Tuberc Respir Dis.  2006 Jul;61(1):34-40.

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

• Lim SY
• Suh GY
• Kyung SY
• An CH
• Lee SP
• Park JW
• Jeong SH
• Ham HS
• Ahn YM
• Lim SY
• Koh WJ
• Chung MP
• Kim HJ
• Kwon OJ

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+/-23.8 vs 233.3+/-147.1ml, p=0.020) or CLP (6.2+/-7.3 vs 44.3+/-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.

Keyword

Extubation failure; Stridor; Cuff leak test

MeSH Terms

Hospital Mortality
Humans
Intubation
Prognosis
Respiratory Sounds*
Risk Factors*

Figure

• 

  Figure 1 Cuff leak volume according to the size of endotracheal tube. Large endotracheal tube size was associated with reduction of cuff leak volume (p=0.04).

• 

  Figure 2 Cuff leak volume according to intubation duration. There was significant negative correlation between cuff leak volume and intubation duration

• 

  Figure 3 Receiver operating characteristic (ROC) plot. True positive fraction is plotted on y-axis and the true-negative fraction is plotted on x-axis.

Reference

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. 158:489–493.

2. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest. 1996. 110:1035–1040.

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. 190:682–687.

4. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest. 1999. 116:1029–1031.

5. Colice GL, Stukel TA, Dain B. Laryngeal complications of prolonged intubation. Chest. 1989. 96:877–884.

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. 120:1262–1270.

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. 27:2109–2112.

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. 163:658–664.

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. 24:976–980.

10. Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care. 2003. 9:59–66.

11. Daley BJ, Garcia-Perez F, Ross SE. Reintubation as an outcome predictor in trauma patients. Chest. 1996. 110:1577–1580.

12. Rady MY, Ryan T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med. 1999. 27:340–347.

13. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997. 112:186–192.

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. 114:541–548.

15. Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med. 2000. 161:1912–1916.

16. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care. 2005. 50:1632–1638.

17. de Bast Y, de Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002. 28:1267–1272.

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.

19. Marik P. The cuff-leak test as a predictor of postextubation stridor: a prospective study. Respir Care. 1996. 41:509–511.

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. 207:125–132.

21. Adderley RJ, Mullins GC. When to extubate the croup patient: the "leak" test. Can J Anaesth. 1987. 34:304–306.