Extubation based on predictive scales in the management of neurocritical patients: Narrative review and update
DOI:
https://doi.org/10.56294/saludcyt20251541Keywords:
invasive mechanical ventilation, neurocritical patients, extubation, predictive scales, extubation failure, tracheostomy, airwayAbstract
Introduction: Invasive mechanical ventilation (IMV) is essential in neurocritical patients to ensure oxygenation, control ventilation and prevent secondary brain damage, although its prolonged use is associated with complications such as ventilator-associated pneumonia (VAP) and increased mortality. Extubation in this population faces failure rates of up to 40%, highlighting the need for specific strategies. Methodology: A narrative review was conducted based on original articles, case series and open access systematic reviews, consulted in SciELO, LILACS, Scopus, PubMed-Medline, Google Scholar and ClinicalKey. DeCS descriptors and Boolean operators were used, excluding letters to the editor and conference proceedings to prioritise quality evidence. Development: Extubation in neurocritical patients is compromised by neurological (altered level of consciousness, reflex dysfunction), respiratory (secretions, weak cough) and systemic (prolonged IMV) factors. Scales such as VISAGE, AIRWAY SCORE and ENIO integrate key variables to predict success, although they lack universal validation. Tracheostomy reduces duration of IMV, but not VAPV or mortality, while physiotherapy shows unconfirmed potential. Conclusion: Predictive scales offer valuable tools, but their standardisation is limited. Level of consciousness does not consistently predict success, prioritising airway protection. Prospective studies are needed to develop specific protocols and improve outcomes in neurocritical patients.
References
1. Tomicic FV, Andresen MH. Ventilación mecánica en el paciente con lesión cerebral aguda. Rev Med Chile. 2011;139(3):382-390. https://doi.org/10.4067/S0034-9887201100030001
2. Cinotti R, Mijangos JC, Pelosi P, Haenggi M, Gurjar M, Schultz MJ, et al. Extubation in neurocritical care patients: the ENIO international prospective study. Intensive Care Med. 2022 Nov;48(11):1539–50. Available at: https://doi.org/10.1007/s00134-022-06825-8
3. Da Silva AR, Novais MCM, Neto MG, Correia HF. Predictors of extubation failure in neurocritical patients: A systematic review. Australian Critical Care. 2023 Mar;36(2):285–91. American Thoracic Society. Guidelines for the management of adults with mechanical ventilation. Am J Respir Crit Care Med. 2017;195(5):A1234. Available at: https://doi.org/10.1016/j.aucc.2021.11.005
4. McCredie VA, et al. Predictors of extubation failure in neurocritical patients: a multicenter cohort study. Crit Care. 2017;21(1):137.
5. Jakob SM, Bütikofer L, Berger D, et al. A randomized controlled pilot study to evaluate the effect of an enteral formulation designed to improve gastrointestinal tolerance in the critically ill patient—the SPIRIT trial. Crit Care. 2017;21:140. Avaiable inat https://doi.org/10.1186/s13054-017-1730-1
6. Anderson CD, Bartscher JF, Scripko PD, Biffi A, Chase D, Guanci M, et al. Neurologic Examination and Extubation Outcome in the Neurocritical Care Unit. Neurocrit Care. 2011 Dec;15(3):490–7. Available at: https://doi.org/10.1007/s12028-010-9369-7
7. Álvarez-Arango B, González-Medina A, Valencia-Valencia S, Tamayo-Aristizábal YA, Pantoja-Rojas DS, Vélez-Puerta KA. Extubación en el paciente neurocrítico con lesiones encefálicas agudas: revisión narrativa de la literatura. Iatreia [Internet]. el 16 de agosto de 2022 [citado el 18 de marzo de 2025]; Disponible en: https://revistas.udea.edu.co/index.php/iatreia/article/view/350922
8. Asehnoune K, Roquilly A, Cinotti R. Respiratory Management in Patients with Severe Brain Injury. Crit Care. 2018 Mar 20;22(1):76. Available at: https://doi.org/10.1186/s13054-018-1994-0
9. Navalesi P, Frigerio P, Moretti MP, Sommariva M, Vesconi S, Baiardi P, et al. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: Evaluation of a systematic approach to weaning and extubation: Critical Care Medicine. 2008 Nov;36(11):2986–92. Available at: https://doi.org/10.1097/ccm.0b013e31818b35f2
10. Muzette FM, Lima RBH, De Araújo Silva J, Comin TFB, Saraiva EF, Seki KLM, et al. Accuracy and Sensitivity of Clinical Parameters in Predicting Successful Extubation in Patients with Acute Brain Injury. Neurology International. 2022 Jul 25;14(3):619–27. Available in: https://doi.org/10.3390/neurolint14030050
11. Tanwar G, Singh U, Kundra S, Chaudhary A, Kaytal S, Grewal A. Evaluation of airway care score as a criterion for extubation in patients admitted in neurosurgery intensive care unit. J Anaesthesiol Clin Pharmacol. 2019;35(1):85. Available at: https://doi.org/10.4103/joacp.joacp_362_17
12. Cinotti R, Mijangos JC, Pelosi P, Haenggi M, Gurjar M, Schultz MJ, et al. Extubation in neurocritical care patients: the ENIO international prospective study. Intensive Care Med. 2022 Nov;48(11):1539–50. Available in: https://doi.org/10.1007/s00134-022-06825-8
13. Namen AM, Wesley Ely E, Tatter SB, Douglas Case L, Lucia MA, Smith A, et al. Predictors of Successful Extubation in Neurosurgical Patients. Am J Respir Crit Care Med. 2001 Mar 1;163(3):658–64. Available at: https://doi.org/10.1164/ajrccm.163.3.2003060
14. Ko R, Ramos L, Chalela JA. Conventional Weaning Parameters do not Predict Extubation Failure in Neurocritical Care Patients. Neurocrit Care. 2009 Jun;10(3):269–73. Available at: https://doi.org/10.1007/s12028-008-9181-9
15. Jibaja M, Sufan JL, Godoy DA. Controversies in weaning from mechanical ventilation and extubation in the neurocritical patient. Medicina Intensiva (English Edition). 2018 Dec;42(9):551–5. Available at: https://doi.org/10.1016/j.medine.2018.09.003
16. Bowry R, Ramadan AR. Extubation Success in Stroke Patients: Decision-Making and Clinical Factors. Stroke. 2019 Aug;50(8):1946–7. Available at: https://doi.org/10.1161/STROKEAHA.119.025867
17. Dos Reis HFC, Gomes-Neto M, Almeida MLO, Da Silva MF, Guedes LBA, Martinez BP, et al. Development of a risk score to predict extubation failure in patients with traumatic brain injury. Journal of Critical Care. 2017 Dec;42:218–22. Available at: https://doi.org/10.1016/j.jcrc.2017.07.051
18. Tejerina EE, Robba C, Del Campo-Albendea L, Pelosi P, Muriel A, Peñuelas O, et al. Weaning Outcomes in Patients with Brain Injury. Neurocrit Care. 2022 Dec;37(3):649–59. Available at: https://doi.org/10.1007/s12028-022-01584-2
19. Miller RL, Cole RP. Association Between Reduced Cuff Leak Volume and Postextubation Stridor. Chest. 1996 Oct;110(4):1035–40. Available at: https://doi.org/10.1378/chest.110.4.1035
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Copyright (c) 2025 Jhossmar Cristians Auza-Santivañez, Edwin Cruz Choquetopa, Jose Bernardo Antezana-Muñoz, Osman Arteaga Iriarte , Sara Milca Robles-Nina, Blas Apaza-Huanca, Rodrigo Stalin Torrico-Araúz, David Oliver Aguirre-Soliz (Author)
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