Fatores associados à falha de extubação orotraqueal de pacientes na unidade de terapia intensiva

Abstract

To investigate the multiple clinical factors already recommended by the literature, such as hemogasometric control, length of IMV, hydric balance, criticality level, coughing efficacy, and presence of pulmonary secretion, which would be more highly associated with extubation failure. Method: An unpaired, longitudinal, retrospective, casecontrol study with a quantitative approach, carried out in a special school hospital in the northwest of São Paulo. From a population of 1703 patients undergoing invasive mechanical ventilation, the sample comprised 480 patients, aged over 18 years, both sexes, on ventilation for more than 24 hours, who were extubated in a planned manner, according to the institutional protocol. based on the Brazilian Mechanical Ventilation Guidelines, over a period of two years (January 2019 to December 2020). Data collection was performed by analyzing electronic medical records of specific clinical parameters for the extubation process: partial pressure of oxygen, partial pressure of carbon dioxide, hemoglobin, days of mechanical ventilation prior to extubation, water balance, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential organ failure assessment score (SOFA score), amount of pulmonary secretion and coughing effectiveness. Comparative analysis and multiple regression were performed using the statistical program StatsDirect 3.3.5. Results: Of the 480 patients, 415 (86.5%) were successful 48 hours after extubation, and 65 (13.5%) failed, in agreement with the rate found in the world literature. Of the control group, those who were successful, the mean age was 55.1 (±17.1) and the result of the variables were: days of orotracheal intubation before the extubation procedure of 4 (2-5), PaO2 of 110 .1 (91-137), PaCO2 of 37.4 (32.5- 42), hemoglobin of 10 (±2.1) g/dL, positive fluid balance of 397 (-653-1654.5) ml, APACHE II in 20 (14-25) points, weak coughing in 58 (13.9%). Of the studied group, who were reintubated, the mean age was 55.9 (±17.7), and the outcome variables were: days of orotracheal intubation before the extubation procedure of 5 (3-5) , PaO2 of 101.4(79-127), PaCO2 39.2 (34-46), hemoglobin of 9.7(±1.7)g/dL, positive fluid balance of 1150 (144- 3025) ml, APACHE II in 23 (19-29) points, weak coughing in 31 (47.7%) with abundant pulmonary secretions in 47.7%. Logistic regression analysis indicated the following associations with the need for reintubation: positive fluid balance (OR, 1000169; 95%CI 1.000061 to 1.000277) and ineffective coughing (OR, 6588996; 95%CI 3.566588 to 12.172661). Conclusions: Among the factors associated with the higher rate of orotracheal extubation failures; positive fluid balance and the presence of inefficient coughing or inability to hygienize the airway were significant, suggesting that these factors should be assessed in the weaning process and taken into account by the multiprofessional team when making a decision on extubating the critically ill patient in the ICU. Furthermore, orotracheal intubation period longer than five days, APACHE II score higher than 23 and abundant bronchial secretion should be considered. The implication for clinical practice was to support the importance of using the safe extubation protocol and to point out the parameters that could be predictors of failures, providing greater safety to the patient in the ICU.