Neurologic Examination and Extubation Outcome in the Neurocritical Care Unit
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Extubation failure in the neurocritical care unit (NCCU) is difficult to predict, and is an important source of prolonged intensive care, exposure to morbidity, and increased cost.
In this observational cohort study in the NCCU of a tertiary care hospital, we examined patients undergoing extubation or tracheostomy with >6 h of intubation. Observational data were collected at the time of the decision to extubate or pursue tracheostomy. The primary end-point was extubation failure within 72 h.
A total of 378 tracheostomy versus extubation decisions were made on 339 individuals, resulting in 93 tracheostomies and 285 extubations. The extubation failure rate was 48/285 (16.8%). Individuals who underwent extubation had similar GCS scores [median 10T (IQR 10–11), P = 0.21]. Extubation failures had similar rates of pneumonia and fever, chest X-ray (CXR) findings, and admission diagnoses (P = NS). Factors associated with success in univariate analysis included intact gag reflex, normal eye movements, ability to close eyes to command, and ability to cough to command (all P < 0.05). In multivariate analysis, the ability to follow four commands (close eyes, show two fingers, wiggle toes, cough to command) was associated with success (P = 0.01). ROC analysis identified a significant difference in favor of a multivariate model incorporating four commands over GCS alone (P = 0.007).
The ability to follow four commands and other examination criteria were strongly associated with extubation success in this observational study. Modeling suggests that specific neurologic examination parameters provide additional predictive information over GCS alone. A prospective, protocol-driven trial is needed to test and expand these findings.
- Coplin WM, Pierson DJ, Cooley KD, et al. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161:1530–6.
- Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112:186–92. CrossRef
- Epstein SK. Putting it all together to predict extubation outcome. Intensive Care Med. 2004;30:1255–7. CrossRef
- MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120:375S–95S. CrossRef
- Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120:1262–70. CrossRef
- Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest. 2003;124:262–8. CrossRef
- Vallverdu I, Calaf N, Subirana M, et al. Clinical characteristics, respiratory functional parameters and outcome of a 24 hour t-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med. 1998;158(6):1855–62.
- Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med. 2004;30:1334–9. CrossRef
- Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001;163:658–64.
- Ko R, Ramos L, Chalela JA. Conventional weaning parameters do not predict extubation failure in neurocritical care patients. Neurocrit Care. 2009;10:269–73. CrossRef
- Navalesi P, Frigerio P, Moretti MP, et al. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med. 2008;36:2986–92. CrossRef
- De Bast Y, De Backer D, Moraine JJ, et al. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002;28:1267–72. CrossRef
- Jaber S, Chanques G, Matecki S, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff leak test. Intensive Care Med. 2003;29:69–74.
- Darmon JY, Rauss A, Dreyfuss D, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology. 1992;77:245–51. CrossRef
- Ho LI, Harn HJ, Lien TC, et al. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Intensive Care Med. 1996;22:933–6. CrossRef
- Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;130:1664–71. CrossRef
- Neurologic Examination and Extubation Outcome in the Neurocritical Care Unit
Volume 15, Issue 3 , pp 490-497
- Cover Date
- Print ISSN
- Online ISSN
- Humana Press Inc
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- Neurocritical care
- Extubation failure
- Mechanical ventilation
- Industry Sectors
- Author Affiliations
- 1. Neurocritical Care Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- 2. Center for Human Genetic Research, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- 3. Stroke Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- 7. CZPN-6818, 185 Cambridge St., Boston, MA, 02114, USA
- 4. Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- 5. Respiratory Care Services, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- 6. Neuroscience Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA