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Risk Factors for Extubation Success in Patients Following Failure of a Spontaneous Breathing Trial

UMDNJ-New Jersey Medical School, Newark, NJ

Correspondence to: John R. Bach, MD, UMDNJ-New Jersey Medical School, Physical Medicine and Rehabilitation, University Hospital, B-403, 150 Bergen St, Newark, NJ 07871; e-mail: bachjr{at}umdnj.edu

To the Editor:

An interesting article considered "Risk factors for extubation failure in patients following a successful spontaneous breathing trial" (December 2006)¹ without considering extubation success rates in those who do not pass a spontaneous breathing trial! Granted, a successful spontaneous breathing trial bodes well for extubation, but what about patients with neuromuscular disease who are continuously ventilator dependent using noninvasive intermittent positive pressure ventilation (NIV) before pneumonia and acute respiratory failure develop? While only three of the reintubated patients in this article¹ had neuromuscular disease, they could not have been continuously NIV dependent if they passed a spontaneous breathing trial. We have extubated > 300 such patients who could not have passed a spontaneous breathing trial even in the months before intubation.² Indeed, our extubation success rates exceed 85% even in infants and small children with Werdnig-Hoffmann disease who cannot breathe at all spontaneously, cannot cooperate with assisted coughing, and who have insufficient bulbar-innervated muscle function for chewing, swallowing, or any verbal output.³⁴ The key is to extubate such patients once the lungs are healthy and to extubate them to full NIV (not low-span bilevel positive airway pressure) and use of assisted coughing as needed. While this critical care article¹ is valuable, it perpetrates the false notion that patients with primarily respiratory muscle failure can, and should, be evaluated and managed in the same manner as patients with intrinsic lung/airways disease. While it can be routine to extubate patients with no functioning inspiratory or expiratory musculature as long as bulbar-innervated muscles retain some function, in this case this can obviously not be predictable by a "spontaneous breathing trial."

Footnotes

Dr. Bach has no conflict of interest to disclose.

References

1. Fernando, FV, Ferguson, ND, Esteban, A, et al (2006) Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 130,1664-1671[Abstract/Free Full Text]
2. Bach, JR eds. Noninvasive mechanical ventilation. 2002,1-348 Hanley & Belfus. Philadelphia, PA:
3. Bach, JR, Niranjan, V, Weaver, B Spinal muscular atrophy type 1: a noninvasive respiratory management approach. Chest 2000;117,1100-1105[Abstract/Free Full Text]
4. Bach, JR, Baird, JS, Plosky, D, et al Spinal muscular atrophy type 1: management and outcomes. Pediatr Pulmonol 2002;34,16-22[CrossRef][ISI][Medline]

This Article Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bach, J. R. Search for Related Content PubMed PubMed Citation Articles by Bach, J. R.