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The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients

Wratney, Angela T. MD; Benjamin, Daniel Kelly Jr MD, PhD, MPH; Slonim, Anthony D. MD, DrPH; He, James MS; Hamel, Donna S. RRT; Cheifetz, Ira M. MD

Pediatric Critical Care Medicine: September 2008 - Volume 9 - Issue 5 - pp 490-496
doi: 10.1097/PCC.0b013e3181849901
Continuing Medical Education Article

Objective: Endotracheal tube air leak pressures are used to predict postextubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine whether the absence of an endotracheal tube air leak (air leak test ≥30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children.

Design: Prospective, blinded cohort.

Setting: Multidisciplinary pediatric intensive care unit of a university hospital.

Patients: Patients younger than or equal to 18 yrs and intubated ≥24 hrs.

Interventions: The pressure required to produce an audible endotracheal tube air leak was measured within 12 hrs of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during air leak test measurements.

Measurements and Main Results: The need for reintubation (i.e., extubation failure) was recorded during the 24-hr postextubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9 of 59). Seven patients were treated for postextubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hrs, p = 0.03. Extubation success was associated with the use of postextubation noninvasive ventilation (p = 0.04). The air leak was absent for the duration of mechanical ventilation (i.e., ≥30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value 27%, 95% confidence interval 6–60). The air leak test was ≥30 cm H2O before extubation in 47% (28 of 59) of patients yet 23 patients extubated successfully (negative predictive value 18%).

Conclusions: An endotracheal tube air leak pressure ≥30 cm H2O measured in the nonparalyzed patient before extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube. (Pediatr Crit Care Med 2008; 9:490–496)

Assistant Professor of Pediatrics (ATW), George Washington University, Critical Care Medicine, Children's National Medical Center, Washington, DC; Associate Professor Duke University Pediatrics (DKB, Jr.), Chief, Division of Quantitative Sciences, Director, Duke Clinical Research Institute Research Fellowship Program, Duke Clinical Research Institute, Durham, NC; Vice President (ADS), Medical Affairs and Pharmacy, Carilion Medical Center, Senior Staff, Departments of Medicine and Pediatrics, Carilion Clinic, Professor, Medicine, Pediatrics, Public Health, University of Virginia, School of Medicine, Roanoke, VA; Research Data Analyst (JH), Children's National Medical Center, McLean, VA; Pediatric Research Coordinator (DSH), Duke Children's Hospital, Durham, NC; and Professor of Pediatrics (IMC), Division Chief, Pediatric Critical Care Medicine, Medical Director, Pediatric Intensive Care Unit, Duke Children's Hospital, Duke University Medical Center, Durham, NC.

Supported, in part, by institutional departmental funds and by a training grant (to A.T.W.) (T32-HD43029) as a fellow in Critical Care Medicine at Duke University Medical Center where the study was conducted, and by AHRQ KO 8 HS 14009 (to A.D.S.).

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: awratney@cnmc.org

©2008The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies