Extubation Success Prediction in a Multicentric Cohort of Patients with Severe Brain Injury

Abstract

Background Patients with brain injury are at high risk of extubation failure. Methods We conducted a prospective observational cohort study in four intensive care units of three university hospitals. The aim of the study was to create a score that could predict extubation success in patients with brain injury. Results A total of 437 consecutive patients with brain injury were included, and 338 patients (77.3%) displayed successful extubation. In the multivariate analysis, four features were associated with success the day of extubation: age less than 40 yr, visual pursuit, swallowing attempts, and a Glasgow coma score greater than 10. In the score, each item counted as one. A score of 3 or greater was associated with 90% extubation success. The area under the receiver–operator curve was 0.75 (95% CI, 0.69 to 0.81). After internal validation by bootstrap, the area under the receiver–operator curve was 0.73 (95% CI, 0.68 to 0.79). Extubation success was significantly associated with shorter duration of mechanical ventilation (11 [95% CI, 5 to 17 days] vs. 22 days [95% CI, 13 to 29 days]; P < 0.0001), shorter intensive care unit length of stay (15 [95% CI, 9 to 23 days] vs. 27 days [95% CI, 21 to 36 days]; P < 0.0001), and lower in-intensive care unit mortality (4 [1.2%] vs. 11 [11.1%]; P < 0.0001). Conclusions Our score exploring both airway functions and neurologic status may increase the probability of successful extubation in patients with severe brain injury.

Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 2

“…In cases of prolonged diminished levels of consciousness, neurocritical patients may never undergo the weaning process, and tracheostomy is commonly employed in the management of these patients, but the timing of this procedure is controversial. Prolonged invasive mechanical ventilation (IMV) in this category of patients can lead to higher rates of ventilator-acquired pneumonia, increased ICU length of stay, and higher mortality rates [24,25,27] compared with non-neurological critically ill patients [28].…”

Respiratory Management in Patients with Severe Brain Injury

“…The clinical features and level of arousal compatible with successful extubation are still debated in brain injury patients and, therefore, the rates of extubation failure and delayed extubation remain high in this population. Extubation failure is associated with significant morbidity: nosocomial pneumonia, longer mechanical ventilation duration, increased ICU length of stay and higher mortality [6,10,11], but the cause of extubation failure is probably more deleterious than the failure itself [6]. The fear of extubation failure explains the high rate of delayed extubation in neuro-ICU patients (extubation is considered as delayed when patients are not extubated within 48 h of meeting defined readiness criteria [6]), even though delaying extubation is not a guarantee of success [6].…”

“…A descriptive monocenter study confirmed that mechanical ventilation discontinuation accounted for 50% of deaths in a population of neurovascular patients (stroke, intracerebral hemorrhage or subarachnoid hemorrhage) [33]. In most studies regarding extubation in brain injury patients, patients undergoing withdrawal of life-sustaining therapies are not included [10,11], but the timing, modalities and consequences of extubation in this context are not addressed in the neuro-ICU literature.…”

“…Withdrawal of life-sustaining therapies is a complex process and its modalities after brain injury cannot be reduced only to extubation, which could remain successful even in comatose patients [6,[10][11][12].…”

“…Interest in the respiratory management of brain injury patients has increased recently. In particular, the use of protective ventilation in the early phase of brain injury [8,9] has been evaluated, and new data regarding the criteria compatible with successful extubation [10][11][12] have been gathered.…”