What is Extubation Advisor?
BACKGROUND
Prolonged mechanical ventilation coupled with failed extubations (i.e., acute need for re-intubation) are associated with increased morbidity, mortality, added healthcare costs and resources. Assessing extubation readiness is a complex critical decision, often compounded by a data-rich ICU environment and variability in current evaluation methods.
The integration of a clinical support tool offers opportunity to combine clinician expertise and advanced monitoring systems to generate personalized patient evaluations and offer a uniform approach to extubation decision-making.
INNOVATION
Our multidisciplinary team has identified the need to enhance extubation decision-making by creating and validating a novel clinical decision support tool, Extubation Advisor (EA). EA combines clinician assessment of extubation readiness with predictive analytics and risk mitigation strategies to optimally support clinical decision-making and individualize patient care following endotracheal tube removal.
EA consists of software installed on a laptop/tablet that attaches directly to the patient’s vitals monitor and continuous capnography line. Using a machine learning predictive model, EA captures real-time patient status during Spontaneous Breathing Trials (SBTs). Following the standardized and comprehensive assessment, EA provides clinicians with a concise report on the overall extubation failure risk.
Unique to EA is the application of the Weaning and Variability Evaluation (WAVE) score within the risk assessment report—a predictive indices of respiratory rate variability. The WAVE score tracks interbreath intervals and quantifies their variation throughout the SBT. We found a decreased respiratory rate variability during reduced ventilatory support was indicative of reduced adaptability and/or increased physiologic stress and was associated with increased extubation failure. Further, the WAVE score demonstrated higher performance compared to conventional predictive indices (e.g., RSBI) of extubation failure rates.
FEATURES
Extubation Advisor provides:
- Simplified Setup—Using an interface cable, the application device (laptop/tablet) connects directly to a standard patient monitor within the ventilator circuit via a continuous capnography line.
- Streamlined Application—Step-by-step navigation provided for a straightforward enrollment.
- Continuous Monitoring—Real-time vitals monitoring during the SBT for a precise evaluation.
- Standardized Application—Synoptic reporting of the SBT and clinical assessment using leading predictive markers for extubation outcomes and a readiness checklist.
- Risk-mitigation Strategies—Individualized clinical suggestions to mitigate extubation failure outcomes for at-risk patients.
IMPACT
Multi-professional critical decision-making can be faced with a marked variability in a data-rich ICU environment; a clinical support tool to guide complex decisions, such as Extubation Advisor, provides a novel opportunity to optimize patient outcomes. This Canadian innovation has the potential to transform how clinicians view and evaluate extubation risk.
FAQ
Q: How does Extubation Advisor predict the risk of extubation failure?
A: EA combines respiratory rate variability performance during the SBT (the WAVE score), the rapid shallow breathing index (RSBI), clinical impression of failure risk, relative medical history, and a standardized readiness checklist to generate a comprehensive report on individual extubation risk to support clinical decision-making.
Q: Extubation Advisor is considered a clinical decision support tool; what does this mean?
A: EA provides a standardized snapshot of patient performance during an SBT and is intended to aid in the clinical assessment of extubation readiness of ventilated patients. Recognizing that extubation decision-making is complex and should incorporate all relevant information (including but not limited to patient history, illness, function and values, some of which may not be included with this tool), EA is meant to supplement other contributing factors in order to optimize decision outcomes.
Q: What is the WAVE Score?
A: EA analyzes capnography waveforms during an SBT to provide a Weaning And Variability Evaluation (WAVE) score. The WAVE score evaluates respiratory rate variability, an indicator of pulmonary function, when a patient is subject to an increased respiratory workload during an SBT to provide a probabilistic estimate of physiologic failure. The WAVE score and associated predictive model were derived from a large multicenter international study of around 800 patients. (DOI: 10.1186/cc13822)
Q: Is Extubation Advisor limited to a specific patient population?
A: EA is intended for adult patients (³18 years of age) with or without COVID-19 in the ICU who have been on invasive mechanical ventilation for >48 hrs by endotracheal tube and are deemed clinically ready for an SBT for extubation assessment purposes.
Q: What mode of ventilation is recommended for the SBT when using Extubation Advisor?
A: While it does not matter what mode of ventilation the patient is on prior to the SBT, EA utilizes pressure-support ventilation during the SBT to assess extubation readiness. Specific weaning criteria for PS, PEEP and FiO2 are institution-dependent and are not mandated by EA.
Q: What patient monitors are compatible with Extubation Advisor?
A: EA has been validated for use on the following patient monitors: Philips IntelliVue Series, GE Datex and Carescape and Medtronic Capnostream CP20. Some monitors may require specific vendor add-on cards to be compatible with EA.
Q: Is the Extubation Advisor support tool available for clinical use?
A: EA is currently approved for clinical use in the EU (CE mark) and in Canada (Licence Number 110048).