Neurology in critical care · Extubating the brain-injured patient
Implications of extubation delay in brain-injured patients meeting standard weaning criteria
| Design | Prospective cohort study of consecutive intubated brain-injured patients |
|---|---|
| Treatment | Extubation at the time standard weaning criteria were met |
| Control | Delayed extubation despite meeting the same criteria |
| Population | Consecutive intubated brain-injured patients meeting standard weaning criteria |
| Follow-up | Hospital discharge |
| Primary endpoint | Nosocomial pneumonia, length of stay and hospital charges |
| Result | Patients whose extubation was delayed developed more pneumonia (38% versus 21%, p<0.05) and had longer ICU stay (median 8.6 versus 3.8 days, p<0.001) and hospital stay (median 19.9 versus 13.2 days, p=0.009). Reintubation rates were similar. Median hospital charges were $29,057 higher with delayed extubation (p<0.001). Practice variation persisted after stratifying for Glasgow Coma Scale score at the time readiness criteria were met, particularly among comatose patients. |
| Secondary endpoints | Reintubation rate, hospital charges, variation by Glasgow Coma Scale score |
This study does not support delaying extubating patients when impaired neurologic status is the only concern prolonging intubation. A randomized trial of extubation at the time brain-injured patients fulfill standard weaning criteria is justifiable.
The trial authors, in the published abstract
Challenged the reflex of keeping neurologically impaired patients intubated for airway protection regardless of respiratory readiness, and the similar reintubation rate is the reassuring part. Observational, so confounding by severity is the obvious objection — which is precisely why the authors called for the randomised trial that has still not been done.
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 May;161(5):1530-6.