Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation

Objective: Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. Methods: We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. Results: Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2–61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34–4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50–3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18–2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35–0.76) was associated with a decreased risk of reinstitution. Conclusions: The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.