Clinical Nutrition xxx (xxxx) xxx

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original article

Evaluation of the association between decreased skeletal muscle mass

and extubation failure after long-term mechanical ventilation
Hye Young Woo a, Seung-Young Oh a, b, *, Hannah Lee c, Ho Geol Ryu c
a
Department of Surgery, Seoul National University College of Medicine, Republic of Korea
b
Critical Care Center, Seoul National University Hospital, Republic of Korea
c
Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Republic of Korea

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Elderly patients are being increasingly admitted to the intensive care unit (ICU) for
Received 17 September 2019 mechanical ventilation (MV) and prevalence of decreased skeletal muscle mass which develop with
Accepted 2 December 2019 aging is subsequently increasing. The objective of this study was to identify the association between
decreased skeletal muscle mass and extubation failure in patients undergoing long-term MV.
Keywords: Methods: Adults (
18 years of age) with long-term MV for > 7 days between January 2014 and February
Decreased skeletal muscle mass
2019 were included retrospectively. Patients who died or were transferred with MV, underwent tra-
Critically ill patients
cheostomy with failure of weaning from MV, and had not undergone abdominal computed tomography
Mechanical ventilation
Extubation failure
within 3 days before or after intubation were excluded. Failed extubation was defined as reintubation
within 48 h after extubation following long-term MV for >7 days. We divided the patients into extu-
bation success and failure groups.
Results: Parameters including patients’ demographics, cause of intubation, initial setting of MV,
maximum inspiratory pressure (MIP) and rapid shallow breath index (RSBI) at extubation, and skeletal
muscle mass were compared between the two groups. Decreased skeletal muscle mass was set a
standard as a L3 muscle index of less than 49 cm2/m2 for men and of less than 31 cm2/m2 for women
using Korean-specific cut-offs for sarcopenia as evaluated on previous epidemiologic study. Among 104
patients who were screened, 45 were included, and 11 (24.4%) failed to be extubated. Mean MIP
(23.5 ± 11.8 vs. 32.4 ± 9.3, p ¼ 0.134) and RSBI (57.2 ± 26.5 vs. 55.3 ± 20.4, p ¼ 0.803) were not different
between the two groups. The proportions of patients whose MIP or RSBI satisfied the cutoff for extu-
bation were not different between the groups. There were no significant differences in age, sex, body
mass index, comorbidities, nutritional status, and cause of intubation between the two groups. The
extubation failure group showed a higher proportion of decreased skeletal muscle mass (90.9% vs. 58.8%,
p ¼ 0.05) and longer duration of MV (10.7 ± 4.1 vs. 9.6 ± 3.4, p < 0.001) than the extubation success
group. Multivariate analysis showed that the duration of intubation (OR ¼ 1.439, 95% CI ¼ 1.12e1.85), and
decreased skeletal muscle mass (OR ¼ 24.382, 95% CI ¼ 1.00e594.86) were associated with extubation
failure.
Conclusions: Decreased skeletal muscle mass was associated with extubation failure after long-term MV
for > 7 days. It is important to diagnose decreased skeletal muscle mass in critically ill patients to reduce
extubation failure rates.
© 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction

As the elderly population has increased globally, the proportion

* Corresponding author. Critical Care Center and Department of Surgery, Seoul
National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of
Korea.
E-mail address: faun1226@gmail.com (S.-Y. Oh).
of elderly patients admitted to the hospital, especially to the
intensive care unit (ICU) is also increasing. Mechanical ventilation
(MV) due to respiratory failure is one of the most common causes
for patients admitted to the ICU, and the incidence of acute respi-
ratory failure in patients older than 65 years of age is three times

https://doi.org/10.1016/j.clnu.2019.12.002
0261-5614/© 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Please cite this article as: Woo HY et al., Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-
term mechanical ventilation, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.12.002
2 H.Y. Woo et al. / Clinical Nutrition xxx (xxxx) xxx

higher than that in the younger population [1]. Advanced age is a (SNUHeNSI) developed by our institution. The validity of this tool
significant factor that increases the risk of extubation failure. About was verified by comparing the results of nutrition assessment with
20e35% of elderly patients experienced extubation failure and those obtained from Patient Generated-Subjective Global Assess-
required reintubation within 48e72 h after extubation [2,3]. This ment (PG-SGA) for 174 patients who underwent gastric resection
number is higher than that in the general population whose inci- [10]. The SNUH-NSI consists of 11 objective nutrition-related fac-
dence of extubation failure ranges from 3 to 19% [4]. tors (body weight change at the point of admission, appetite status,
Several studies have shown that many classic predictors for patient's subjective statement of gastrointestinal disorders,
successful extubation such as the rapid shallow breathing index biochemistry results, such as levels of serum-albumin, serum-
(RSBI), maximal inspiratory pressure (MIP), negative inspiratory cholesterol, total lymphocyte count, hemoglobin, and C-reactive
force, and minute ventilation cannot be applied to predict the risk protein, obtained within 2 weeks before admission, type of meal,
of extubation failure in elderly patients [2,5,6]. For this reason, to age, and BMI on the admission day). Nutritional screening for all
predict successful extubation in elderly patients, other additional hospitalized patients is performed within 24 h after admission
factors should be considered together with known predictors. using this tool, and patients were classified into high, moderate,
The skeletal muscles that account for about 40% of the human and low risk groups according to their total risk factors
body contribute significantly to body functions such as posture, (Supplementary Table 1) [11].
movement, and respiration [7]. Sarcopenia is defined as low
measured values of three parameters: muscle strength, muscle
2.3. Evaluation of skeletal muscle mass using abdominal CT
quantity/quality and physical performance caused by aging [8]. The
annual rate of muscle mass decline is about 1e2%, and it accelerates
On the axial CT image at the level of the third lumbar vertebrae,
2e3% annually after 60 years of age [9].
cross-sectional areas (cm2) of skeletal muscle (musculus psoas
We hypothesized that decreased skeletal muscle mass which
major, musculus erector spinae, quadratus lumborum, musculus
could lead to respiratory depression could affect extubation failure.
obliquus externus abdominis, musculus obliquus internus abdom-
The aim of this study was to identify the association between
inis, musculus transversus abdominis, and musculus rectus
decreased skeletal muscle mass and extubation failure in patients
abdominis) were manually measured using the Picture Archiving
undergoing long-term MV.
and Communication System (PACS) (Fig. 1). The values were
normalized for stature to determine the L3 skeletal muscle index
2. Materials and methods
(cm2/m2). In addition, Korean-specific cut-offs for sarcopenia, as
defined in a previous epidemiologic study (49 cm2/m2 for men and
This retrospective study's protocol was approved by the insti-
of 31 cm2/m2 for women) and Global cut-off, as defined in Asian
tutional review board (IRB) of Seoul National University Hospital
Working Group for Sarcopenia (AWGS) consensus (7.0 kg/m2 for
(SNUH) (IRB number: 1901-128-1005). All procedures followed
men and 5.4 kg/m2 for women), were applied [12,13].
were in accordance with the Helsinki Declaration of 1964 and later
versions and performed in accordance with the relevant guidelines.
2.4. Statistical analysis
2.1. Patients
Comparisons of patient demographics and clinical variables
Adult patients (
18 years of age) who were admitted to the between extubation success and failure groups were performed
surgical ICU and underwent long-term MV for > 7 days between using Student's t-test to analyze continuous variables and Pearson's
January 2014 and February 2019 in SNUH, a tertiary center in South c2 test and Fisher's exact test to analyze categorical variables.
Korea, were included in this study. Patients who died or were Continuous variables are described as a mean ± standard deviation
transferred with MV, underwent tracheostomy with failure of
weaning from MV, and had not undergone abdominal computed
tomography (CT) within 3 days before or after intubation were
excluded. We divided the patients into two groups: the extubation
success group and extubation failure group. Extubation failure was
defined as reintubation within 48 h after extubation following
long-term MV for >7 days [2,3].

2.2. Variables evaluated

The electronic medical records of all included patients were

reviewed, and data were collected about (1) patient demographics
and anthropometric data (age, sex, height, weight, body mass index
[BMI], and comorbidities), (2) patient characteristics at the point of
intubation (Acute Physiology and Chronic Health Disease Classifi-
cation System [APACHE] II score, cause of intubation, mode of MV,
PaO2/FiO2, peak inspiratory pressure, and nutritional status
including the albumin level, total protein level, and presence of
decreased skeletal muscle mass), (3) patient characteristics at the
point of extubation (respiratory parameters such as RSBI and MIP,
duration of MV after first intubation, intervals to reintubation, and
cause of reintubation), and (4) operative factors (type of operation Fig. 1. Structures that are segmented for body composition analysis and skeletal
muscle mass assessment. 1; m. rectus abdominis, 2;- m. obliquus externus abdominis,
and operation time). 3; m. obliquus internus abdominis, 4; m. transversus abdominis, 5; m. quadratus
The nutritional status of each patient was evaluated using the lumborum, 6; m. psoas major, 7; m. erector spinae, 8; body of the 3rd lumbar
Seoul National University Hospital-Nutrition Screening Index vertebrae.

Please cite this article as: Woo HY et al., Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-
term mechanical ventilation, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.12.002
 H.Y. Woo et al. / Clinical Nutrition xxx (xxxx) xxx 3

(SD). Categorical variables are reported as number (percentage).
Multivariate analysis using the logistic regression test was per-
formed to analyze factors that were significantly associated with
extubation failure in the univariate analyses. A p-value < 0.05 was
considered as statistically significant.
(306.8 ± 424.5 min) than in the extubation success group
(160.4 ± 134.3 min), but this was not statistically different (Table 4).
Multivariate analysis revealed that the duration of MV (OR
1.439, 95% CI 1.12e1.85, p ¼ 0.004) and decreased skeletal muscle
mass (OR 21.382, 95% CI 0.10e594.86, p ¼ 0.050) had significant
effects on extubation failure after long-term MV (Table 5).

3. Results 4. Discussion

During the study period, 104 patients underwent long-term MV
for >7 days in the surgical ICU and 59 patients were excluded for
the following reasons: died or transferred with MV (n ¼ 9), received
tracheostomy (n ¼ 17), or did not undergone abdominal CT within 3
days before or after intubation (n ¼ 33). Forty-five patients were
included, and among them, 11 patients (24.4%) failed extubation.
There were no differences in age, sex, BMI, comorbidities, and
proportion of elderly patients (age
65 years) between the two
groups. However, the length of ICU stay was longer in the extuba-
tion failure group than in the extubation success group (31.4 ± 14.9
days vs. 17.9 ± 13.5 days, p ¼ 0.007) (Table 1).
The patient characteristics at the point of intubation are shown
in Table 2. In the extubation success group, general anesthesia for
the operation was the most common cause of intubation (12/34,
35.3%), followed by hypoxic respiratory failure (10/34, 29.4%).
Otherwise, metabolic respiratory failure was the most common
cause of intubation in the extubation failure group, as with general
anesthesia. The proportion of patients with low skeletal muscle was
higher in the extubation failure group than in the extubation suc-
cess group, regardless of whether we used AWGS cut-off values or
Korean cut-off values. However, a statistically significant difference
was found only when the Korean cut-off values were used (58.8%
vs. 90.9%, p ¼ 0.05).
At the point of extubation, no significant differences between
the two groups were found in the respiratory parameters such as
RSBI and MIP as shown in Table 3. The mean interval between
extubation and reintubation was 17.3 ± 17.3 h. And, the most
common cause of reintubation was hypoxic respiratory failure (7/
11, 63.6%).
Regarding operative factors, there was no significant difference
between the two groups in the type of operation. Emergency
operation was the most frequent type in both groups. The mean
operation time was longer in the extubation failure group
Sarcopenia, low levels of muscle strength, muscle quantity/
quality and physical performance, can be caused by various factors.
Depending on the causative factors, sarcopenia can be divided into
primary caused by aging and secondary caused by severe illness,
malnutrition, and inactivity [14,15]. Recently, the European Work-
ing Group on sarcopenia in older people newly identified sub-
categories of sarcopenia as acute and chronic. In these
subcategories, sarcopenia that has lasted less than 6 months is
considered an acute condition, while sarcopenia that has lasted
more than 6 months is considered a chronic condition [8]. Since in
addition to aging, severe illness and malnutrition are commonly
found in critically ill patients who are affected by a rapidly aggra-
vated chronic disease and are admitted to the ICU, it is easy to
speculate that the incidence of sarcopenia in ICU will be high. In
addition, Sarcopenia is associated with significant morbidities such
as functional decline, falls, fractures and increased mortality
[16e18]. The prognostic value of sarcopenia was determined for
patients with cancer or after surgery [19e24]. In patients who
underwent resection for locally advanced rectal cancer after neo-
adjuvant chemoradiotherapy, sarcopenia at initial diagnosis
showed a negative effect on overall survival [25]. In patients who
underwent radical cystectomy for bladder cancer or curative sur-
gery for esophageal carcinoma, sarcopenic patients showed a lower
survival rate than non-sarcopenic patients [26]. Recently, a pro-
spective study revealed that sarcopenia could be used as a strong
prognostic factor for poor surgical and oncologic outcomes in pa-
tients after surgery for gastrointestinal tract cancer [27]. However,
its value as a predictor for extubation failure has not been evaluated
yet. Since MV causes rapid diaphragmatic wasting and weakening
of the muscle strength is needed to produce the appropriate tidal
volume to supply the physiological needs of the body [28,29], it can
be assumed that sarcopenia, of which the major mechanism is
muscle mass loss and atrophy, can be associated with the

Table 1
Patient demographic and anthropometric data.

All patients (n ¼ 45) Extubation success (n ¼ 34) Extubation failure (n ¼ 11) p - valuea

Age (years) 66.4 ± 14.5 67.9 ± 10.9 61.8 ± 22.3 0.400b

Elderly (
65) (n, %) 29 (64.4) 22 (64.7) 7 (63.6) 0.949c
Sex, M/F 28/17 20/14 8/3 0.408c
Height (cm) 161.8 ± 7.9 161.3 ± 7.7 163.6 ± 8.9 0.410b
Weight (kg) 65.1 ± 15.4 65.7 ± 16.0 63.0 ± 13.9 0.616b
BMI (kg/m2) 24.8 ± 5.5 25.2 ± 5.7 23.5 ± 4.8 0.384b
ICU stay (days) 21.2 ± 14.9 17.9 ± 13.5 31.4 ± 14.9 0.007b
Comorbidities (n, %)
Hypertension 25 (55.6) 19 (55.9) 6 (54.5) 0.938c
Diabetes mellitus 15 (33.3) 12 (35.3) 3 (27.3) 0.624c
Chronic liver disease 12 (26.7) 10 (29.4) 2 (18.2) 0.464c
Chronic kidney disease 3 (6.7) 2 (5.9) 1 (9.1) 0.711c
COPD or Asthma 3 (6.7) 2 (5.9) 1 (9.1) 0.711c
Coronary artery disease 5 (11.1) 5 (14.7) 0 (0.0) 0.177c
Cerebrovascular disease 3 (6.7) 2 (5.9) 1 (9.1) 0.711c
Malignancy 18 (40.0) 13 (38.2) 5 (45.5) 0.671c

Data are presented as mean ± standard deviation or number (percentage).

BMI, Body mass index; ICU, Intensive care unit; COPD, Chronic obstructive pulmonary disease.
a
Statistical significant when p - value < 0.05.
b
Unpaired double-sided Student t-test.
c
ChieSquare test.

Please cite this article as: Woo HY et al., Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-
term mechanical ventilation, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.12.002
4 H.Y. Woo et al. / Clinical Nutrition xxx (xxxx) xxx

Table 2
Patient characteristics associated at the point of intubation.

Extubation success (n ¼ 34) Extubation failure (n ¼ 11) p - valuea

APACHE II score 29.7 ± 9.1 28.0 ± 9.1 0.585b

Cause of intubation (n, %) 0.138c
Hypoxic respiratory failure 10 (29.4) 0 (0.0)
Hypercapnic respiratory failure 2 (5.9) 2 (18.2)
Metabolic respiratory failure 9 (26.5) 4 (36.4)
Failure to protect airway from aspiration 0 (0.0) 1 (9.1)
Unstable vital sign 1 (2.9) 0 (0.0)
For general anesthesia 12 (35.3) 4 (36.4)
Values during Mechanical ventilation
PaO2/FiO2 (mmHg) 195.3 ± 106.3 195.3 ± 102.1 0.999b
PIP (cmH2O) 21.4 ± 3.8 22.4 ± 5.7 0.500b
Nutrition status (n, %) 0.705c
High risk 24 (70.6) 9 (81.8)
Moderate risk 9 (26.5) 2 (18.2)
Mild risk 1 (2.9) 0 (0.0)
Albumin (mg/dL) 2.9 ± 0.4 2.8 ± 0.5 0.431b
Total protein (g/dL) 5.1 ± 1.1 5.2 ± 1.2 0.651b
Decreased skeletal muscle mass using AWGS cut-off (n, %) 28 (82.4) 11 (100.0) 0.134c
Decreased skeletal muscle mass using Korean cut-off (n, %) 20 (58.8) 10 (90.9) 0.05c

Data are presented as mean ± standard deviation or number (percentage).

APACHE II score, Acute Physiology and Chronic Health Disease Classification System II score; PIP, Peak inspiratory pressure; AWGS, Asian Working Group for Sarcopenia.
a
Statistical significant when p - value < 0.05.
b
Unpaired double-sided Student t-test.
c
ChieSquare test.

Table 3
Patient characteristics at the point of extubation.

Extubation success (n ¼ 34) Extubation failure (n ¼ 11) p - valuea

RSBI (breaths/min/L) 55.3 ± 20.4 57.2 ± 26.5 0.803b

RSBI < 105 (n, %) 32 (94.1) 11 (100.0) 0.411c
MIP (cmH2O) 32.4 ± 9.3 23.5 ± 11.8 0.134b
MIP
25 (n, %) 24 (80.0) 4 (50.0) 0.087c
MIP unchecked (n, %) 4 (13.3) 3 (27.3)
PIP (cmH2O) 12.4 ± 5.4 10.8 ± 2.2 0.360b
Duration of MV (days) 9.6 ± 3.4 10.7 ± 4.1 <0.001b
Reintubation
Interval between extubation and reintubation (hrs) 17.3 ± 17.3
Cause of reintubation (n, %)
Hypoxic respiratory failure 7 (63.6)
Hypercapnic respiratory failure 3 (27.3)
Metabolic respiratory failure 1 (9.1)

Data are presented as mean ± standard deviation or number (percentage).

RSBI, Rapid shallow breathing index; MIP, Maximal inspiratory pressure; PIP, Peak inspiratory pressure.
a
Statistical significant when p - value < 0.05.
b
Unpaired double-sided Student t-test.
c
ChieSquare test.

Table 5
Table 4
Multivariate analysis of risk factors for extubation failure after long-term mechanical
Operative factors.
ventilation.
Extubation Extubation p - valuea
p - value OR (95% CI)
success (n ¼ 34) failure (n ¼ 11)
c Duration of mechanical 0.004 1.439 (1.12e1.85)
Operation type (n, %) 0.999
ventilation (days)
No operation 6 (17.6) 2 (18.2)
Decreased skeletal muscle mass 0.050 24.382 (0.10e594.86)
Elective operation 3 (8.8) 1 (9.1)
Emergent operation 25 (73.5) 8 (72.7) OR, odds ratio; CI, cofidence interval.
Operation time (min) 160.4 ± 134.3 306.8 ± 424.5 0.285b

Data are presented as mean ± standard deviation or number (percentage).
a
Statistical significant when p - value < 0.05.
b
Unpaired double-sided Student t-test.
c
ChieSquare test.
extubation failure after long-term MV. The result of this study
revealed that the proportion of patients with decreased skeletal
muscle mass, which is one of the parameters of sarcopenia, was
higher in the extubation failure group than in the extubation suc-
cess group, and it suggested the possibility of decreased skeletal
muscle mass as a predictor of successful extubation, which is in line
with our hypothesis.
Decreased muscle mass can be evaluated using various methods
to measure muscle mass, such as bioelectrical impedance analysis,
dual X-ray absorptiometry (DXA), CT, magnetic resonance imaging
(MRI), ultrasonography, and anthropometry. Among these, CT and
DXA are relatively common methods. DXA accurately differentiates
between lean and fat body compartments, and involves less radi-
ation exposure than CT [30]. CT is a precise method for quantifying
muscle that focuses on a specific area of the body, and it has the

Please cite this article as: Woo HY et al., Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-
term mechanical ventilation, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.12.002
 H.Y. Woo et al. / Clinical Nutrition xxx (xxxx) xxx
ability to estimate whole-body muscle mass [21,31,32]. Ultraso-
nography is also widely used to measure muscle quantity and its
use has recently expanded in clinical practice to support the diag-
nosis of sarcopenia in elderly adults. A systematic review of the use
of ultrasonography to assess muscle mass in this population
concluded that the tool was reliable and valid for the assessment of
muscle size in elderly adults with comorbidities [33]. BIA is an easy,
non-invasive, portable method to assess body composition. Several
studies showed correlation between BIA and CT-derived muscle
mass [34,35]. With precision errors of about 2%, CT image analysis is
an ideal method for detecting changes in muscle since many pa-
tients undergo CT repeatedly as part of their diagnostic and treat-
ment assessments [21]. Because of these advantages, several
previous studies have used CT as a diagnostic tool for decreased
skeletal muscle mass [20,21,32,36e38]. In this study, because all
the subjects were patients who were admitted to the surgical ICU
postoperatively for abdominal disease, baseline abdominal CT im-
ages were already obtained within a few days before or after sur-
gery, so we were able to evaluate the skeletal muscle mass without
further evaluation. This is another strength of our study in that its
result can be easily applied to other surgical critically ill patients
because no further evaluation is required.
Regarding the cut-off values to determine decreased skeletal
muscle mass, AWGS introduced a new sarcopenia diagnostic algo-
rithm considering the differences in ethnicity, physical character-
istics, and culture between European and Asian populations [13].
However, despite such efforts and the growing awareness of the
importance of decreased skeletal muscle mass for critically-ill pa-
tients admitted, the modalities and cut-offs used in current clinical
practice to evaluate skeletal muscle reduction vary considerably
[39]. Since there are many ethnic groups in Asia, and the basic
concept of cut-off for sarcopenia presented by AWGS is 2 standard
deviations below the mean muscle mass of young reference group,
we used Korean cut-off values (6.54 kg/m2 for men and 4.91 kg/m2
for women) which was calculated through the population based
database well as AWGS cut-off values. AWGS cut-off values (7.50 kg/
m2 for men and 5.40 kg/m2 for women) were higher than the
Korean Class II cut-off values and similar to the Korean Class I cut-
off values [40].
The literature suggests that the combination of nutrition and
exercise is the key intervention for preventing, treating, and
slowing down the progress of sarcopenia [41,42]. The mechanism of
sarcopenia is muscle atrophy that is most commonly related to
reduced protein synthesis and increased protein breakdown [43].
In a prospective observational cohort study of 113 ICU patients, a
higher provision of protein and amino acids was associated with
lower mortality [44]. Additionally, the European Society for Clinical
Nutrition and Metabolism guideline from 2018 recommended the
progressive delivery of 1.3 g/kg of protein equivalents per day
during critical illness [45]. The American Society for Parenteral and
Enteral Nutrition guideline from 2016 reported that protein re-
quirements are expected to be within the range of 1.2e2.0 g/kg
actual body weight per day for critically ill patients [46]. Although
different recommendations have been suggested in various clinical
literature and optimal protein targets change over time in the ICU,
most critically ill patients should receive at least 1.5 g/kg/day of
protein, and clinical studies strongly suggest that 2.0e2.5 g/kg/day
of protein is safe [47e49]. With the administration of increased
protein intake, exercise has been suggested in several studies to
be effective in preventing anabolic resistance [50,51]. Systematic
review and meta-analysis showed significant positive effects fa-
voring physical therapy in ICUs for improving peripheral and res-
piratory muscle strength, quality of life, physical function,
increasing ventilator-free days, and reducing hospital and ICU
length of stay [52].
Please cite this article as: Woo HY et al., Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-
term mechanical ventilation, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.12.002
5
RSBI and MIP are conventional predictors of successful extuba-
tion for a long time [53e55]. RSBI was first described by Yang and
Tobin in 1991 as the ratio of respiratory rate to tidal volume [56],
and has been commonly used as a predictor of weaning failure with
a cut-off value of 105 breaths/min/L. MIP, which also has been
proposed as a predictor of the outcome of weaning [57,58], repre-
sents maximum pressure during inhalation against an obstructed
airway and is used to assess inspiratory muscle strength [59,60].
The authors reported that an RSBI <105 breaths/min/L predicts
weaning success with a sensitivity and specificity of 0.97 and 0.64,
respectively, and MIP
15, 20, and 30 cm H2O predicts weaning
success with excellent sensitivity (1.00, 1.00, and 0.86, respectively)
and poor specificity (0.11, 0.14, and 0.21, respectively) [56]. How-
ever, in the present study, there were no statistical differences
between the two groups in RSBI and MIP, either as a continuous
variable or categorical variable depending on whether the cut-off
had been passed. The sensitivity and specificity of RSBI were 0.74
and 0.00, respectively, and those of MIP
25 cmH2O were 0.80 and
0.50, respectively. On the basis of these results, we can infer that
RSBI and MIP alone cannot be used to predict extubation success
after long-term MV in critically ill patients. In addition, a previously
published study reported that conventional weaning parameters
may not be applicable in deciding when to stop MV in elderly pa-
tients because of increased residual volume and decreased vital
capacity with aging [61,62].
Other studies reported a significant difference in age between
the patients who were successfully extubated and those who failed
extubation [63,64]. Considering that sarcopenia is caused mainly by
aging, these results are consistent with those of our study in some
aspects. The result of age itself not being identified as a risk factor in
multivariate analysis can be explained by the similar proportion of
elderly patients (age
65 years) and consequent similar risk be-
tween the two groups. Although not identified as a risk factor for
extubation failure in this study, previously known risk factors for
extubation failure include chronic respiratory disease [6,65] and
severity at the point of ICU admission (high APACHE II score) [66].
Although this study reported meaningful results, there are
several limitations. First, this was the retrospective study. Second,
the sample size was too small. Thus, we expect decreased skeletal
muscle mass to be revealed as a strong predictor of extubation
failure in a study with a larger number of patients.
5. Conclusions
We suggest decreased skeletal muscle mass as a new risk factor
for predicting extubation failure after long-term MV for >7 days. To
prevent unexpected extubation failure, early identification with the
appropriate method and timely management of decreased skeletal
muscle mass in critically ill patients should be considered.
Statement of Authorship
SYO is the guarantor of the content of the manuscript.
HYW contributed substantially to the study design, data
collection, analysis, and interpretation, and the writing of the first
draft and subsequent revisions of the manuscript.
HL and HGR contributed substantially to data interpretation,
and the writing of the manuscript.
SYO contributed substantially to the study design, data collec-
tion, analysis and interpretation, and the writing of the first draft
and subsequent revisions of the manuscript.
Conflict of Interest
All authors declare that they have no conflict of interests.
6 H.Y. Woo et al. / Clinical Nutrition xxx (xxxx) xxx
Acknowledgements
None.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.clnu.2019.12.002.
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