Reengineering respiratory support following extubation - Avoidance of critical care unit costs

Study objective: We prospectively investigated alternative clinical practic e strategies for critically ill trauma patients following extubation to eva luate the cost-effectiveness of these maneuvers. The primary change was eli mination of the routine use of postextubation supplemental oxygen, with con current utilization of noninvasive positive pressure ventilatory support (N PPV) 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 ventilatio n using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode, The patients were extubated to room ai r following a 20-min preextubation trial of 5 cm H2O CPAP at FIO2 of 0.21, and demonstrating a spontaneous respiratory rate less than or equal to 38 b reaths/min, pH greater than or equal to 7.30, PaCO2 less than or equal to 5 0 mm Hg, and PaO2 greater than or equal to 50 mm Hg, The subgroup of patien ts who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of e xtubation were treated with NPPV for up to 48 h duration. Patients who fail ed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room a ir. Seventy-two patients(13%) became hypoxic within 24 h, and NPPV was admi nistered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, an d received mechanical ventilation for a mean of 4 days, Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overa ll reintubation rate for the group (n = 536) was 6.2%; for the postextubati on hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The eli mination of routine supplemental oxygen via nasal cannula following extubat ion resulted in a potential direct cost avoidance of $50,006.88 for 451 pat ient days. Moreover, die 52 patients who were spared reintubation and mecha nical ventilation provided an additional potential cost avoidance of $19,74 0.24 in unused ventilator days per patient, Conclusion: Eliminating the routine use of supplemental oxygen and employin g 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.