Source: http://medintensiva.org/en-controversies-in-weaning-from-mechanical-articulo-S2173572718301735
Timestamp: 2019-04-19 21:00:21+00:00

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Question#1. What is the clinical evidence on weaning from MV in the neurocritical patient?
Question#2. Do conventional criteria apply when weaning from MV and extubation?
Question#3. Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation?
Question#4. What are factors associated with successful extubation processes?
Question#5. What is the extubation failure rate?
Question#6. Tracheostomy: is it necessary? If so, when and how?
Question#7. Early mobility: does it really help?
Table 1. Airway care score (ACS).
Table 2. Extubation failure rate of neurocritical patients in different studies.
The information available on the processes of weaning from mechanical ventilation (MV) and extubation after severe neurological injury is scarce.1–4 The strategies used have been extrapolated from researches and protocols obtained from populations of patients without neurocritical conditions1,2 – situations that cannot be compared for several reasons. In the first place, most individuals with a brain injury are not ventilated because of a primary respiratory failure but because they show an altered state of consciousness due to their incapacity to keep their airways patent, meaning that the actual goal of artificial ventilation is to avoid fatal secondary damage factors such as hypoxemia, hypercapnia and hypocapnia.3,4 In the second place, neurocritical patients usually remain long periods of time with MV and artificial airways.2,4 Lastly, because it is not unusual to find, during ventilatory support and artificial airway withdrawal, several degrees of compromise of the state of consciousness followed by an inability to follow commands and move in order to obtain the classical parameters of MV and/or extubation withdrawal.5–8 So, because of all these controversial issues we will be trying to expose our point of view through the following questions.
The actual recommendations suggest that to initiate the withdrawal of MV, the patient should be awake and capable of following commands.8 However, in the case of brain injuries, this parameter is not strictly necessary.3–7,9 Coplin et al.13 reported successful extubation rates in 80% of the patients who scored ≤8 on the GS and in 91% of those who scored ≤4 on such scale. Ko et al.5 used the Four Score to assess the patients’ neurological state, but they did not find any significant differences in the average score between those whose extubation failed and those whose extubation was successful. Similar results were reported by Anderson et al.6 using the GS. McCredie et al.7 confirmed that the GS is not associated with successful extubations.
Both the control of the airway and post-extubation complications play a key role in the success or failure of the entire process.
In one (1) out of every five (5) patients the extubation procedure fails. Table 2 shows data from the extubation failure rates in neurocritical patients available today at the actual medical literature.
Extubation failure rate of neurocritical patients in different studies.
Controversial issue with uncertain benefits. Two retrospective database studies conducted on severe brain trauma, one of them with associated thoracic trauma recommend conducting early tracheostomy procedures based on fewer pneumonias, days on MV and stay at the intensive care unit (ICU). Nevertheless, the mortality rate was similar in the group that underwent late tracheostomy procedures.23,24 Other than the limitations of the methodological design of both studies per se, the reason why the tracheostomy was indicated was not specified.23,24 In another open randomized controlled study with a small sample of ischemic and hemorrhagic stroke victims, early tracheostomies did not reduce the stay at the ICU, but they did reduce the mortality rate, although this was a secondary outcome measure.25 One recent systematic review and one meta-analysis including 10 studies with 503 patients with acute brain injuries showed that early tracheostomies did reduce the long-term mortality rate, the duration of the MV, and the stay at the ICU; however, in the sensitivity analysis conducted, when excluding one biased study, statistical significance went down.26 Even though the Panamerican Iberian consensus does not deal with neurocritical patients, it does not recommend conducting early tracheostomies because, even though this shortens the duration of MV, it does not reduce the rates of pneumonia, days at the ICU, or long-term mortality.27 The percutaneous tracheostomy is preferred to the surgical one due to its lower rate of infections.27 Certain situations favor conducting early tracheostomies: (a) severe cervical spine injuries; (b) infratentorial severe injuries; (c) repeated failed extubations; (d) prolonged MV and (e) poor neurological state.3,27 The role played by primary tracheostomies is still controversial.23–28 In our own opinion, most individuals meet the necessary conditions to be extubated before attempting primary tracheostomies. This is why we firmly believe that conducting one tracheostomy procedure with an organized protocol and team work is a valid option.
Traditionally, neurocritical patients used to remain at rest during the acute phase of their disease. One binational multicenter study backs up this statement, since 84% of individuals could not move during such phase.29 We are standing at the doors of what will be a change of paradigm and cultural approach when it comes to the early mobility of critically ill patients.30–32 The available evidence today states that this new therapeutic approach is safe and feasible if conducted under controlled multidisciplinary programs.30–32 One recent meta-analysis conducted among individuals who required prolonged intensive care confirmed that implementing early mobility protocols reduced the duration of MV, the stay at the hospital and mortality rate, and improved the functional state.30 Specific programs implemented among patients who have not moved for long periods of time confirm their positive effect on the final outcomes.31 These results are encouraging and require large-scale validation among different populations of patients.
Since we need one protocolized organized multidisciplinary algorithm for every neurocritical patient based on their individual needs when it comes to MV and extubation withdrawals, we hereby propose an algorithm we can use when having to deal with all these issues (Fig. 1).
Algorithm for weaning from MV and extubation in neurocritical patients.
The usual criteria to initiate the withdrawal of MV and extubation cannot be extrapolated to neurocritical patients.
Not answering to verbal commands or low scores on the GS does not mean delaying or contraindicating MV and/or extubation withdrawal.
The airway care score (ACS) is a useful tool to predict the capability of keeping an open airway safely.
The Cuff Leak Test predicts the odds of postoperative swelling and stridor.
Conducting one primary tracheostomy is advisable in groups at risk.
The authors declare no conflicts of interest associated with this article whatsoever.
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Please cite this article as: Jibaja M, Sufan JL, Godoy DA. Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico. Med Intensiva. 2018;42:551–555.

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