Acute Respiratory Failure Requiring Reintubation Clinical Trial
Official title:
Evaluation of Laryngeal Ultrasonography Performance in Predicting Major Post Extubation Laryngeal Edema in Intensive Care Patients
- For patient in intensive care unit, extubation failure is defined as the necessity of
early reintubation after scheduled extubation, with Increased morbidity and mortality,
so it seems important to quickly identify patients with high risk of post-extubation
acute respiratory failure.
- Major post-extubation laryngeal edema is one of extubation failure causes, and its
incidence vary in literature from 4 to 37%.
- We can't currently predict arising of a major post-extubation laryngeal edema. However,
a recent pilot study showed that laryngeal ultrasonography could help to identify
patients with high risk of post-extubation stridor, measuring ultrasonic leak volume
and cuff-deflated air-column width, of which we propose to assess diagnostic
performance.
Definitions:
Intubation is a traumatism for laryngeal mucous membrane. Due to local inflammatory
reaction, laryngeal edema occurs in nearly all intubated patients, but only some of them
develop clinical symptoms, as post-extubation stridor or acute respiratory distress. Stridor
is commonly defined as a high-pitched sound produced by airflow through a narrowed airway,
and accepted as a clinical marker of post-extubation laryngeal edema. The main complication
of post-extubation laryngeal edema is reintubation, defining major post-extubation laryngeal
edema. Early recognition of laryngeal edema is essential since these patients have the
highest risk of evolving to respiratory distress and extubation failure. Even before
extubation, signs indicative of laryngeal edema may be present. The search for a test that
adequately identifies patients at risk for extubation failure is ongoing.
Trial Procedures:
- At day 0: Selection of patients filling inclusion criteria. Oral and written
information of patient and his refer person, and collecting of non-opposition.
- At day 0: inclusion of patients ventilated with inspiratory assistance just before
schedulded extubation. Information of patient on procedure course.
- First ultrasonography of protocol: The patient is in the supine position, with the neck
hyper-extended, and the probe is placed on cricothyroid membrane with a transverse view
of the larynx. The standard scanning plane is predetermined: it should contain several
landmarks, including the vocal cords, false cords, thyroid cartilage and arytenoids
cartilage. The oral and laryngeal secretions are suctioned. Ultrasonic air-leak volume
is defined by difference between air-column width cuff inflated and air-column width
cuff deflated. Shape of air-column cuff inflated and cuff deflated is also recorded in
observation notebook.
- Then the patient is extubated after spontaneous ventilation trial, according to unit
protocol, by the physician in charge. After extubation, surveillance of post-extubation
stridor and acute respiratory distress occurrence during the first 24 hours.
- If the patient is reintubated for major post-extubation laryngeal edema, onset of 48
hours corticotherapy, and realization of second, third and fourth laryngeal
ultrasonography, daily to next schedulded extubation.
- At discharge of intensive care unit, data collection about mechanical ventilation
duration, intensive care hospitalization duration, occurrence of ventilation-acquired
pneumopathy, mortality at 28 days.
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