Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
권호 표지

Risk Factors of Extubation Failure and Analysis of Cuff Leak Test as a Predictor for Postextubation Stridor

발관 실패의 위험 인자 및 발관 후 천음과 재삽관의 예측에 있어 Cuff Leak Test 의 유용성과 의미 분석

  • Lim, Seong Yong (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine) ;
  • Suh, Gee Young (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kyung, Sun Yong (Division of Pulmonary Medicine, Department of Internal Medicine, Gachon Medical School, Gil Medical Center) ;
  • An, Chang Hyeok (Division of Pulmonary Medicine, Department of Internal Medicine, Gachon Medical School, Gil Medical Center) ;
  • Park, Jung Woong (Division of Pulmonary Medicine, Department of Internal Medicine, Gachon Medical School, Gil Medical Center) ;
  • Lee, Sang Pyo (Division of Pulmonary Medicine, Department of Internal Medicine, Gachon Medical School, Gil Medical Center) ;
  • Jeong, Sung Hwan (Division of Pulmonary Medicine, Department of Internal Medicine, Gachon Medical School, Gil Medical Center) ;
  • Ham, Hyoung Suk (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Ahn, Young Mee (Division of Pulmonary Medicine, Department of Internal Medicine, Veterans Hospital) ;
  • Lim, Si Young (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine) ;
  • Koh, Won Jung (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Chung, Man Pyo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kim, Ho Joong (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kwon, O Jung (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • 임성용 (성균관대학교 의과대학 내과학교실, 강북삼성병원 호흡기내과) ;
  • 서지영 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과) ;
  • 경선영 (가천의대 길병원 호흡기내과) ;
  • 안창혁 (가천의대 길병원 호흡기내과) ;
  • 박정웅 (가천의대 길병원 호흡기내과) ;
  • 이상표 (가천의대 길병원 호흡기내과) ;
  • 정성환 (가천의대 길병원 호흡기내과) ;
  • 함형석 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과) ;
  • 안영미 (보훈병원 호흡기내과) ;
  • 임시영 (성균관대학교 의과대학 내과학교실, 강북삼성병원 호흡기내과) ;
  • 고원중 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과) ;
  • 정만표 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과) ;
  • 김호중 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과) ;
  • 권오정 (성균관대학교 의과대학 내과학교실, 삼성서울병원 호흡기내과)
  • Received : 2006.05.11
  • Accepted : 2006.07.04
  • Published : 2006.07.30
Download PDF
⟨ Previous Next ⟩

Abstract

Background: Extubation failure was associated with poor prognosis and high hospital mortality. Cuff leak test (CLT) has been proposed as a relatively simple method for detecting laryngeal obstruction that predispose toward postextubation stridor (PES) and reintubation. We examined the risk factors of extubation failure and evaluated the usefulness and limitation of CLT for predicting PES and reintubation. Methods: Thirty-four consecutive patients intubated more than 24 hours were examined. The subjects were evaluated daily for extubation readiness, and CLT was performed prior to extubation. Several parameters in the extubation success and failure group were compared. The accuracy and limitation of CLT were evaluated after choosing the thresholds values of the cuff leak volume (CLV) and percentage (CLP). Results: Of the 34 patients studied, 6 (17.6%) developed extubation failure and 3 (8.8%) were accompanied by PES. The patients who had extubation failure were more likely to have a longer duration of intubation and more severe illness. The patients who developed PES had a smaller cuff leak than the others: according to the CLV ($22.5{\pm}23.8$ vs $233.3{\pm}147.1ml$, p=0.020) or CLP ($6.2{\pm}7.3$ vs $44.3{\pm}24.7%$, p=0.013). The best cut off values for the CLV and CLP were 50ml and 14.7%, respectively. The sensitivity, negative predictive value, and specificity of CLT were relatively high, but the positive predictive value was low. Conclusion: The likelihood of developing extubation failure increases with increasing severity of illness and duration of intubation. A low CLV or CLP (<50ml or 14.7%) is useful in identifying patients at risk of PES, but the CLT is not an absolute predictor and should not be used an indicator for delaying extubation.

연구배경: 발관 실패와 관련된 위험 인자를 살펴보고, 기관내 삽관의 합병증으로 인한 후두부 폐쇄와 PES로 인한 재삽관의 위험성을 발관 전에 미리 예측하기 위한 CLT 검사의 의의 및 제한점을 알아보고자 하였다. 방 법: 24시간 이상 삽관과 인공 호흡기 치료 후 발관을 시도한 34명의 연속적인 환자들을 대상으로 발관 실패군에서 성공군과 차이를 보이는 인자를 살펴보고 CLT 를 시행해서 PES와 재삽관을 예측하는 CLV, CLP의 기준값을 구하였다. 결 과: 총 34명중 발관 실패는 6명(17.6%), PES는 3명(8.8%) 이었고 PES가 있던 3명은 모두 재삽관을 받았다. 발관 실패 환자에서 삽관 기간이 길었고, SAPS II score가 컸으며, 삽관 기간은 CLV, CLP와 역상관관계를 보였다. PES 양성 환자의 평균 CLV은 $22.5{\pm}23.8ml$로 음성 환자의 $233.3{\pm}147.1ml$보다 낮았고, CLP도 양성군에서 $6.2{\pm}7.3%$로 음성군의 $44.3{\pm}24.7%$보다 유의하게 낮았다. 가장 신뢰성 있는 CLV, CLP의 기준값은 50 ml, 14.7% 였고 CLV의 민감도는 100%, 특이도 93.5%, 양성예측도 60%, 음성예측도 100% 였고, CLP의 민감도는 100%, 특이도 87.1%, 양성예측도 42.9%, 음성예측도 100% 였다. 결 론: 삽관 기간이 길고 중증 질환 환자에서 발관 실패의 가능성이 높다. CLV, CLP가 감소되어 있을 경우 PES로 인한 재삽관 위험이 높아지므로 발관 시 주의가 필요하지만 발관의 불필요한 연기나 시도 자체에 대한 기준은 아닐것으로 생각된다.

Keywords

References

  1. Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998;158:489-93 https://doi.org/10.1164/ajrccm.158.2.9711045
  2. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest 1996;110:1035-40 https://doi.org/10.1378/chest.110.4.1035
  3. Sandhu RS, Pasquale MD, Miller K, Wasser TE. Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation. J Am Coll Surg 2000;190:682-7 https://doi.org/10.1016/S1072-7515(00)00269-6
  4. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest 1999;116:1029-31 https://doi.org/10.1378/chest.116.4.1029
  5. Colice GL, Stukel TA, Dain B. Laryngeal complications of prolonged intubation. Chest 1989; 96:877-84 https://doi.org/10.1378/chest.96.4.877
  6. Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120:1262-70 https://doi.org/10.1378/chest.120.4.1262
  7. Srivastava S, Chatila W, Amoateng-Adjepong Y, Kanagasegar S, Jacob B, Zarich S, et al. Myocardial ischemia and weaning failure in patients with coronary artery disease: an update. Crit Care Med 1999; 27:2109-12 https://doi.org/10.1097/00003246-199910000-00005
  8. Namen AM, Ely EW, Tatter SB, Case LD, Lucia MA, Smith A, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 2001;163:658-64 https://doi.org/10.1164/ajrccm.163.3.2003060
  9. DeHaven CB, Kirton OC, Morgan JP, Hart AM, Shatz DV, Civetta JM. Breathing measurement reduces false-negative classification of tachypneic preextubation trial failures. Crit Care Med 1996; 24:976-80 https://doi.org/10.1097/00003246-199606000-00017
  10. Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care 2003;9:59-66 https://doi.org/10.1097/00075198-200302000-00011
  11. Daley BJ, Garcia-Perez F, Ross SE. Reintubation as an outcome predictor in trauma patients. Chest 1996; 110:1577-80 https://doi.org/10.1378/chest.110.6.1577
  12. Rady MY, Ryan T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 1999;27:340-7 https://doi.org/10.1097/00003246-199902000-00041
  13. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997;112:186-92 https://doi.org/10.1378/chest.112.1.186
  14. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998;114:541-8 https://doi.org/10.1378/chest.114.2.541
  15. Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000;161:1912-6 https://doi.org/10.1164/ajrccm.161.6.9908068
  16. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care 2005;50:1632-8
  17. de Bast Y, de Backer D, MoraineJJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002;28:1267-72 https://doi.org/10.1007/s00134-002-1422-3
  18. Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, et al. Post-extubation stridor in intensive care unit patients: risk factors evaluation and importance of the cuff-leak test. Intensive Care Med 2003;29:69-74 https://doi.org/10.1007/s00134-002-1563-4
  19. Marik P. The cuff-leak test as a predictor of postextubation stridor: a prospective study. Respir Care 1996;41:509-11
  20. Erginel S, Ucgun I, Yildirim H, Metintas M, Parspour S. High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation. Tohoku J Exp Med 2005; 207:125-32 https://doi.org/10.1620/tjem.207.125
  21. Adderley RJ, Mullins GC. When to extubate the croup patient: the 'leak' test. Can J Anaesth 1987; 34:304-6 https://doi.org/10.1007/BF03015171