“When a distinguished but elderly scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is very probably wrong.” – Clark’s First Law
It is only fair to follow up my provocative post about a “trial of extubation” by chronicling a case or two that didn’t go as I had hoped. Reader comments from the prior post described very low re-intubation rates. As I alluded in that post, decisions regarding extubation represent the classic trade-off between sensitivity and specificity. If your test for “can breathe spontaneously” has high specificity, you will almost never re-intubate a patient. But unless the criteria used have correspondingly high sensitivity, patients who can breathe spontaneously will be left on the vent for an extra day or two. Which you (and your patients) favor, high sensitivity or high specificity (assuming you can’t have both) depends upon the values you ascribe to the various outcomes. Though these are many, it really comes down to this: what do you think is worse (or more fearsome), prolonged mechanical ventilation, or reintubation?
What we fear today we may not seem so fearsome in the future. Surgeons classically struggled with the sensitivity and specificity trade-off in the decision to operate for suspected appendicitis. “If you never have a negative laparotomy, you’re not operating enough” was the heuristic. But this was based on the notion that failure to operate on a true appendicitis would lead to serious untoward outcomes. More recent data suggest that this may not be so, and many of those inflamed appendices could have been treated with antibiotics in lieu of surgery. This is what I’m suggesting with reintubation. I don’t think the Epstein odds ratio (~4) of mortality for reintubation from 1996 applies today, at least not in my practice.
