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Predictors of extubation success in acute ischemic stroke patients

Published on Sep 1, 2016in Journal of the Neurological Sciences2.651
· DOI :10.1016/j.jns.2016.07.017
Vasileios-Arsenios Lioutas10
Estimated H-index: 10
(BIDMC: Beth Israel Deaconess Medical Center),
Khalid A. Hanafy15
Estimated H-index: 15
(BIDMC: Beth Israel Deaconess Medical Center),
Sandeep Kumar16
Estimated H-index: 16
(BIDMC: Beth Israel Deaconess Medical Center)
Abstract
Abstract Background Acute ischemic stroke (AIS) patients often undergo intubation and mechanical ventilation (MV). Prolonged intubation and MV have disadvantages and complications. Conventional extubation criteria based only on respiratory parameters are insufficient to guide extubation practices in stroke patients where capacity for airway protection is a major concern. Objective To identify clinical and neuroanatomical markers of successful extubation in AIS patients requiring MV. Methods Retrospective review of tertiary care hospital patient database from May 2009–November 2012 to identify consecutive patients with AIS intubated during hospitalization. We assessed the effect of age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, level of consciousness, facial weakness, dysarthria, neglect, infarct location, dysphagia, respiratory parameters and history of pneumonia on successful extubation by hospital discharge using multivariate logistic regression analysis. Results 112 subjects met study criteria and were included in the analysis. Age and NIHSS scores (mean ± standard deviation) were 74.5 ± 16.1 years and 19 ± 9.8, respectively; 56% were women. In multivariate analysis, NIHSS score ≤ 15 (Odds Ratio 4.6, 95% Confidence Interval 1.9–11.3, p  Conclusions Milder stroke and absence of dysarthria prior to intubation were independently associated with extubation success. Our findings could help inform extubation practices in patients with AIS though prospective validation is necessary.
  • References (17)
  • Citations (3)
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References17
Newest
#1Silvia Schönenberger (Heidelberg University)H-Index: 11
#2Wolf-Dirk Niesen (University of Freiburg)H-Index: 13
Last. Julian Bösel (Heidelberg University)H-Index: 23
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BackgroundTracheostomy is a common procedure in long-term ventilated critical care patients and frequently necessary in those with severe stroke. The optimal timing for tracheostomy is still unknown, and it is controversial whether early tracheostomy impacts upon functional outcome.MethodThe Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2 (SETPOINT2) is a multicentre, prospective, randomized, open-blinded endpoint (PROBE-design) trial. Patient...
17 CitationsSource
Patients with severe ischemic and hemorrhagic stroke may require tracheostomy in the course of their disease. This may apply to stroke unit patients whose deficits include a severe dysphagia posing such risk of aspiration as it cannot be sufficiently counteracted by tube feeding and swallowing therapy alone. More often, however, tracheostomy is performed in stroke patients so severely afflicted that they require intensive care unit treatment and mechanical ventilation. In these, long-term ventil...
25 CitationsSource
#1Julian BöselH-Index: 23
#2Petra SchillerH-Index: 13
Last. Thorsten SteinerH-Index: 49
view all 12 authors...
Background and Purpose—Optimal timing of tracheostomy in ventilated patients with severe stroke is unclear. We aimed to investigate feasibility, safety, and potential advantages of early tracheostomy in these intensive care unit (ICU) patients. Methods—This prospective, randomized, parallel-group, controlled, open, and outcome-masked pilot trial was conducted in neurological/neurosurgical ICUs of a university hospital. Patients with severe ischemic or hemorrhagic stroke and an estimated need for...
90 CitationsSource
#1Julian Bösel (Heidelberg University)H-Index: 23
#2Petra Schiller (Heidelberg University)H-Index: 13
Last. Thorsten Steiner (Heidelberg University)H-Index: 49
view all 4 authors...
RationaleVentilated intensive care patients with ischemic or hemorrhagic strokes have a poor prognosis. Early tracheostomy has led to advantages in selected groups of non-cerebrovascular intensive care patients, including shorter ventilation time, shorter intensive care unit length of stay, and reduced complications. It is completely unclear whether ventilated stroke patients might benefit from early tracheostomy, too.AimStroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in N...
22 CitationsSource
#1Linda C. Wendell (Brown University)H-Index: 6
#2Jonathan RaserH-Index: 3
Last. Soo-Jin ParkH-Index: 80
view all 4 authors...
Introduction. Stroke patients often meet respiratory guidelines for extubation, but uncertainty exists if patients will protect their airway due to impaired mental status. Patients with middle cerebral artery (MCA) acute ischemic stroke (AIS) might have specific predictors of successful extubation. Methods. Retrospective cohort of MCA AIS patients requiring intubation. Results. Thirty-seven MCA AIS patients were extubated successfully and ten failed extubation. Those who successfully extubated h...
18 CitationsSource
#1Navaz Karanjia (Johns Hopkins University)H-Index: 3
#2Diana Nordquist (WMC: Westchester Medical Center)H-Index: 1
Last. Paul A. Nyquist (Johns Hopkins University)H-Index: 22
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Background Patients with acute brain injury but normal lung function are often intubated for airway protection, but extubation often fails. Currently, no clinical data exist that describe the events leading to extubation failure in this population. We examined the extubation failure rate, reintubation rate, and clinical characteristics of patients whose reason for intubation was a primary neurological injury. We then identified the clinical characteristics of those patients with primary brain in...
31 CitationsSource
#1Richard Ko (USC: University of South Carolina)H-Index: 1
#2Leah Ramos (MUSC: Medical University of South Carolina)H-Index: 1
Last. Julio A. Chalela (MUSC: Medical University of South Carolina)H-Index: 25
view all 3 authors...
Objective Predicting extubation failure (EF) is one of the most challenging aspects of critical care medicine. The literature on EF in neurocritical care patients is very scarce. We sought to determine the ability of traditional weaning parameters to predict EF in neurocritical patients.
64 CitationsSource
#1Edward M. Manno (Mayo Clinic)H-Index: 29
#2Alejandro A. Rabinstein (Mayo Clinic)H-Index: 59
Last. Rolf D. Hubmayr (Mayo Clinic)H-Index: 59
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Introduction To assess the safety and feasibility of recruiting mechanically ventilated patients with brain injury who are solely intubated for airway protection and randomising them into early or delayed extubation, and to obtain estimates to refine sample-size calculations for a larger study. The design is a single-blinded block randomised controlled trial. A single large academic medical centre is the setting.
24 CitationsSource
BACKGROUND: Unsuccessful extubation may be due to swallowing dysfunction that causes airway obstruction and impairs patients' ability to cough and expectorate. OBJECTIVE: To determine whether swallowing assessment before extubation is helpful in predicting unsuccessful extubation due to airway secretions. METHODS: This prospective study included all patients intubated orotracheally for more than 6 days. Before extubation, 3 tests designed to assess (1) cervical, oral, labial, and lingual motilit...
14 Citations
#1Maged A. TaniosH-Index: 13
#2Michael L. NevinsH-Index: 4
Last. Scott K. EpsteinH-Index: 40
view all 7 authors...
Objective:Weaning predictors are often incorporated in protocols to predict weaning outcome for patients on mechanical ventilation. The predictors are used as a decision point in protocols to determine whether a patient may advance to a spontaneous breathing trial. The impact of including predictors
102 CitationsSource
Cited By3
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#1Mary P. Amatangelo (Brigham and Women's Hospital)H-Index: 1
#1Sarah Beth Thomas (Brigham and Women's Hospital)
Last. Sarah Beth Thomas (Brigham and Women's Hospital)H-Index: 1
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Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.
Source
#1Sonja Suntrup-Krueger (WWU: University of Münster)H-Index: 7
#2Sarah Schmidt (WWU: University of Münster)H-Index: 1
Last. Rainer Dziewas (WWU: University of Münster)H-Index: 35
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Background and Purpose— Predicting safe extubation represents a clinical challenge in acute stroke patients. Classical respiratory weaning criteria have not proven reliable. Concerning the paramoun...
4 CitationsSource
#1Chang-Shu TuH-Index: 1
#2Chih-Hao ChangH-Index: 1
Last. Ching-Ter ChangH-Index: 8
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Approximately 40% of patients admitted to the medical intensive care unit (ICU) require mechanical ventilation. An accurate prediction of successful extubation in patients is a key clinical problem in ICU due to the fact that the successful extubation is highly associated with prolonged ICU stay. The prolonged ICU stay is also associated with increasing cost and mortality rate in healthcare system. This study is retrospective in the aspect of ICU. Hence, a total of 41 patients were selected from...
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Patients admitted to the neuroscience intensive care unit (NICU) may have respiratory compromise from either central or peripheral neurological pathology, and may hence require intubation and mechanical ventilation for very diverse reasons. Liberation from invasive ventilation, that is, extubation, at the earliest possible time is a widely accepted principle in intensive care. For this, classic extubation criteria have been established in the general critical care setting, mainly targeting pulmo...
1 CitationsSource