Eric Tsung, MD
Fellow
Thomas Jefferson University Hospital, United States
Disclosure information not submitted.
Bridget Gekas, RRT
Respiratory Care
Thomas Jefferson University Hospital, United States
Disclosure information not submitted.
Leigha Gambino, CRNP
Advanced Practice Provider
Thomas Jefferson University Hospital, United States
Disclosure information not submitted.
Jessica Latona, MD
Assistant Professor of Surgery
Thomas Jefferson University Hospital, United States
Disclosure information not submitted.
Shari Reid, MD
Assistant Professor of Surgery
Thomas Jefferson University Hospital, United States
Disclosure information not submitted.
Joshua Marks, MD, FACS
Associate Professor of Surgery
Thomas Jefferson University Hospitals
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Title: Post-Extubation Protocol Utilizing High Flow Nasal Cannula Reduces Reintubation in a Surgical ICU
Introduction: 10-20% of intubated patients experience post-extubation respiratory failure and require reintubation. As a quality improvement project in our surgical ICU (SICU), we aimed to decrease the incidence of post-extubation respiratory failure by implementing a standardized post-extubation protocol. We hypothesized that universally utilizing high flow nasal cannula (HFNC) on high-risk patients would reduce our reintubation rate.
Methods: All intubated adult patients in the SICU of a single tertiary care, level I trauma center during a three-month period were included in this pilot study. Patients were screened for previously validated risk factors of post-extubation respiratory failure (intubation > 48 hours; prior reintubation or unplanned intubation; GCS ≤ 8 as reason for intubation; copious secretions at extubation; thoracic surgery; albumin < 2g/dL; ARISCAT score ≥ 45). Patients were extubated to HFNC at 40L/m with 50% FiO2 for 16 hours if they met ≥1 high risk criterion. A baseline arterial blood gas (ABG) was obtained within 60 minutes of successful spontaneous breathing trial and placement on HFNC. A follow-up ABG was obtained at 16 hours. Patients were transitioned to conventional oxygen therapy if oxygen saturation was ≥93% or no abnormalities on ABG were identified. The primary outcome was the rate of reintubation within 48 hours. Total ventilator days and average ventilator episodes were compared pre and post protocol. The student’s T test was used to determine significance.
Results: During the pilot study, there were no significant differences in total ventilator days pre and post protocol implementation; 235 vs 262 respectively. Similarly, average ventilator episodes were unchanged; 3.8 vs. 5.1. Reintubation within 48 hours overall decreased. Six patients were reintubated during the three-month pilot study compared to 15 reintubations during a similar time period prior to initiation of HFNC in high-risk patients; p=0.04.
Conclusions: Adherence to a post-extubation protocol successfully reduced reintubation rate in this pilot study. A standardized approach to post-extubation care utilizing routine HFNC can increase overall success in remaining extubated. Further evaluation is necessary to assess the full benefit of the protocol in decreasing the incidence of postoperative respiratory failure.