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Ann Am Thorac Soc. 2017 Jan;14(1):85-93. doi: 10.1513/AnnalsATS.201608-620OC.

Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study.

Author information

1
1 Interdepartmental Division of Critical Care and.
2
2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
3
3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
4
4 Department of Medicine and.
5
5 Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
6
6 Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada.
7
7 Toronto General Research Institute, Toronto, Ontario, Canada.
8
8 Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
9
9 Division of Respirology, Department of Medicine, Markham Stouffville Hospital, Markham, Ontario, Canada.
10
10 Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; and.
11
11 Department of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Abstract

RATIONALE:

Patients with acute brain injury are frequently capable of breathing spontaneously with minimal ventilatory support despite persistent neurological impairment.

OBJECTIVES:

We sought to describe factors associated with extubation timing, success, and primary tracheostomy in these patients.

METHODS:

We conducted a prospective multicenter observational cohort study in three academic hospitals in Toronto, Canada. Consecutive brain-injured adults receiving mechanical ventilation for at least 24 hours in three intensive care units were screened by study personnel daily for extubation consideration criteria. We monitored all patients until hospital discharge and used logistic regression models to examine associations with extubation failure and delayed extubation.

MEASUREMENTS AND MAIN RESULTS:

Of 192 patients included, 152 (79%) were extubated and 40 (21%) received a tracheostomy without an extubation attempt. The rate of extubation failure within 72 hours was 32 of 152 (21%), which did not vary significantly between those extubated before (early; 6 of 37; 16.2%), within 24 hours (timely; 14 of 70; 20.0%), or more than 24 hours after meeting criteria to consider extubation (delayed; 12 of 45; 26.7%; Pā€‰=ā€‰0.49). Delayed extubation was associated with lower a Glasgow Coma Scale (GCS) score at the time of consideration of extubation, absence of cough, and new positive sputum cultures. Factors independently associated with successful extubation were presence of cough (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.42-9.09), fluid balance in prior 24 hours (OR, 0.75 per 1-L increase; 95% CI, 0.57-0.98), and age (OR, 0.97 per 10-yr increase; 95% CI, 0.95-0.99). A higher GCS score was not associated with successful extubation.

CONCLUSIONS:

Extubation success was predicted by younger age, presence of cough, and negative fluid balance, rather than GCS score at extubation. These results do not support prolonging intubation solely for low GCS score in brain-injured patients.

KEYWORDS:

acute brain injury; extubation; mechanical ventilation; tracheostomy; weaning

PMID:
27870576
DOI:
10.1513/AnnalsATS.201608-620OC
[Indexed for MEDLINE]

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