretions during extubation were identified as risk factors for extubation failure (p<0.05). The main cause of failure was retention of secretion (50%). Extubation failure was associated with prolonged length of stay (34 vs. 19 days, P= 0.005), increased infectious complications (P=0.007) and mortality rate (79.4%, 1.5%, P<0.001).