Prognostic Factors Associated With Extubation Failure in Acutely Brain-Injured Patients: A Systematic Review and Meta-Analysis*

Abstract

Objective: Extubation failure in brain-injured patients is associated with increased morbidity. Our objective was to systematically review prognostic factors associated with extubation failure in acutely brain-injured adult patients receiving invasive ventilation in an ICU. Data Sources: MEDLINE, Embase, and Cochrane Central were searched from inception to January 31, 2022. Study Selection: Two reviewers independently screened citations and selected English-language cohort studies and randomized trials examining the association of prognostic factors with extubation failure. Studies were considered if they included greater than or equal to 80% adult patients with acute brain injury admitted to the ICU and mechanically ventilated for greater than or equal to 24 hours. Data Extraction: Two reviewers extracted data on population, prognostic factors, extubation outcomes, and risk of bias (using the quality in prognostic factors tool). Data Synthesis: In the primary analysis, adjusted odds ratios (aOR) for each prognostic factor were pooled using random-effects models. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The search identified 7,626 citations, of which 21 studies met selection criteria. Moderate-certainty evidence suggested increased risk of extubation failure with older age (aOR, 3.0 for upper vs lower tertile; 95% CI, 1.78–5.07) and longer duration of mechanical ventilation (aOR, 3.47 for upper vs lower tertile; 95% CI, 1.68–7.19). Presence of cough (aOR, 0.40; 95% CI, 0.28–0.57) and intact swallow (aOR, 0.34; 95% CI, 0.21–0.54) probably decreased risk of extubation failure (moderate certainty). Associations of other factors with extubation failure were informed by low or very low certainty evidence. Conclusions: Patient age, duration of mechanical ventilation, and airway reflexes were associated with extubation failure in brain-injured patients with moderate certainty. Future studies are needed to determine the optimal application of these variables in clinical practice.

Respiratory challenges and ventilatory management in different types of acute brain-injured patients

“…Among ABI patients, data are lacking to precisely decipher the relative contributions of sequelae of the initial cerebral insult and intensive care acquired long-term neurological, muscular and cognitive symptoms. Patients with ABI have higher extubation failure than patients without [ 85 , 86 ].…”

Extubation Anxiety, It Is All in the Brain*

“…In this issue of Critical Care Medicine , Taran et al (13) published a new meta-analysis. It systematically reviews the literature and identifies patient characteristics associated with poor clinical outcomes that are potential prognostic factors associated with extubation failure in acute brain-injured adults.…”

“…The study by Taran et al (13) is a well-executed meta-analysis. It encompasses most of the subject literature.…”

Reply to Li et al. and to Bhattacharya et al.

“…We are less convinced that Glasgow Coma Scale (GCS) thresholds should be used to select patients likely to benefit from HFNC use or NIPPV. The prognostic usefulness of the GCS score as a marker of extubation readiness in brain-injured patients remains uncertain ( 6 ), and there are no data to support its use as an eligibility criterion for HFNC or NIPPV in patients with ABI. The randomized controlled trial (RCT) by Namen and colleagues cited by the authors does not explicitly highlight the use of HFNCs or NIPPV based on GCS thresholds ( 7 ).…”