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Inspiratory and peripheral muscle strength as predictors for extubation failure in COVID-19 patients

Dear editor,

With great interest, I read the article by Fleuren et al. on determining the predictors for extubation failure in COVID-19 patients [1]. The authors have methodically utilised the machine learning models to identify the potential parameters that would predict the extubation failure in critically ill COVID-19 patients. They discuss the potential predictors selected by a team of intensivists for modeling from the Dutch Data Warehouse (DDW). With this study, they concluded that the individual ventilatory characteristics, inflammatory markers, neurological status and body mass index (BMI) were the most important parameters to predict extubation failure in COVID-19 patients.

However, as the article discusses the indicators for predicting extubation failure, it becomes essential to consider the inspiratory muscle strength and gross peripheral muscle strength as independent indicators for predicting extubation. Extubation is a complicated process and requires a balance between global respiratory load and ability to overcome this load for separation from invasive mechanical ventilation (IMV). Evidence from the meta-analysis carried out shows that non-COVID-19 patients receiving IMV in ICU have a high risk of developing respiratory and limb muscle weakness [2]. Similarly, considering the novelty of the disease, there is sufficient literature available stating that patients with severe COVID-19 requiring prolonged ICU stay and IMV have been diagnosed with ICU-acquired weakness (ICUAW) [3]. Further, from the growing evidence, it has been observed that poor peripheral muscle strength, particularly quadriceps muscle, is effective indicator (p = 0.02) in predicting extubation failure in critically ill patients [4]. We have also observed that in non-COVID-19 patients, inspiratory muscle training (IMT) achieved either by threshold pressure training or adjusting ventilator sensitivity, did not directly predict extubation outcome; however, it concluded that IMT significantly improved maximal inspiratory pressure (MIP) (MD 7 cmH2O, 95% CI 5–9), rapid shallow breathing index (RSBI) (MD 15 breaths/minute/l, 95% CI 8–23) and weaning success (RR 1.34, 95% CI 1.02–1.76) [5].

In closing, I believe that inspiratory and peripheral muscle testing can be added to the variables listed by Fleuren et al. to predict extubation failure and avoid the serious sequelae caused by re-intubation in COVID-19 patients. Once again, I commend the authors for their excellent work in this area, which remains to be the need of the hour.

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References

  1. Fleuren LM, Dam TA, Tonutti M, et al. Predictors for extubation failure in COVID-19 patients using a machine learning approach. Crit Care. 2021;25:448.

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  2. Medrinal C, Combret Y, Hilfiker R, Prieur G, Aroichane N, Gravier F-E, et al. ICU outcomes can be predicted by non invasive muscle evaluation: a meta-analysis. Eur Respir J. 2020;56:1902482.

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  3. Van Aerde N, Van den Berghe G, Wilmer A, Gosselink R, Hermans G, Meersseman P, Gunst J, Aerts V, Balthazar T, Barbé A, et al. Intensive care unit acquired muscle weakness in COVID-19 patients. Intensive Care Med. 2020;26:2083–5.

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  4. Wang TH, Wu CP, Wang LY. Impact of peripheral muscle strength on prognosis after extubation and functional outcomes in critically ill patients: a feasibility study. Sci Rep. 2021;11(1):1.

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  5. Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review. J Physiother. 2015;61(3):125–34.

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Correspondence to Shraddha Shah.

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Shah, S. Inspiratory and peripheral muscle strength as predictors for extubation failure in COVID-19 patients. Crit Care 26, 45 (2022). https://doi.org/10.1186/s13054-022-03926-0

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  • DOI: https://doi.org/10.1186/s13054-022-03926-0