Dear editor,
We appreciate the opportunity to respond to the letter written by Drs Salturk and Esquinas regarding our study on "Factors Associated With Reintubation in Patients With Chronic Obstructive Pulmonary Disease."
We agree with the idea that the patient has "a good cough" is a subjective statement and that this conclusion might vary from observer to observer. Our respiratory therapists and nurses record this information in the electronic medical radical record periodically throughout the day. It is part of the respiratory therapist's required assessment. We also agree that the use of a semiquantitative cough strength score would likely provide better and more consistent information.
We do not routinely use noninvasive mechanical ventilation after extubation of patients with COPD. Patients who do poorly after extubation are placed on this mode of ventilation provided that their overall status seems good enough to provide enough time to determine whether or not this mode of ventilation can support them. Patients who required reintubation but who did not have a trial of noninvasive ventilation presumably had sufficient respiratory distress postextubation that their clinicians did not think they would stabilize with this mode of ventilatory support. This conclusion, of course, may be arguable and certainly would depend on the patients' clinical status and comorbidity. None of the patients who required mechanical ventilation in this study were initially on noninvasive mechanical ventilation.
We would agree that prospective studies on patients with successful and failed extubation would be very helpful to identify critical factors preextubation, which increase the likelihood of postextubation respiratory failure. We would consider participation in such a trial if the authors have an ongoing project evaluating extubation strategies. We appreciate the comments made by these authors.
Respectfully yours,
-Nopakoon Nantsupawat, MD
-Kenneth Nugent, MD
Texas Tech University Health Sciences Center
Lubbock, Texas.