Exploring predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

GAO Min , HAN Xiaotong , ZHANG Xingwen , JIA Aijun , CAO Huanxin , WEN Hui , XU Furong , FAN Maiying ,  XU Jing

Department of Emergency Medicine, Clinical Research Center For Emergency and Critical Care In Hunan Province, Hunan Provincial Institute of Emergency Medicine, Hunan Provincial Key Laboratory of Emergency and Critical Care Metabonomics, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P. R. China;

Corresponding?author：

XU Jing, Email: 6795326@qq.com

Keywords：

Brain injury; tracheal extubation; cough peak flow; Glasgow coma scale

DOI：

10.7507/1671-6205.202209066

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Objective To explore the predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury (TBI). Methods Mechanically ventilated adult patients with moderate to severe brain injuries admitted to the People’s Hospital of Hunan province were selected between April 2020 and March 2022. The general data, neurological function and airway protective ability of the patients were collected. The patients were divided into successful extubation and failed extubation groups based on extubation outcomes. The differences in various indicators between the two groups were compared. Univariate and multivariate logistic regression analyses were conducted to determine the influencing factors for tracheal tube extubation in patients with moderate to severe TBI. Receiver operating characteristic (ROC) curves were plotted to analyze the predictive value of each indicator for extubation in TBI patients. Results A total of 263 patients with moderate to severe TBI were included in the analysis, with 183 patients in the successful extubation group and 80 patients in the failed extubation group. The successful extubation group had higher Glasgow coma scale (GCS) and cough peak flow (CPF) compared to the failed extubation group. The incidence of ventilator-associated pneumonia (VAP), duration of mechanical ventilation, length of ICU stay, and length of hospital stay were all lower in the successful extubation group. Univariate and multivariate logistic regression analyses showed that the predictive factors for tracheal tube extubation in patients with moderate to severe TBI were CPF and GCS at the time of extubation. Adjusting for confounding factors, every 1 L/min increase in CPF at the time of extubation reduced the risk of extubation failure by 2% [odds ratio (OR) = 0.98, 95% confidence interval (CI) 0.97 - 0.99], and every 1-point increase in GCS reduced the risk of extubation failure by 12% (OR = 0.88, 95%CI 0.79 - 0.98). ROC curve analysis showed that CPF, GCS, GCS eye, and GCS motor had predictive value for tracheal tube extubation in patients with moderate to severe TBI. When patients simultaneously met the criteria of GCS≥8 (GCS motor≥5, GCS eye≥3) and CPF ≥68.5 L/min, the diagnostic value for predicting successful extubation was highest, with an area under the ROC curve of 0.946 (95%CI 0.917 - 0.975), sensitivity of 0.850, and specificity of 0.907. Conclusion CPF ≥ 68.5 L/min and GCS ≥ 8 have clinical guiding value for successful extubation in mechanically ventilated patients with moderate to severe traumatic brain injury.

Citation： GAO Min, HAN Xiaotong, ZHANG Xingwen, JIA Aijun, CAO Huanxin, WEN Hui, XU Furong, FAN Maiying, XU Jing. Exploring predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury. Chinese Journal of Respiratory and Critical Care Medicine, 2023, 22(4): 274-280. doi: 10.7507/1671-6205.202209066 Copy

1.	馬淑娟, 程瑋濤, 徐躍嶠. 神經外科重癥患者計劃拔管失敗的相關因素分析. 神經損傷與功能重建, 2018, 13(4): 184-186, 189.
2.	韓昌霖, 嵇朝暉, 倪水妹, 等. 顱腦外傷術后病人氣管拔管失敗的研究進展. 全科護理, 2020, 18(18): 2210-2213.
3.	Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med, 2001, 163(3 Pt 1): 658-664.
4.	Reis HF, Almeida ML, Silva MF, et al. Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury. J Bras Pneumol, 2013, 39(3): 330-338.
5.	Dawes AJ, Sacks GD, Cryer HG, et al. Compliance with Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients with Severe Traumatic Brain Injury. JAMA Surg, 2015, 150(10): 965-972.
6.	Hui X, Haider AH, Hashmi ZG, et al. Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!. J Surg Res, 2013, 184(1): 438-443.
7.	Robba C, Poole D, McNett M, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med, 2020, 46(12): 2397-2410.
8.	Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery, 2017 , 80(1): 6-15.
9.	陳彬. 醫學多因素分析設計樣本例數估算—多因素分析設計樣本例數綜合估算法. 傷害醫學(電子版), 2012, 1(4): 58-60.
10.	Asehnoune K, Seguin P, Lasocki S, et al. Extubation success prediction in a multicentric cohort of patients with severe brain injury. Anesthesiology, 2017, 127(2): 338-346.
11.	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(6 Suppl): 375S-395S.
12.	Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med, 2017, 195(1): 115-119.
13.	Vetrugno L, Guadagnin GM, Brussa A, et al. Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1. Ultrasound J, 2020, 12(1): 9.
14.	Green SM, Haukoos JS, Schriger DL. How to measure the Glasgow Coma Scale. Ann Emerg Med, 2017, 70(2): 158-160.
15.	Duan J, Liu JH, Xiao ML, et al. Voluntary is better than involuntary cough peak flow for predicting re-intubation after scheduled extubation in cooperative subjects. Respir Care, 2014 , 59(11): 1643-1651.
16.	Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care, 2005, 50(12): 1632-1638.
17.	Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. Crit Care, 2020, 24(1): 640.
18.	Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med, 2017, 195(1): 120-133.
19.	Cinotti R, Pelosi P, Schultz MJ, et al. Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study. Ann Transl Med, 2020 , 8(7): 503.
20.	Béduneau G, Pham T, Schortgen F, et al. Epidemiology of weaning outcome according to a new definition. The WIND Study. Am J Respir Crit Care Med, 2017, 195(6): 772-783.
21.	Abedini M, Froutan R, Bagheri Moghaddam A, et al. Comparison of "cough peak expiratory flow measurement" and "cough strength measurement using the white card test" in extubation success: a randomized controlled trial. J Res Med Sci, 2020, 25(1): 52.
22.	Smailes ST, McVicar AJ, Martin R. Cough strength, secretions and extubation outcome in burn patients who have passed a spontaneous breathing trial. Burns, 2013 , 39(2): 236-342.
23.	Salam A, Tilluckdharry L, Amoateng-Adjepong Y, et al. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med, 2004, 30(7): 1334-1339.
24.	Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest, 2003, 124(1): 262-268.
25.	Su WL, Chen YH, Chen CW, et al. Involuntary cough strength and extubation outcomes for patients in an ICU. Chest, 2010, 137(4): 777-782.
26.	Kutchak FM, Debesaitys AM, Rieder Mde M, et al. Reflex cough PEF as a predictor of successful extubation in neurological patients. J Bras Pneumol, 2015, 41(4): 358-364.
27.	McCredie VA, Ferguson ND, Pinto RL, et al. Airway management strategies for brain-injured patients meeting standard criteria to consider extubation. A prospective cohort study. Ann Am Thorac Soc, 2017, 14(1): 85-93.
28.	Dos Reis HFC, Gomes-Neto M, Almeida MLO, et al. Development of a risk score to predict extubation failure in patients with traumatic brain injury. J Crit Care, 2017, 42: 218-222.
29.	Robba C, Rebora P, Banzato E, et al. Incidence, risk factors, and effects on outcome of ventilator-associated pneumonia in patients with traumatic brain injury: analysis of a large, multicenter, prospective, observational longitudinal study. Chest, 2020 , 158(6): 2292-2303.
30.	Bai LF, Duan J. Use of cough peak flow measured by a ventilator to predict re-intubation when a spirometer is unavailable. Respir Care, 2017, 62(5): 566-571.

1. 馬淑娟, 程瑋濤, 徐躍嶠. 神經外科重癥患者計劃拔管失敗的相關因素分析. 神經損傷與功能重建, 2018, 13(4): 184-186, 189.
2. 韓昌霖, 嵇朝暉, 倪水妹, 等. 顱腦外傷術后病人氣管拔管失敗的研究進展. 全科護理, 2020, 18(18): 2210-2213.
3. Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med, 2001, 163(3 Pt 1): 658-664.
4. Reis HF, Almeida ML, Silva MF, et al. Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury. J Bras Pneumol, 2013, 39(3): 330-338.
5. Dawes AJ, Sacks GD, Cryer HG, et al. Compliance with Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients with Severe Traumatic Brain Injury. JAMA Surg, 2015, 150(10): 965-972.
6. Hui X, Haider AH, Hashmi ZG, et al. Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!. J Surg Res, 2013, 184(1): 438-443.
7. Robba C, Poole D, McNett M, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med, 2020, 46(12): 2397-2410.
8. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery, 2017 , 80(1): 6-15.
9. 陳彬. 醫學多因素分析設計樣本例數估算—多因素分析設計樣本例數綜合估算法. 傷害醫學(電子版), 2012, 1(4): 58-60.
10. Asehnoune K, Seguin P, Lasocki S, et al. Extubation success prediction in a multicentric cohort of patients with severe brain injury. Anesthesiology, 2017, 127(2): 338-346.
11. 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(6 Suppl): 375S-395S.
12. Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med, 2017, 195(1): 115-119.
13. Vetrugno L, Guadagnin GM, Brussa A, et al. Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1. Ultrasound J, 2020, 12(1): 9.
14. Green SM, Haukoos JS, Schriger DL. How to measure the Glasgow Coma Scale. Ann Emerg Med, 2017, 70(2): 158-160.
15. Duan J, Liu JH, Xiao ML, et al. Voluntary is better than involuntary cough peak flow for predicting re-intubation after scheduled extubation in cooperative subjects. Respir Care, 2014 , 59(11): 1643-1651.
16. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care, 2005, 50(12): 1632-1638.
17. Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. Crit Care, 2020, 24(1): 640.
18. Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med, 2017, 195(1): 120-133.
19. Cinotti R, Pelosi P, Schultz MJ, et al. Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study. Ann Transl Med, 2020 , 8(7): 503.
20. Béduneau G, Pham T, Schortgen F, et al. Epidemiology of weaning outcome according to a new definition. The WIND Study. Am J Respir Crit Care Med, 2017, 195(6): 772-783.
21. Abedini M, Froutan R, Bagheri Moghaddam A, et al. Comparison of "cough peak expiratory flow measurement" and "cough strength measurement using the white card test" in extubation success: a randomized controlled trial. J Res Med Sci, 2020, 25(1): 52.
22. Smailes ST, McVicar AJ, Martin R. Cough strength, secretions and extubation outcome in burn patients who have passed a spontaneous breathing trial. Burns, 2013 , 39(2): 236-342.
23. Salam A, Tilluckdharry L, Amoateng-Adjepong Y, et al. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med, 2004, 30(7): 1334-1339.
24. Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest, 2003, 124(1): 262-268.
25. Su WL, Chen YH, Chen CW, et al. Involuntary cough strength and extubation outcomes for patients in an ICU. Chest, 2010, 137(4): 777-782.
26. Kutchak FM, Debesaitys AM, Rieder Mde M, et al. Reflex cough PEF as a predictor of successful extubation in neurological patients. J Bras Pneumol, 2015, 41(4): 358-364.
27. McCredie VA, Ferguson ND, Pinto RL, et al. Airway management strategies for brain-injured patients meeting standard criteria to consider extubation. A prospective cohort study. Ann Am Thorac Soc, 2017, 14(1): 85-93.
28. Dos Reis HFC, Gomes-Neto M, Almeida MLO, et al. Development of a risk score to predict extubation failure in patients with traumatic brain injury. J Crit Care, 2017, 42: 218-222.
29. Robba C, Rebora P, Banzato E, et al. Incidence, risk factors, and effects on outcome of ventilator-associated pneumonia in patients with traumatic brain injury: analysis of a large, multicenter, prospective, observational longitudinal study. Chest, 2020 , 158(6): 2292-2303.
30. Bai LF, Duan J. Use of cough peak flow measured by a ventilator to predict re-intubation when a spirometer is unavailable. Respir Care, 2017, 62(5): 566-571.

Chinese Journal of Respiratory and Critical Care Medicine

Exploring predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury

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