title: Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study.
abstract: BACKGROUND
  Patients with acute brain injury are frequently capable of breathing spontaneously with minimal ventilatory support despite persistent neurological impairment.
  
  
  OBJECTIVE
  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.
  
  
  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%; P = 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.
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Victoria A
authors.identifier: http://orcid.org/0000-0002-1590-2846
authors.initials: VA
authors.lastname: McCredie
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|4 Department of Medicine and.|5 Department of Physiology, University of Toronto, Toronto, Ontario, Canada.|6 Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada.|7 Toronto General Research Institute, Toronto, Ontario, Canada.
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.affiliation: 2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Ruxandra L
authors.initials: RL
authors.lastname: Pinto
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|4 Department of Medicine and.|8 Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Neill K J
authors.initials: NK
authors.lastname: Adhikari
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|4 Department of Medicine and.|8 Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Fowler
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Martin G
authors.initials: MG
authors.lastname: Chapman
authors.affiliation: 9 Division of Respirology, Department of Medicine, Markham Stouffville Hospital, Markham, Ontario, Canada.
authors.forename: Althea
authors.initials: A
authors.lastname: Burrell
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|10 Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; and.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Baker
authors.affiliation: 11 Department of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
authors.affiliation: 11 Department of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Maureen O
authors.initials: MO
authors.lastname: Meade
authors.affiliation: 1 Interdepartmental Division of Critical Care and.|2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|4 Department of Medicine and.|8 Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D060666:Airway Extubation; D058109:Airway Management / Q000379:methods*; D001930:Brain Injuries / Q000150:complications / Q000628:therapy*; D000070642:Brain Injuries, Traumatic / Q000150:complications / Q000628:therapy; D002543:Cerebral Hemorrhage / Q000150:complications / Q000628:therapy; D015331:Cohort Studies; D003371:Cough / Q000453:epidemiology; D003399:Craniotomy; D019468:Disease Management; D015600:Glasgow Coma Scale; D006408:Hematoma, Subdural / Q000150:complications / Q000628:therapy; D006801:Humans; D007362:Intensive Care Units; D016015:Logistic Models; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000628:therapy; D014139:Tracheostomy
keywords: acute brain injury; extubation; mechanical ventilation; tracheostomy; weaning