We performed a retrospective case review of the experience at the Southern New Jersey Regional Trauma Center from October 1992 to March 1994. The Southern New Jersey Regional Trauma Center has a catchment area of nearly 2 million people. Data were obtained from review of the patients’ hospital records, the Trauma Registry, and minutes of the Quality Assurance Committee of the Division of Trauma, where reintubation is a mandatory review filter.
Patients admitted to the trauma ICU who required reintubation during the course of their hospitalization were studied. Patients were intubated in the field by experienced emergency medical technicians at the paramedic level or flight nurses. In the trauma admitting area or operating room, intubation was performed by experienced certified registered nurse anesthetists or anesthesiologists.
Patients were maintained on a regimen of mechanical ventilation until resuscitation was complete, operative therapeutic measures were completed, and issues compromising respiratory function (sepsis, paralysis, mechanical impediments) had been addressed or were resolved. Endotracheal tube taping, suctioning, circuit maintenance, and ventilator setting changes are performed by respiratory therapists dedicated to the trauma ICU. Minimal occlusion pressure techniques were checked twice daily at a minimum to avoid high endotracheal tube cuff pressures.
Termination of ventilatory support was determined by the trauma ICU attending surgeon, based on these initial criteria, and the achievement of objective weaning parameters (Table 1). Extuba-tions were characterized as “planned”—meeting the subjective and objective criteria, and extubated with the physician present and on his/her order; “self-extubation”—prior to meeting subjective and objective criteria, without physician orders, by the direct actions of the patient; or “unplanned”—extubation prior to meeting subjective and objective criteria, without a physician order, and as a result of actions of a third party.
Extubation failure was determined clinically, with supporting laboratory testing when possible. Reintubation was performed by experienced certified registered nurse anesthetist or anesthesiologists. Cause for extubation failure was assigned based on the notation in the chart at the time of reintubation. Pulmonary complications were identified at chart review—criteria for a diagnosis of pneumonia included a new or persistent infiltrate on chest radiograph, fever, leukocytosis, purulent sputum, and/or a positive sputum culture; patients without radiographic findings were defined as having tracheobronchitis. Atelectasis was defined as a radiographic finding of a lobar infiltrate without clinical or laboratory signs of infection. Timing of tracheostomy was determined by the attending surgeon in the trauma ICU.
Table 1—Extubation Criteria
|1. Resuscitation complete, sepsis controlled, urgent procedures|
|2. Respiratory rate <30 breaths/min|
|3. Negative inspiratory force >25 cm H2O|
|4. Vital capacity >10 mL/kg|
|5. Tidal volume >5 mL/kg|
|6. Minute ventilation <10 L/min|