Predictors of Successful Extubation in Neurosurgical Patients

Abstract

A respiratory therapist-driven weaning protocol incorporating daily screens, spontaneous breathing trials (SBT), and prompts to caregivers has been associated with superior outcomes in mechanically ventilated medical patients. To determine the effectiveness of this approach in neurosurgical (NSY) patients, we conducted a randomized controlled trial involving 100 patients over a 14-mo period. All had daily screens of weaning parameters. If these were passed, a 2-h SBT was performed in the Intervention group. Study physicians communicated positive SBT results, and the decision to extubate was made by the primary NSY team. Patients in the Intervention (n = 49) and Control (n = 51) groups had similar demographic characteristics, illness severity, and neurologic injuries. Among all patients, 87 (45 in the Control and 42 in the Intervention group) passed at least one daily screen. Forty (82%) patients in the Intervention group passed SBT, but a median of 2 d passed before attempted extubation, primarily because of concerns about the patient's sensorium (84%). Of 167 successful SBT, 126 (75%) did not lead to attempted extubation on the same day. The median time of mechanical ventilation was 6 d in both study groups, and there were no differences in outcomes. Overall complications included death (36%), reintubation (16%), and pneumonia (9%). Tracheostomies were created in 29% of patients. Multivariate analysis showed that Glasgow Coma Scale (GCS) score (p < 0.0001) and partial pressure of arterial oxygen/fraction of inspired oxygen ratio (p < 0.0001) were associated with extubation success. The odds of successful extubation increased by 39% with each GCS score increment. A GCS score > or = 8 at extubation was associated with success in 75% of cases, versus 33% for a GCS score < 8 (p < 0.0001). Implementation of a weaning protocol based on traditional respiratory physiologic parameters had practical limitations in NSY patients, owing to concerns about neurologic impairment. Whether protocols combining respiratory parameters with neurologic measures lead to superior outcomes in this population requires further investigation.

Predictors of Reintubation in Critically Ill Patients

“…7 In a randomized controlled trial comparing a non-physician-directed ventilator weaning protocol to routine care in a neurosurgical ICU, Namen et al reported a Glasgow coma score Ն 8 to be strongly associated with extubation success in neurosurgical patients. 22 Salam and colleagues reported that subjects unable to complete 4 task commands (open eyes, follow with eyes, grasp hand, and stick out tongue) prior to extubation were 4 times more likely to require reintubation. 6 However, the study by Coplin et al reported similar extubation failure among brain injured subjects regardless of their Glasgow coma score.…”

The Timed Inspiratory Effort: A Promising Index of Mechanical Ventilation Weaning for Patients With Neurologic or Neuromuscular Diseases

“…1 Weaning decisions based solely on expert clinical judgment are not always correct. 3 Previous reports suggest that clinical judgment based on traditional respiratory parameters and the level of neuromuscular impairment [4][5][6][7] may prevent unnecessary delay of withdrawal from mechanical ventilation and mitigate complications such as diaphragm atrophy and weakness. 8,9 A number of procedures to verify patients' readiness for weaning have been proposed.…”

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

“…Published November 28, 2011 Extubation failure is defined as the reinstitution of respiratory support from 24 to 72 h following the scheduled extubation. This condition occurs in 2 to 25% of extubated patients (1)(2)(3). Extubation failure increases the incidence of mortality, pneumonia, number of days in the intensive care unit (ICU) and hospital, time spent on mechanical ventilation (MV), hospital costs, and the need for a tracheostomy (4)(5).…”

“…A number of studies have demonstrated an increased incidence of reintuba-tion, pneumonia, and prolonged MV among such patients (2)(3)(4)(5)7,9,14,15).…”