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Clinical Investigations in Critical Care |

Reengineering Respiratory Support Following Extubation*: Avoidance of Critical Care Unit Costs

Imtiaz A. Munshi, MD; Bryan DeHaven, PhD; Orlando Kirton, MD, FCCP; Danny Sleeman, MD; Miguel Navarro, RRT
Author and Funding Information

*From the Department of Surgery (Dr. Munshi), Baystate Medical Center, Springfield, MA; and the Departments of Respiratory Care (Dr. DeHaven and Mr. Navarro) and Surgery (Drs. Kirton and Sleeman), Jackson Memorial Hospital, Ryder Trauma Center, Miami, FL.

Correspondence to: Orlando C. Kirton, MD, FCCP, Associate Professor of Surgery, Department of Surgery, University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030-3955



Chest. 1999;116(4):1025-1028. doi:10.1378/chest.116.4.1025
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Study objective: We prospectively investigated alternative clinical practice strategies for critically ill trauma patients following extubation to evaluate the cost-effectiveness of these maneuvers. The primary change was elimination of the routine use of postextubation supplemental oxygen, with concurrent utilization of noninvasive positive pressure ventilatory support (NPPV) to manage occurrences of postextubation hypoxemia.

Design: Prospective, consecutive accrual of patients undergoing extubation.

Setting: Trauma ICU in a university hospital.

Interventions and measurements: All patients received mechanical ventilation using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode. The patients were extubated to room air following a 20-min preextubation trial of 5 cm H2O CPAP at Fio2 of 0.21, and demonstrating a spontaneous respiratory rate ≤ 38 breaths/min, pH ≥ 7.30, Paco2 ≤ 50 mm Hg, and Pao2 ≥ 50 mm Hg. The subgroup of patients who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of extubation were treated with NPPV for up to 48 h duration. Patients who failed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room air. Seventy-two patients (13%) became hypoxemic within 24 h, and NPPV was administered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, and received mechanical ventilation for a mean of 4 days. Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overall reintubation rate for the group (n = 536) was 6.2%; for the postextubation hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The elimination of routine supplemental oxygen via nasal cannula following extubation resulted in a potential direct cost avoidance of $50,006.88 for 451 patient days. Moreover, the 52 patients who were spared reintubation and mechanical ventilation provided an additional potential cost avoidance of $19,740.24 in unused ventilator days per patient.

Conclusion: Eliminating the routine use of supplemental oxygen and employing NPPV as a method to prevent reintubation can facilitate a more aggressive, cost-effective strategy for the management of the trauma ICU patient who has been extubated.


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