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Scott K Epstein

Publications and source records attributed to Scott K Epstein.

5 recordsLinked to original sources
PubMed2003

Extubation failure: magnitude of the problem, impact on outcomes, and prevention.

Extubation failure, defined as the need for reinstitution of ventilatory support within 24 to 72 hours of planned endotracheal tube removal, occurs in 2 to 25% of extubated patients. The pathophysiologic causes of extubation failure include an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy, and cardiac dysfunction. Compared with patients who tolerate extubation, those who require reintubation have a higher incidence of hospital mortality, increased length of ICU and hospital stay, prolonged duration of mechanical ventilation, higher hospital costs, and an increased need for tracheostomy. Given the lack of proven treatments for extubation failure, clinicians must be aware of the factors that predict extubation outcome to improve clinical decision making. Risk factors for extubation failure include being a medical, multidisciplinary, or pediatric patient; age greater than 70 years; a longer duration of mechanical ventilation; continuous intravenous sedation; and anemia. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough can help to improve prediction of extubation failure. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.

Hospital Costs↗
PubMed2002

Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study.

CONTEXT: The outcome of patients receiving mechanical ventilation for particular indications has been studied, but the outcome in a large number of unselected, heterogeneous patients has not been reported. OBJECTIVE: To determine the survival of patients receiving mechanical ventilation and the relative importance of factors influencing survival. DESIGN, SETTING, AND SUBJECTS: Prospective cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1, 1998, and March 31, 1998. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days. MAIN OUTCOME MEASURE: All-cause mortality during intensive care unit stay. RESULTS: Of the 15 757 patients admitted, a total of 5183 (33%) received mechanical ventilation for a mean (SD) duration of 5.9 (7.2) days. The mean (SD) length of stay in the intensive care unit was 11.2 (13.7) days. Overall mortality rate in the intensive care unit was 30.7% (1590 patients) for the entire population, 52% (120) in patients who received ventilation because of acute respiratory distress syndrome, and 22% (115) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease. Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69%. The main conditions independently associated with increased mortality were (1) factors present at the start of mechanical ventilation (odds ratio [OR], 2.98; 95% confidence interval [CI], 2.44-3.63; P<.001 for coma), (2) factors related to patient management (OR, 3.67; 95% CI, 2.02-6.66; P<.001 for plateau airway pressure >35 cm H(2)O), and (3) developments occurring over the course of mechanical ventilation (OR, 8.71; 95% CI, 5.44-13.94; P<.001 for ratio of PaO(2) to fraction of inspired oxygen <100). CONCLUSION: Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit.

Adult↗
PubMed2002

Weaning from mechanical ventilation.

Invasive mechanical ventilation can be lifesaving for patients with acute respiratory failure, but numerous complications have been identified. Therefore, once clinical improvement has occurred, emphasis is placed on quickly weaning (ie, liberating) the patient from mechanical ventilation. Weaning can be subdivided into 2 components: readiness testing and progressive withdrawal. Traditionally, both clinical factors and weaning predictors have been used to assess readiness for spontaneous breathing trials, which can be carried out using a T-piece or a low level of ventilatory support. The role of weaning predictors is under investigation, and their role in clinical decision making remains poorly defined. Recent insights into the pathophysiology of weaning failure have provided a framework for identifying potentially correctable limiting factors. Randomized controlled trials suggest that several approaches to progressive withdrawal may be acceptable, though only a minority of patients require progressive withdrawal. Emerging evidence indicates that protocol-directed weaning, driven by respiratory therapists and intensive care nurses, can improve outcome.

Humans↗
PubMed2002

Extubation.

As many as 20% of extubated patients require reintubation (ie, extubation failure) within 72 hours of extubation, with the exact prevalence depending on numerous factors. The pathophysiologic basis of extubation failure is often different from the cause of weaning failure. Extubation failure substantially prolongs the duration of mechanical ventilation, intensive care unit stay, and hospital stay, and substantially increases hospital mortality. Therefore, prediction of extubation outcome and prevention of extubation failure may be critically important. Unfortunately, standard weaning tests have not proven sufficiently accurate in predicting extubation outcome. New semi-objective measurements of cough strength and secretion volume can help identify patients at increased risk for extubation failure. It is important to note that mortality increases with reintubation delay, which indicates that clinical worsening may take place during the period without ventilatory support. Therefore, improved outcome may derive from rapid identification of patients at increased risk, followed by expeditious reinstitution of ventilatory support when extubation failure occurs.

Humans↗