Abstract
Background and objective
Microsurgical resection of tumor is an important treatment for children with fourth ventricular tumors. There is a lack of data describing risk factors for postoperative extubation failure (EF) in these children. We aimed to identify risk factors for EF in children with fourth ventricular tumors and to determine the association between EF and clinical outcomes.
Methods
A retrospective study review of children after fourth ventricular tumors surgery who had an extubation attempt between January 2020 to December 2023. Extubation failure was defined as re-intubation within 7 days of extubation. Multivariate logistic regression analysis was performed to explore the risk factors for EF. Bivariate statistical analysis was performed to determine associations between EF and clinical outcomes. Only the first extubation attempt was included in the analysis.
Results
We included 103 children, of whom 10 (9.7%) experienced EF. In the logistic regression analysis, a weak/absent cough reflex was independently associated with EF (p < 0.001). Compared to those with a fair/ strong cough, patients with a weak/absent cough had a odds ratio (OR) of 41.25 for EF (95% CI,8.01–212.37; p < 0.001).Glasgow Coma Score(GCS), the obvious adhesion between the tumor and the fourth ventricle floor, and pulmonary variables were not associated with EF. Children who failed extubation had longer durations of mechanical ventilation [13 days (IQR 6.8–22.8) vs. 1 days (IQR 0.5–3), p < 0.001]; longer PICU lengths of stay [16.5 days (IQR 9.4–27.5) vs. 2 days (IQR1.5–4.3), p < 0.001] and longer hospital lengths of stay [27 days (IQR 21–31.8) vs. 20 days (IQR16–29), p = 0.05] than successfully extubated children.
Conclusions
Children with weak/absent cough reflex after surgery are at increased risk for extubation failure. Extubation failure is associated with significant adverse outcomes in our setting.
Keywords: Fourth ventricle, Cerebral ventricle neoplasms, Child, Airway extubation, Risk factors
Background
The fourth ventricle tumor is one of the tumors with higher incidence rate in pediatrics. Microsurgical resection is the main treatment for patients with fourth ventricular tumors. As a part of preoperative preparations, patients are routinely given tracheal intubation in the operating room. After surgery, all patients still require tracheal intubation and mechanical ventilation in the intensive care unit for a period of time. Delayed extubation may lead to complications such as ventilator-associated pneumonia, while ‘premature’ extubation may result in extubation failure (EF), both of which are associated with adverse outcomes in brain-injured patients [1, 2]. Although earlier extubation may be advantageous, compared with successfully extubated patients, those who experience EF because of ‘premature’ extubation are at increased risk of mortality, longer durations of MV, and longer hospital stays [3, 4]. Therefore, we suggest appropriately extending the duration of mechanical ventilation and delaying extubation to prevent and reduce EF.
Identifying risk factors for EF is crucial to decreasing EF. Many studies have shown that for neurosurgical patients, in addition to routine lung evaluation parameters, neurologic-based variables should be included in the extubation assessment [5, 6]. Fourth ventricular tumors often approach or even invade the brainstem which is the vital center of the body [7]. Therefore, surgical resection may affect brainstem function. The brainstem contains the respiratory center, the ascending reticular activating and cranial nerves. Thus, the surgery may affect the intensity of breathing, level of consciousness, and cough reflex, ultimately leading to EF.
At present, there are a few studies about the predictors of extubation failure or extubation success in patients with lesions occurring in the posterior fossa region [8]. However, there is currently no relevant research about the risk factors of EF in children with fourth ventricular tumors. This study aims to retrospectively analyze the clinical data of pediatric patients who underwent microsurgical resection of fourth ventricular tumors in Guangzhou Women and Children’s Medical Center and identify risk factors and outcomes of postoperative EF. In addition to studying conventional measures of EF, we wished to study neurologic-based variables in order to improving ability to predict EF.
Methods
Design, setting, and patients
This is a retrospective study of children who underwent microsurgical resection of fourth ventricular tumors at Guangzhou Women and Children’s Medical Center, Guangzhou, China, from January 2020 to December 2023. The approval of the study was waived by the Ethical Committee of Guangzhou Women and Children’s Medical Center, Guangzhou, China. Patients were waived from informed consent due to the retrospective nature of the study by the Ethical Committee of Guangzhou Women and Children’s Medical Center. The diagnosis of fourth ventricular tumor was based on magnetic resonance imaging (MRI) results and discharge diagnosis recorded in the electronic medical records (EMR). The inclusion criteria of the patients included: (1) Through preoperative MRI and surgical reports, the tumor was confirmed to be located in the fourth ventricle with extensions into the vermis or medial cerebellar hemispheres, cerebellopontine angle (CPA) via foramina of Luschka, and exophytic midbrain or medullary. (2) All patients undergo routine tracheal intubation and mechanical ventilation in the operating room on the day of surgery. (3) patients were transferred to PICU with tracheal tube after surgery. (4) Children aged 0–18 years with at least one extubation attempt were included. Exclusion criteria were the following: (1) tumors purely in the cerebellar hemispheres, CPA, or intrinsic brainstem tumors, (2) unsurgical patients due to severe illness although they have fourth ventricular tumors, (3) postoperative patients who did not have an extubation attempt due to severe illness and death, (4) incomplete data.
Weaning and extubation protocol
The predominant mode of mechanical ventilation in the patients is either volume control or pressure control. We follow the routine of our PICU for weaning and extubation. We usually look into the following criteria before considering weaning: (a) absence of sedatives; (b) the presence of adequate gas exchange and ventilation as indicated by arterial oxygen saturation ≥ 94% while breathing an FiO2 of ≤ 0.40 and positive end-expiratory pressure of ≤ 5 cmH2O, PaO2 > 60 mm Hg, PaCO2 <45 mm Hg; resolution or improvement of pneumonia; (c) level of consciousness acceptable for extubation; (d) presence of gag or cough when suctioning; (e) presence of respiratory drive; (f) hemodynamic stability and no need for vasoactive agents. In addition to the above criteria, the intensive care physician would have to agree that the patient was in a stable condition and was ready for extubation.
Subjects who fulfilled the above weaning criteria were submitted to a spontaneous breathing trial (SBT). The SBT consisted of 30 min trials of spontaneous breathing performed on a T-tube or continuous positive airway pressure (CPAP)of 5 cm H2O. All subjects who ultimately passed an SBT were extubated. The following criteria were used to define failure to tolerate the SBT: (a) respiratory rate outside the acceptable range for their age (for age<6 months 20–60/min; 6 months to 2 yrs, 15–45/min; 2–5 yrs, 15–40/min;>5 yrs, 10–35/min); (b) signs of increased respiratory work (i.e., retractions, use of accessory respiratory muscles, paradoxical breathing); (c) heart rate outside acceptable range for age (for age <12 months, 100–160/min; 1–3 yrs, 90–150/min; 3–6 yrs, 70–130/min; >6 yrs, 65–120 /min); (d) pulse oxygen saturations<90%.
Post-extubation therapies and EF definitions
If the child experiences respiratory dysfunction after extubation, immediate treatments will be given by various interventions such as nebulized inhalation of β-receptor agonists and other airway clearance and cough assist therapies. Some patients need non-invasive ventilation. The decision to reintubate was based on clinical deterioration, as evidenced by at least one of the following criteria: altered arterial pH or PaCO2; decrease in oxygen saturation to < 90% despite FIO2 > 0.5; and increased signs of respiratory distress (tachypnea, use of accessory respiratory muscles, thoracoabdominal paradox). EF was defined as reintubation within 7 days of extubation for any reason [8]. Extubation was considered successful if the patient remained extubated for 7 days. The primary end point was EF. Patients who failed an extubation attempt were compared with patients who were successfully extubated. In cases in which patients failed extubation more than once, only the first attempt was included in the analysis.
Data collection and statistical analysis
A single investigator reviewed the EMR to collect pre-extubation data, clinical information, and extubation outcomes. Collected data included age, sex, duration of mechanical ventilation before extubation, pre-extubation physiologic and ventilatory parameters, adhesion between the tumor and the fourth ventricular floor, extent of tumor resection, hydrocephalus, placement of ventricular drainage tubes before or during surgery, cough reflex, GCS at the time of extubation, postoperative intracranial infection, and post-extubation laryngeal edema. Pre-extubation physiologic and ventilatory parameters included PaCO2, PaO2, the fraction of inspired oxygen (FiO2), a ratio of PaO2 to FiO2(P/F ratio), tidal volume/body weight, positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and respiratory rate before weaning. Pre-extubation physiologic and ventilatory parameters refer to the last recorded related variable prior to extubation. By reviewing surgical records, whether there is adhesion between the tumor and the fourth ventricular floor can be identified. The strength of the cough reflex was assessed by the physician for the intensity of the cough reflex during spontaneous or induced cough through tracheal tube and recorded in the EMR as strong, fair, weak, or absent. The cough reflex was categorized as a binary variable (weak/absent vs. strong/ fair) for statistical analysis. Post-extubation stridor (PES) was used to assess post-extubation laryngeal edema. Post-extubation stridor is commonly defined as a high-pitched inspiratory wheeze produced by airflow through a narrowed airway [9].
The outcome measures included days of mechanical ventilation, PICU lengths of stay (LOS), hospital LOS and the condition at discharge. The condition at discharge is divided into two categories: (1)the parents abandoning treatment and requesting discharge when the child’s condition remains unstable, (2) normal discharge when the patient’s condition is stable. The outcomes were compared between patients with failed and successful extubation.
Multivariate logistic regression analysis was performed to identify the risk factors for EF. First, bivariate statistical analysis was performed to screen variables. It includes two-sample t test, Mann-Whitney U test, and Chi-square test. Shapiro–Wilk method was used to test normality of the continuous variables. Normally distributed data were presented as mean and standard deviation, and two-sample t test was used for comparison between two groups. Nonnormally distributed data were presented as median and interquartile range (IQR), and Mann-Whitney U test was used to compare two groups. Categorical variables were presented as counts and percentages. Chi-square test was used to test association between two categorical variables. After screening the variables, further analysis was performed using multivariable logistic regressions models. Variables with p values < 0.10 in bivariate analysis results were considered as candidate variables for multivariable modeling. Associations between risk factors and EF were expressed with odds ratios (OR) and 95% confidence intervals (CI). Bivariate statistical analysis was performed to determine associations between EF and clinical outcomes. All tests were two sided, and p values ≤ 0.05 were considered statistically significant. A statistical software program (IBM SPSS Statistics 23) was employed.
Results
Patient characteristics
There are a total of 160 children with posterior fossa tumors. We excluded: 37 cases with tumors purely in the cerebellar hemispheres, CPA, and intrinsic brainstem tumors; 4 unsurgical patients due to severe illness; 3 postoperative patients who did not have an extubation attempt and ultimately died due to severe illness; 13 cases with incomplete data. In the 13 cases with missing data: GCS at the time of extubation was not recorded in 3 cases; whether there was post-extubation laryngeal edema were not recorded in 6 cases; tidal volume was not recorded in 4 cases. 103 patients with fourth ventricular tumors were included in the final analysis. As a preoperative preparation, all patients undergo routine tracheal intubation in the operating room on the day of surgery. The first extubation attempt was given after a median of 1 (IQR 1–3) days from the day of first intubation. EF occurred in 10/103 (9.7%) patients after the first extubation attempt. Two of the 10 patients required long-term mechanical ventilation and did not attempt extubation again. The other eight patients attempted a second extubation, of which two patients failed extubation. The patient who failed the second extubation was successfully extubated on the third attempt. A flowchart summarizing the inclusion/exclusion and extubation outcomes of study patients is presented in Fig. 1.
Fig. 1.
Flow diagram of inclusion/exclusion and extubation outcomes. (1) Due to the critical condition of the disease, 4 patients did not have the opportunity to undergo surgery, 3 patients did not have the opportunity to attempt the first extubation after surgery, and 2 patients did not have the opportunity to attempt the second extubation. (2) In the 13 cases with missing data: GCS at the time of extubation was not recorded in 3 cases; whether patient had laryngeal edema was not recorded in 6 cases; tidal volume was not recorded in 4 cases
Median (IQR) age of the patients was 3 years (IQR 1–6), and 61 (59%) were male. Median mechanical ventilation duration of the patients was 1 days (IQR 0.6–4), median ICU stay of the entire cohort was 3 days (IQR 1.5–6) and median hospital stay was 21 days (IQR 17–29). 12 patients had weak cough reflex after surgery, of which 3 cases still had weak cough reflex at discharge.
Table 1 shows tumor histology and MRI results. The “other” category in tumor histology comprised 1 embryonic tumor with multiple layers of chrysanthemum shaped clusters,1 immature teratoma,1 neuroglioma,1 vascular malformation,1 spindle cell tumor, and 1 glial ependymal cyst. All patients underwent MRI examination, which showed that (1) all or nearly all of the tumors were located in the fourth ventricle, (2) the maximum diameter of the tumor is 1.5–8.8 cm.
Table 1.
Tumor histology and MRI in 103 patients with fourth ventricle tumors
| Characteristic | No. | % |
|---|---|---|
| Histology | ||
| Medulloblastoma | 53 | 51.5 |
| Ependymoma | 15 | 14.6 |
| Pilocytic astrocytoma | 26 | 25.2 |
| Atypical teratoid/rhabdomyoid tumor | 3 | 2.91 |
| Other | 6 | 5.82 |
| MRI | ||
| Hydrocephalus of the supratentorial ventricle | 92 | 89.3 |
| The brainstem compressed by tumor | 76 | 73.8 |
| Tumor invasion of the brainstem | 7 | 6.8 |
MRI magnetic resonance imaging
Out of 10 children who failed extubation, only 1 was re-intubated 144 h after extubation, while the remaining 9 were re-intubated within 8 h after extubation. Median (IQR) time to the first re-intubation was 1.5 (0.5–8) hours after extubation. There were no events of any self-extubation/accidental extubation.
Variables associated with extubation failure
In the bivariate analyses, factors associated with EF are shown in Table 2. Younger age [median 1 years (IQR 0.6–3.8) vs. median 3 years (IQR 2–6), p = 0.015] and weakened cough reflex [7 (70%) vs. 5 (5.4%), p < 0.001] were associated with EF. GCS ≤ 8 at the time of extubation was associated with EF in 3 (30%) vs. 4(4.3%) patients(p = 0.016). Gender, duration of mechanical ventilation before extubation, pre-extubation physiologic and ventilatory parameters, adhesion between the tumor and the fourth ventricular floor, extent of tumor resection, hydrocephalus, placement of ventricular drainage tubes before or during surgery, post-extubation laryngeal edema, and postoperative intracranial infection were not significantly different between patients with EF and those who were successfully extubated (P > 0.05).
Table 2.
Bivariate analysis of factors associated with extubation failure—first attempt
| Variables | Extubation success | Extubation failure | P value |
|---|---|---|---|
| (n = 93) | (n = 10) | ||
| Male sex, no. (%) | 54(58.1) | 7(70) | 0.696 |
| Age, years (median, IQR) | 3(2–6) | 1(0.6–3.8) | 0.015 |
| Mechanical ventilation duration before extubation, no. (%) | 0.130 | ||
| MV < 3 days | 72(77.4) | 5(50) | |
| MV ≥ 3 days | 21(22.6) | 5(50) | |
| Pre-extubation Physiologic and ventilatory parameters | |||
| PaCO2 (mm Hg) (mean, std) | 37.9(6.28) | 37.8(4.46) | 0.958 |
| PaO2 (mm Hg) (mean, std) | 163.41(33.51) | 147.45(26.06) | 0.148 |
| FiO2 (median, IQR) | 0.35(0.30–0.40) | 0.35(0.30–0.35) | 0.536 |
| P/F ratio (median, IQR) | 493.13(424.46-528.39) | 463.75(390.27-509.73) | 0.179 |
| TV/weight(ml/kg) (mean, std) | 9.06(1.29) | 9.34(1.18) | 0.505 |
| PEEP, cmH2O (median, IQR) | 5(4–5) | 5(4–5) | 0.957 |
| PIP cmH2O (median, IQR) | 16(14–18) | 18(15.75-19) | 0.107 |
| Respiratory rate (median, IQR) | 25(22–27) | 25(19.75–28.5) | 0.937 |
| Adhesion between tumor and the fourth ventricular floor, no. (%) | 36(38.7) | 7(70) | 0.117 |
| Hydrocephalus, no. (%) | 83(89.2) | 9(90) | 1.000 |
| Placement of ventricular drainage tubes before or during surgery, no. (%) | 53(57) | 4(40) | 0.489 |
| Cough reflex, no. (%) | < 0.001 | ||
| Weak/absent | 5(5.4) | 7(70) | |
| Strong/fair | 88(94.6) | 3(30) | |
| Extent of tumor resection, no. (%) | 0.522 | ||
| Gross total resection | 87(93.5) | 9(90) | |
| Subtotal resection | 6(6.5) | 1(10) | |
| Postoperative intracranial infection, no. (%) | 29(31.2) | 4(40) | 0.833 |
| Post-extubation laryngeal edema, no. (%) | 31(33.3) | 5(50) | 0.483 |
| GCS total at the time of extubation, no. (%) | 0.016 | ||
| GCS > 8 | 89(95.7) | 7(70) | |
| GCS ≤ 8 | 4(4.3) | 3(30) |
No. (%) is frequency with column percentage value
IQR Interquartile range,
MV Mechanical ventilation,
FiO2 fraction of inspired oxygen,
P/F ratio: A ratio of PaO2 to FiO2,
TV Tidal volume,
PEEP Positive end-expiratory pressure,
PIP Peak inspiratory pressure,
GCS Glasgow Coma Score
In the logistic regression analysis (Table 3), weak cough reflex was independently associated with EF (p < 0.001). Compared to those with a fair/ strong cough, patients with a weak/absent cough had a odds ratio (OR) of 41.25 (95% CI,8.01–212.37; p < 0.001) for EF. Age and GCS ≤ 8 did not significantly affect EF(P > 0.05).
Table 3.
Multivariate logistic regression analysis of factors associated with extubation failure
| Variables | Odds ratio | 95% confidence interval | p value |
|---|---|---|---|
| Age (years) | 1.07 | 0.83–1.38 | 0.593 |
| Cough reflex Weak/absent | 41.25 | 8.01–212.37 | < 0.001 |
| GCS ≤ 8 | 1.57 | 0.07–33.41 | 0.774 |
GCS Glasgow Coma Score
Association of extubation failure with short-term outcomes
Compared with successfully extubated patients, patients who failed extubation had longer duration of mechanical ventilation [median13 days (IQR 6.8–22.8) vs. median 1 days (IQR 0.5–3), p < 0.001], longer PICU LOS [median16.5 days (IQR 9.4–27.5) vs. median 2 days (IQR1.5–4.3), p < 0.001], longer hospital LOS [median 27 days (IQR 21–31.8) vs. median 20 days (IQR16–29), p = 0.05] (Table 4).
Table 4.
Comparison of outcomes between the failed and successful extubation groups
| Variables | Extubation success | Extubation failure | p value |
|---|---|---|---|
| (n = 93) | (n = 10) | ||
| Days of mechanical ventilation (median, IQR) | 1(0.5-3) | 13(6.8–22.8) | < 0.001 |
| PICU LOS, days (median, IQR) | 2(1.5–4.3) | 16.5(9.4–27.5) | < 0.001 |
| Hospital LOS, days (median, IQR) | 20(16–29) | 27(21,31.8) | 0.05 |
| Condition at discharge | < 0.001 | ||
| Requesting discharge when the condition is unstable, no. (%) | 2(2.2) | 5(50) | |
| Normal discharge when the condition is stable, no. (%) | 91(97.8) | 5(50) |
No. (%) is frequency with column percentage value
IQR Interquartile range
PICU Pediatric intensive care unit
LOS Length of stay
The children with failed extubation had a poorer prognosis, leading to more parents abandoning treatment and requesting discharge when the child’s condition is unstable [5(50%) vs. 2(2.2%), p < 0.001].
Discussion
In this cohort of postoperative children with fourth ventricular tumors, we found that a weak/absent cough reflex was the most significant risk factor for predicting EF, while other neurologic-based variables and pulmonary variables did not accurately predict EF risk. We also found that EF was associated with longer duration of mechanical ventilation, longer duration of PICU stay, longer hospital LOS, and more abandoning treatment.
Currently, although a few studies show no correlation between cough reflex and EF, most studies have identified an association between cough reflex strength and EF in patients with neurological damage [10–13]. In a study by Guru et al. on patients with posterior fossa stroke, they found that cough reflex was not associated with successful extubation [8]. That study is about adults, so the reason why the result of our study is different from theirs may be due to the age difference [8]. Cohn et al. found that a weak/absent cough reflex was associated with an increased risk of failing extubation for pediatric neurocritical care patients [6]. Dos Reis et al. reported that moderate-to-large secretion volume and absent or weak cough were independent predictors of EF in TBI patients [14]. Kutchak et al. found that reflex cough PEF was an independent predictor of EF in neurocritical care patients [15]. In agreement with these studies, we report that patients with a weak/absent cough are at increased risk for EF. The centers of cough and swallowing reflexes are located in the brainstem. Brainstem dysfunction may occur after fourth ventricular tumors surgery, so postoperative children may experience weak cough reflexes and decreased swallowing reflexes [16, 17]. Weak swallowing reflexes make it easier for oral secretions aspiration into the airways, and weak cough reflexes make it difficult to effectively clear secretions of the airways. This may lead to the accumulation of a moderate to large volume of secretion, increasing airway resistance which ultimately cause respiratory failure and EF [18–20]. In our study, there were 12 patients with weak cough reflexes after surgery, of which only 3 cases had weak cough reflex at discharge. It indicates that a small number of children do indeed have long-term weak cough reflex, but more children’s cough reflexes will gradually improve after treatment. Our study shows that a reasonable strategy might be to evaluate cough reflex daily, appropriately prolong the weaning process for children with weak cough reflex, and treat remediable causes of cough weakness. Extubation after the improvement of cough reflex is helpful for the successful extubation in children with fourth ventricular tumors.
There is controversy on the association of the GCS with EF in patients with neurological damage [21–24]. Our study showed that GCS ≤ 8 was not an independent risk factor for EF. Guru et al. noted that extubation was less likely to be successful in posterior fossa stroke patients with a GCS ≤ 6 [8]. The result of our study differs from theirs. The reason for the different results may be due to the different cutoff scores for grouping according to GCS [8]. Qureshi et al. reported that GCS > 7 at time of intubation was independently associated with successful extubation in patients with infratentorial lesions [25]. The result of our study also differs from theirs. This may be due to the types and severity of diseases in the two studies are different. Most patients in that study were diagnosed with intracerebral hemorrhage and cerebral infarction, and they are more severe and have a poorer prognosis after surgery [25]. However the diseases of our patients are less severe, so the correlation between GCS and EF was not strong in our study. A study by Cohn et al. showed that GCS was not associated with EF in pediatric neurocritical care (NCC) patients [6]. McCredie et al. reported that higher GCS was not associated with successful extubation in brain-injured patients [26]. We also found that there was no association between GCS and EF, indicating that some children may be safely extubated with lower GCS. This may be because that some patients with a lower level of consciousness did not exhibit cough deficiency or swallowing deficiency in cases of brainstem dysfunction. The impact of consciousness level on EF warrants further research.
When the tumor is closely adhered to the fourth ventricular floor, the surgical process may injury brainstem. However, we found that the adhesion between the tumor and the fourth ventricular floor was not a risk factor of EF. Hydrocephalus is a serious complication after fourth ventricular tumors surgery [27]. Hydrocephalus may cause intracranial hypertension, which in turn affects brainstem function. Therefore, we analyzed whether hydrocephalus and placement of ventricular drainage tubes were associated with EF. Our study showed hydrocephalus and placement of ventricular drainage tubes were not associated with EF. Secondary intracranial infection after posterior cranial fossa surgery is also a postoperative complication. Our study showed intracranial infection was not associated with EF. Unlike other studies showing that younger age was associated with EF, we found that younger age was not a risk factor for EF [28, 29]. Our study showed that pulmonary function was not related to EF. That may be because that patients with fourth ventricle tumors usually do not have severe pulmonary insufficiency after surgery.
Our study showed that EF was associated with longer duration of mechanical ventilation, longer PICU stay, longer hospital LOS, and more abandoning treatment, which is consistent with the previous studies [30, 31]. Multiple studies show that EF is associated with significant adverse outcomes, including increased mortality rate, prolonged PICU stay and total hospital stay, and increased costs [32–34]. None of these prior studies specifically evaluated patients with fourth ventricular tumors. We found that EF was associated with short-term adverse outcomes in these children. The underlying reason for the increased risk of adverse outcomes is unclear. EF may be only a marker of underlying severity of illness. This requires further investigation. Due to the fact that there were no deaths among postoperative children with fourth ventricular tumors in our study, it is not possible to analyze the relationship between EF and mortality rate.
The study strengths include the large number of pediatric fourth ventricle tumors patients and inclusion of several neurologic-based variables. However, the present study also has some limitations. First, as a single-center retrospective study, admission bias may be present in our sample. Second, we did not compare the long-term neurological outcomes of these children, such as cognitive or motor outcomes during follow-up. It may be a future research direction. Third, our study lacks an objective measure for cough reflex which was the main variable associated with EF. Using more objective measures of cough reflex would improve the study’s conclusions. Prospective comparative trials with larger cohorts or multicenter studies are needed to further evaluate the risk factors of EF.
Conclusions
In this retrospective study, postoperative EF occurred in 9.7% of fourth ventricle tumors patients and a weak/absent cough reflex was the only risk factor of EF. A weak/ absent cough reflex conferred a forty-onefold increase in risk of EF in patients on their first attempt of extubation. GCS, adhesion between the tumor and the fourth ventricular floor, and conventional pulmonary variables were not associated with EF. EF was associated with longer duration of mechanical ventilation, longer PICU and hospital LOS, and more abandoning treatment. This study adds to our knowledge of risk factors and short-term outcomes for postoperative EF in children with fourth ventricular tumors.
Acknowledgements
Not applicable.
Abbreviations
- EF
Extubation failure
- GCS
Glasgow Coma Score
- No. (%)
Frequency with column percentage value
- IQR
Interquartile range
- MV
Mechanical ventilation
- FiO2
Fraction of inspired oxygen
- P/F ratio
A ratio of PaO2 to FiO2
- TV
Tidal volume
- PEEP
Positive end-expiratory pressure
- PIP
Peak inspiratory pressure
- PICU
Pediatric intensive care unit
- LOS
Length of stay
- OR
Odds ratio
- CPA
Cerebellopontine angle
- SBT
Spontaneous breathing trial
- CPAP
Continuous positive airway pressure
- EMR
Electronic medical record
- CI
Confidence intervals
- MRI
Magnetic resonance imaging
Author contributions
Y.Y. and W.Y. designed the study and interpreted the findings. F.C. was responsible for data collection. C.Z. conducted data analysis. W.Y. was a major contributor in writing the manuscript which was revised by Y.Y. W.Y. was responsible for data management. Y.Y. and J.H. reviewed and edited the article. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Patients were waived from informed consent due to the retrospective nature of the study by the Ethical Committee of Guangzhou Women and Children’s Medical Center. The approval of the study was waived by the Ethical Committee of Guangzhou Women and Children’s Medical Center, Guangzhou, China.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Venkataraman ST. Weaning and extubation in infants and children: religion, art, or science. Pediatr Crit Care Med. 2002;3(2):203–5. [DOI] [PubMed] [Google Scholar]
- 2.Epstein SK. Extubation failure: an outcome to be avoided. Crit Care. 2004;8(5):310–2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39(12):2612–8. [DOI] [PubMed] [Google Scholar]
- 4.Kilba MF, Salie S, Morrow BM. Risk factors and outcomes of extubation failure in a South African tertiary paediatric intensive care unit. South Afr J Crit Care 2022;38(1). [DOI] [PMC free article] [PubMed]
- 5.Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001;163(3 Pt 1):658–64. [DOI] [PubMed] [Google Scholar]
- 6.Cohn EC, Robertson TS, Scott SA, Finley AM, Huang R, Miles DK. Extubation Failure and Tracheostomy Placement in Children with Acute Neurocritical Illness. Neurocrit Care. 2018;28(1):83–92. [DOI] [PubMed] [Google Scholar]
- 7.Toescu SM, Samarth G, Layard Horsfall H, et al. Fourth ventricle tumors in children: complications and influence of surgical approach. J Neurosurg Pediatr. 2020;27(1):52–61. [DOI] [PubMed] [Google Scholar]
- 8.Guru PK, Singh TD, Pedavally S, Rabinstein AA, Hocker S. Predictors of Extubation Success in Patients with Posterior Fossa Strokes. Neurocrit Care. 2016;25(1):117–27. [DOI] [PubMed] [Google Scholar]
- 9.Roberts RJ, Welch SM, Devlin JW. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother. 2008;42(5):686–91. [DOI] [PubMed] [Google Scholar]
- 10.Savi A, Teixeira C, Silva JM, et al. Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care. 2012;27(2):e2211–8. [DOI] [PubMed] [Google Scholar]
- 11.Mayordomo-Colunga J, Medina A, Rey C, et al. Non invasive ventilation after extubation in paediatric patients: a preliminary study. BMC Pediatr. 2010;10:29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120(4):1262–70. [DOI] [PubMed] [Google Scholar]
- 13.Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161(5):1530–6. [DOI] [PubMed] [Google Scholar]
- 14.Dos Reis HFC, Gomes-Neto M, Almeida MLO, et al. Development of a risk score to predict extubation failure in patients with traumatic brain injury. J Crit Care. 2017;42:218–22. [DOI] [PubMed] [Google Scholar]
- 15.Kutchak FM, Debesaitys AM, Rieder Mde M, et al. Reflex cough PEF as a predictor of successful extubation in neurological patients. J Bras Pneumol. 2015;41(4):358–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Cata JP, Saager L, Kurz A, Avitsian R. Successful extubation in the operating room after infratentorial craniotomy: the Cleveland Clinic experience. J Neurosurg Anesthesiol. 2011;23(1):25–9. [DOI] [PubMed] [Google Scholar]
- 17.Jahangiri FR, Minhas M, Jane J. Jr. Preventing lower cranial nerve injuries during fourth ventricle tumor resection by utilizing intraoperative neurophysiological monitoring. Neurodiagn J. 2012;52(4):320–32. [PubMed] [Google Scholar]
- 18.Harel Y, Vardi A, Quigley R, et al. Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients. Int J Pediatr Otorhinolaryngol. 1997;39(2):147–58. [DOI] [PubMed] [Google Scholar]
- 19.Kutchak FM, Rieder MM, Victorino JA, et al. Simple motor tasks independently predict extubation failure in critically ill neurological patients. J Bras Pneumol. 2017;43(3):183–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med. 2004;30(7):1334–9. [DOI] [PubMed] [Google Scholar]
- 21.Asehnoune K, Seguin P, Lasocki S, et al. Extubation Success Prediction in a Multicentric Cohort of Patients with Severe Brain Injury. Anesthesiology. 2017;127(2):338–46. [DOI] [PubMed] [Google Scholar]
- 22.Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med. 1998;158(6):1855–62. [DOI] [PubMed] [Google Scholar]
- 23.Godet T, Chabanne R, Marin J, et al. Extubation Failure in Brain-injured Patients: Risk Factors and Development of a Prediction Score in a Preliminary Prospective Cohort Study. Anesthesiology. 2017;126(1):104–14. [DOI] [PubMed] [Google Scholar]
- 24.Vidotto MC, Sogame LC, Gazzotti MR, Prandini MN, Jardim JR. Analysis of risk factors for extubation failure in subjects submitted to non-emergency elective intracranial surgery. Respir Care. 2012;57(12):2059–66. [DOI] [PubMed] [Google Scholar]
- 25.Qureshi AI, Suarez JI, Parekh PD, Bhardwaj A. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support. Crit Care Med. 2000;28(5):1383–7. [DOI] [PubMed] [Google Scholar]
- 26.McCredie VA, Ferguson ND, Pinto RL, et al. Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study. Ann Am Thorac Soc. 2017;14(1):85–93. [DOI] [PubMed] [Google Scholar]
- 27.Dubey A, Sung WS, Shaya M, et al. Complications of posterior cranial fossa surgery–an institutional experience of 500 patients. Surg Neurol. 2009;72(4):369–75. [DOI] [PubMed] [Google Scholar]
- 28.Edmunds S, Weiss I, Harrison R. Extubation failure in a large pediatric ICU population. Chest. 2001;119(3):897–900. [DOI] [PubMed] [Google Scholar]
- 29.Fontela PS, Piva JP, Garcia PC, Bered PL, Zilles K. Risk factors for extubation failure in mechanically ventilated pediatric patients. Pediatr Crit Care Med. 2005;6(2):166–70. [DOI] [PubMed] [Google Scholar]
- 30.Kulkarni AP, Agarwal V. Extubation failure in intensive care unit: predictors and management. Indian J Crit Care Med. 2008;12(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Gowardman JR, Huntington D, Whiting J. The effect of extubation failure on outcome in a multidisciplinary Australian intensive care unit. Crit Care Resusc. 2006;8(4):328–33. [PubMed] [Google Scholar]
- 32.Elisa P, Francesca C, Marco P, et al. Ventilation Weaning and Extubation Readiness in Children in Pediatric Intensive Care Unit: A Review. Front Pediatr. 2022;10:867739. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Baisch SD, Wheeler WB, Kurachek SC, Cornfield DN. Extubation failure in pediatric intensive care incidence and outcomes. Pediatr Crit Care Med. 2005;6(3):312–8. [DOI] [PubMed] [Google Scholar]
- 34.Laham JL, Breheny PJ, Rush A. Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit? J Intensive Care Med. 2015;30(2):89–96. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.