Use of a Physiotherapy Assessment to Predict Extubation Failure in Mechanically Ventilated Patients: the EPIC Assessment

Adult patients admitted to the ICU and placed on invasive mechanical ventilation for more than 48 hours will be screened by the investigators (physiotherapists in conjunction with a doctor).

The spontaneous ventilation test will be carried out in the T-Tube, on the basis of a medical decision and within the framework of care, if the patients meet the weaning conditions:

• No sedation
• No inotropes or vasopressors
• Consistent response to simple commands
• FiO2 < 50%
• PEEP < 5 cmH2O

The criteria for a successful T-Tube test are:

• FR < 35 cycles/min
• SpO2 > 90%,
• Variation of less than 20% in FR or systolic blood pressure,
• No sweating, agitation or vigilance disorders.

Inclusion of patients by investigators after a successful spontaneous ventilation test.

Data will be collected describing the characteristics of patients on the day of their T-Tube test, and will also list the various risk factors for extubation failure already known in the literature, in order to avoid confounding bias

EPIC Assessment by physiotherapists: Within 30 minutes of a successful spontaneous ventilation test, the physiotherapists are called in by the nursing team to carry out the EPIC Assessment. This assessment takes the form of a table containing the following criteria:

• Glasgow Coma Scale (GCS): X < 11 ≤ O
• Rapid Shallow Breathing Index (RSBI): X ≤ 75 < O
• Maximum Inspiratory Pressure (MIP): X < l-25l < O
• Peak Expiratory Flow (PEF): X < l-60l < O
• Bronchial congestion: X = "++" and "+++"; O = "+" and "Ø"
• Salivary stasis: X = "++" and "+++"; O = "+" and "Ø".
• Orofacial motricity: X = Incomplete and O = Complete
• Cervical spine flexion: X = Impossible and O = Possible
• Nausea reflex: X = Absent and O = Present on at least one side.
• Medical Research Council (MRC): X < 36 and O > 36.

The patient is placed in a semi-sitting position, having been lifted into bed beforehand.

The physiotherapist first takes information about the starting conditions, then decreases the Inspiratory Pressure (IP) to 7 and the Positive Expiratory Pressure (PEP) to 0.

Each criterion is then assessed by the physiotherapist with the patient's participation. The cut-offs described in the literature are taken into account to validate each criterion: an "X" sign predicts extubation failure, an "O" sign predicts extubation success.

Inter-rater reproducibility study: the EPIC grids will be reviewed at the end of the research by a physiotherapist who has not carried out this EPIC, who will be responsible for giving a "favorable" or "unfavorable" opinion based on the results of the EPIC assessment (opinion not taken into account for the extubation decision - for reproducibility analysis only).

Binary global assessment: "favorable" or "unfavorable" opinion, issued collectively by the entire team in charge of the patient (physiotherapist, senior doctor, junior doctor (intern), state-registered nurse, nursing auxiliary).

Extubation decision: taken by the doctor after the spontaneous ventilation test and communication by the physiotherapists of their favorable or unfavorable opinion. Participation in the research will not affect patient management. A patient who has not been extubated will be reassessed according to the care plan in the following days (new spontaneous ventilation test, new EPIC assessment).

Inclusion criteria

• Patient 18 years of age or older
• Admitted to intensive care and placed on invasive mechanical ventilation for more than 48 hours
• Having passed a T-Tube spontaneous ventilation test < 24h

Exclusion criteria

• Tracheostomized patient
• Severe psychiatric pathology or cognitive disorders
• Uncooperative patient
• Patient under therapeutic restriction (terminal extubation)
• Patient who has already participated in research
• Patient or close relative (if patient not able) opposed to research
• No relative if patient unable to receive information