NIGHTMARE SCENARIO – Airway Roulette!

Does this scenario sound familiar….?

You start your morning ward round and you have already heard on the grapevine that one of the patients is ready to extubate. The numbers say so, the nurses are badgering you to make that decision, and their sedation has been off since 07:00 ready for your ward round.

You agree in principle and keep tabs on them over the course of the day. Problem is, they are still flat as a pancake, only rousable with constant poking and prodding…..not ideal! The race to extubate is on, as you know there is potential morbidity associated with prolonged physiological trespass of their airway – their muco-ciliary escalator is crying out to pump out that sputum it just can’t shift past that blasted tube!

It’s now 19:00, the night team are walking round with you on the handover review and you appear to still be teetering on the, ‘do we or don’t we’??! Then….the patient snaps awake as if objecting to one of the night team’s aftershave! Your next worry is that they will be grabbing at the tube and needing 2-3 nurses and hospital security to calm them and keep them safe.

Is that patient ready? Do you risk it now, only for the relative skeleton crew team on overnight to have to deal with the repercussions of it failing later? Your colleague taking over next day may certainly not, ‘love you tomorrow’, if they are having to cope with further morbidity as a result of a rash decision! Wouldn’t it be easier to just leave it until the morning then??

Numerous factors are always at play when making the bold decision to pull the tube at the end of the day:

  • A doctor’s past experiences of extubations at night
  • Bed pressures at the time and staffing issues over nursing level 3 patients
  • Expectations of the patient’s family and friends – they see extubation as a route to rapid improvement and better patient comfort in the short term. They’ve also been told that this is the ‘plan’.
  • The doctor’s temperament and inclination towards risk (the cowboy effect)
  • The doctor’s fear of reprisal by colleagues for making a rash decision – will you love me tomorrow?
  • The doctor’s aversion to any morbidity / increased length of stay associated with an unsuccessful attempt
  • The nurses opinions at that point in time, influenced by their level of confidence and experience, help available etc – these may be entirely different to the nurses’ opinions by light of day
  • The decision makers ability to simplify the decision into a more binary form – extubate Yes / No!
  • The level of experience of available support for the remainder of the night

Some doctors are very averse to extubating at night, but don’t give clear reasons behind why. Some don’t bat an eyelid at the prospect.

So, is there really a huge difference between extubating a patient during the day or at night?

STUDY EVIDENCE

Study 1 – studied outcomes in 2240 extubated patients. There were 2 groups of patients:

  1. The night-time group – those extubated between 1900 and 0659
  2. The day-time group – those extubated from 0700 onwards

1555 patients were extubated during the day and 685 at night. The figures were surprising!

Re-intubation

  • 7.7% extubated during the day, were reintubated within 24 hours
  • 3.7% extubated at night, were reintubated within 24 hours

So the likelihood of reintubation was actually lower for night-time compared to day-time extubations (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3 – 0.9, P= 0.01). And similarly, lower for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = 0.07).

Mortality and L.O.S

Furthermore, the results showed decreased mortality (OR = 0.6, 95% CI = 0.3-1.0, P = 0.06) in patients extubated at night and a significantly lower length of stay (LOS) (P = .002).

The conclusion of this study was unequivocal. We never thought this would be the case but in this study, extubations at night do not have higher likelihood of reintubation, LOS or mortality compared to those during the day.

So, patients meeting parameters should be extubated ASAP to decrease any complications of mechanical ventilation and not delayed until daytime.

BUT – and there always is one!!

Study 2 – another much larger consisting of 97844 patients (40.7% men; 59.2%), concluded the exact opposite!

This mega study spanning 165 ICUs used data from the Project IMPACT database from 1st October, 2000 to 29th March 2009. They defined overnight extubation in the same way as the first study – between 1900 to 0659.

This study found that:

  • 20.1% of patients were extubated overnight and this percentage decreased over time
    • 23.3% in 2000-2001 vs 18.8% in 2009; P = .001
  • Duration of mechanical ventilation (MV) of <12 hours was most associated with overnight extubation. This compares to:
    • 12h to <1 day: AOR, 0.20 [95% CI, 0.19-0.21]
    • 1 to <2 days: AOR, 0.26 [95% CI, 0.24-0.28]
    • 2 to <7 days: AOR, 0.22 [95% CI, 0.21-0.24]
    • ≥7 days: AOR, 0.24 [95% CI, 0.22-0.26])

For mechanical ventilation of <12 hours:

  • Reintubation rates were similar for overnight and daytime extubations
    • 5.9% and 5.6%, respectively; P = .50
  • Mortality was higher for patients extubated overnight
    • ICU, 5.6% vs 4.6%, P = .01
    • Hospital, 8.3% vs 7.0%, P = .01

For mechanical ventilation ≥ 12 hours:

  • Patients extubated at night were more frequently reintubated
    • 14.6% vs 12.4%; P < .001
  • Mortality was higher
    • In the ICU 11.2% vs 6.1%; P < .001
    • In hospital 16.0% vs 11.1%; P < .001
  • LOS was no different

Length of stay:

  • ICU length of stay (LOS) was shorter for patients extubated overnight compared to daytime extubations
    • 1.1 [0.8-2.3] vs 1.4 [0.9-2.5] days
  • Hospital LOS was similar
    • 7.0 [4.0-12.0] vs 7.0 [3.0-12.0] days

So…this study concluded that patients extubated at night had higher rates of mortality, both in ICU and in hospital.

As is often the case in medicine, research yields conflicting results and conclusions. Certainly, there is scope for more research looking into exactly why extubating patients at night leads to poorer outcomes and where the risks arise from.

SO WHERE DO WE GO FROM HERE?!

For now, regardless what your decision would be, there is evidence to support either option. The bottom line here is that in reality, this is a pure judgement call made by the attending intensivist there at the time. We can all pick holes in these post hoc and state  ‘well I wouldn’t have done x’, or ‘I wouldn’t have done y’. None of us are crystal ball readers, but we all do what we see as the best for our patients and if this ‘best’, is to take a risk with the hope they will ultimately do better in the long-run….then that risk is worth taking even if it’s dark outside the ICU.

‘Will you love me tomorrow’…..if you are that patient who got out of ICU more quickly due to earlier extubation near bed-time, then yes you will!!

Written by Dr Richard Pertwee (Research fellow, ICU)

Edited by Dr Jonny Wilkinson