Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes

Objective: To determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure. Design: Twelve-month prospective, observational, clinical study. Setting: Sixteen diverse PICUs in the United States. Patients: Patients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial. Interventions: None. Measurements and Main Results: A descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3-7.1). Patient features associated with extubation failure (p < .05) included age ≤24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, SD ± 207.8 vs. success, 107.9 hrs, SD ± 171.3; p < .001), longer PICU length of stay (17.5 days, SD ± 15.6 vs. 7.6 days, SD ± 11.1; p < .001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p < .001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not. Conclusion: A variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.