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Analysis identifies extubation failure risk factors in acute brain injury

9th March 2023

A review suggests extubation failure in acute brain injury is more likely in older patients and following longer mechanical ventilation

In a meta-analysis by Canadian and European researchers it was shown that the risk of extubation failure (EF) in acute brain injury is elevated in older patients and following a longer duration of mechanical ventilation.

Patients with acute brain injury admitted to the intensive care unit (ICU) frequently require mechanical ventilation or other forms of respiratory support, as a consequence of respiratory failure due to loss of airway protective reflexes or decreased respiratory drive. In fact, delaying extubation has been shown to increase the incidence of pneumonia and prolong the length of stay in ICU. However, guidelines designed to support the extubation decision-making process have found limited evidence to support clinicians. Identification of prognostic factors of extubation failure are therefore clearly needed but most evidence on such factors has been derived from non-brain injury patient cohorts.

In the current study, researchers undertook a systematic review and meta-analysis in an effort to identify possible prognostic factors that were associated with EF in acute brain-injured adult patients receiving invasive ventilation in an ICU. The team defined extubation failure as unplanned re-intubation within 72 hours of extubation.

Extubation failure prognostic factors

A total of 21 studies with 3,274 patients and a median age of 53 years were included in the analysis and median incidence of EF was 25%.

The researchers found moderate certainty evidence demonstrating that the risk of EF was associated with increased age (adjusted Odds ratio, aOR = 3, 95% CI 1.78 – 5.07, upper vs lower tertile) as well as a longer duration of mechanical ventilation (aOR = 3.47, 95% CI 1.68 – 7.19, upper vs lower tertile).

In contrast, there was moderate certainty evidence that risk of EF was reduced in the presence of intact cough on the day of extubation (aOR = 0.40, 95% CI 0.28 – 0.57) as well as intact swallow (aOR = 0.34, 95% CI 0.21 – 0.54). However, the certainty of evidence for association with any other factors was either low or very low.

The authors concluded that among adult patients with acute brain injury receiving mechanical ventilation for at least 24 hours, there was moderate certainty evidence to suggest that both older age, a longer duration mechanical ventilation and a lack of intact cough or swallow, were associated with increased risk of extubation failure.

Taran S et al. Prognostic Factors Associated With Extubation Failure in Acutely Brain-Injured Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2023