To assess the association of age with extubation failure in neurocritical care patients.

Posthoc analysis of the 'Extubation strategies in Neuro-Intensive care unit patients and associations with Outcomes (ENIO) study', an international prospective observational study.

ENIO was conducted in 73 centers in 18 countries from 2018 to 2020.

Neurocritical care patients with a Glasgow Coma Scale score ≤ 12 and receiving ventilationfor at least 24 h were included. We categorized patients into four age groups based on age quartiles.

This analysis included 1095 patients with a median age of 53 [35 to 65] years. Younger patients were more likely to be admitted with traumatic brain injury, whereas older patients more often had cerebral hemorrhage, ischemic stroke, central nervous infection, or brain malignancies. Extubation failure occurred in 209 (19 %) patients. In the unadjusted analysis, older patients had a higher risk of extubation failure (odds ratio (OR), 1.012 [95 %-confidence interval (CI) 1.004 to 1.021]; P = 0.006). However, after adjusting for confounding factors, the effect of age on extubation failure was no longer significant (OR, 1.008 [0.997 to 1.019]; P = 0.172).

In this international cohort of intubated and ventilated neurocritical care patients, after adjusting for baseline covariates and for previously identified risk factors for extubation failure, age was not associated with extubation failure. Age may not be a factor to consider in extubation decisions for brain-injured patients.

ENIO is registered at clinicaltrials.gov (study identifier NCT03400904).

Long-term ventilator-dependent patients often face problems such as decreased quality of life, increased mortality, and increased medical costs. Respiratory therapists must perform complex and time-consuming ventilator weaning assessments, which typically take 48-72 hours. Traditional disengagement methods rely on manual evaluation and are susceptible to subjectivity, human errors, and low efficiency.

This study aims to develop an artificial intelligence-based prediction model to predict whether a patient can successfully pass a spontaneous breathing trial (SBT) using the patient's clinical data collected before SBT initiation. Instead of comparing different SBT strategies or analyzing their impact on extubation success, this study focused on establishing a data-driven approach under a fixed SBT strategy to provide an objective and efficient assessment tool. Through this model, we aim to enhance the accuracy and efficiency of ventilator weaning assessments, reduce unnecessary SBT attempts, optimize intensive care unit resource usage, and ultimately improve the quality of care for ventilator-dependent patients.

This study used a retrospective cohort study and developed a novel deep learning architecture, hybrid CNN-MLP (convolutional neural network-multilayer perceptron), for analysis. Unlike the traditional CNN-MLP classification method, hybrid CNN-MLP performs feature learning and fusion by interleaving CNN and MLP layers so that data features can be extracted and integrated at different levels, thereby improving the flexibility and prediction accuracy of the model. The study participants were patients aged 20 years or older hospitalized in the intensive care unit of a medical center in central Taiwan between January 1, 2016, and December 31, 2022. A total of 3686 patients were included in the study, and 6536 pre-SBT clinical records were collected before each SBT of these patients, of which 3268 passed the SBT and 3268 failed.

The model performed well in predicting SBT outcomes. The training dataset's precision is 99.3% (2443/2460 records), recall is 93.5% (2443/2614 records), specificity is 99.3% (2597/2614 records), and F1-score is 0.963. In the test dataset, the model maintains accuracy with a precision of 89.2% (561/629 records), a recall of 85.8% (561/654 records), a specificity of 89.6% (586/654 records), and an F1-score of 0.875. These results confirm the reliability of the model and its potential for clinical application.

This study successfully developed a deep learning-based SBT prediction model that can be used as an objective and efficient ventilator weaning assessment tool. The model's performance shows that it can be integrated into clinical workflow, improve the quality of patient care, and reduce ventilator dependence, which is an important step in improving the effectiveness of respiratory therapy.

Postextubation dysphagia is a major risk factor for extubation failure in acute stroke. Pharyngeal electrical stimulation (PES) is a novel neurostimulation technique for neurogenic dysphagia rehabilitation. We conducted a randomized controlled pilot trial evaluating PES early after extubation in acute stroke (N ​= ​60) focusing on dysphagia recovery trajectories and related outcomes until discharge. Patients with severe postextubation dysphagia, defined as Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) score >4, received daily PES (real or sham, 10 ​min/day) for 3 consecutive days. By day 3, significantly fewer patients in the PES group exhibited persistent absence of spontaneous swallows (8 vs. 41 ​%) or pharyngeal sensory loss (4 vs. 55 ​%) compared to the sham group, indicating enhanced airway safety. Functional Oral Intake Scale (FOIS) score at day 3 was significantly higher in the PES group (4.1 vs 2.1 ​pts). FEDSS at days 5-7 and 8-10 showed a sustained treatment effect over time (2.4 vs. 3.7 ​pts. and 2.2 vs. 3.4 ​pts), resulting in better FOIS at discharge (4.7 vs. 3.5 pts.). PES shortened LOS in the intensive care unit (ICU) (3.1 vs. 8.5 days, p ​= ​0.008) and total hospital stay (13.8 vs. 21.9 days, p ​= ​0.004) from study inclusion. Tracheotomy rates were 13 vs. 33 ​% (p ​< ​0.067). The proportion of patients still cannulated at discharge (7 vs. 10 ​%) and the modified Rankin Scale at discharge (3.9 vs. 4.0) were comparable. PES enhanced recovery of postextubation dysphagia, improved airway safety and shortened length of ICU and hospital stay in acute stroke.

Pulmonary complications from mechanical ventilation are a significant concern in intensive care. Reducing the duration of respiratory support is vital to minimize these risks. Extubation, the final step in the weaning process, is critical. Most weaning indices rely on complex ventilatory parameters. This study aimed to evaluate the utility of the heart rate, acidosis, Glasgow Coma Scale, oxygenation, respiratory rate (HACOR) score, and Lung Ultrasound Score (LUS) as predictors of weaning outcomes in the intensive care unit.

This prospective observational study was conducted in the Department of Critical Care Medicine at Sri Ramachandra Institute of Higher Education and Research, involving 100 patients aged 18 years and above. Both the HACOR score and LUS were assessed at the 30th minute during a 60-minute spontaneous breathing trial (SBT).

Of the 100 patients, 65 (65%) were successfully weaned, while 35 (35%) experienced weaning failure. The median HACOR score was 3 (interquartile range: 0-3) in the successful group and 6 (IQR: 5-8) in the failed group. The median LUS was 10 (IQR: 8-10) in the successful group and 16 (IQR: 13-16) in the failed group. A HACOR score ≥5 predicted weaning failure with a sensitivity of 87.7%, specificity of 77.1%, and area under the curve of 0.824. The LUS had an area under curve of 0.831, sensitivity of 86.2%, specificity of 80% at a threshold of ≥13 for failure.

A HACOR score of ≥5 and a Lung Ultrasound Score of ≥13 are excellent predictors of weaning failure and can be incorporated into ICU weaning strategies.

Background/Objectives: Critically ill patients with acute neurological injury commonly require intubation. The true incidence of and risk for extubation failure in pediatric patients with an acute neurologic injury is not well reported, making the assessment of these patients for extubation readiness or the need for tracheostomy challenging. This study aims to better delineate the incidence of extubation failure and factors associated with the need for tracheostomy in pediatric patients surviving an acute neurologic injury. Methods: We conducted a retrospective cohort study using the Virtual Pediatric System (VPS) database of neonates, infants, children, and adolescents < 18 years of age with a neurological injury requiring intubation from 2012 to 2022. Demographic and clinical variables were compared between subjects that were successfully extubated, those with early tracheostomy placement (≤14 days), and those with late tracheostomy placement (>14 days). Results: Of the 38,810 enrolled subjects, 37,661 (97.04%) were successfully extubated, 481 (1.24%) underwent early tracheostomy, and 668 (1.72%) underwent late tracheostomy. The most common etiologies were seizures (60.6%), trauma (20.9%), and intoxication (9.1%). The successfully extubated subjects had a higher median initial GCS score (8 vs. 5 and 4, p < 0.001) and fewer extubation attempts (1 vs. 3 and 3, p < 0.001) than the tracheostomy cohorts. There was a significant difference in median ICU days between the three groups (2.52 vs. 18.3 vs. 38.3, p < 0.001). Conclusions: The majority of pediatric patients requiring intubation following an acute neurological injury can be successfully extubated. Among patients requiring a tracheostomy, those who received it early had significantly shorter ICU and hospital stays.

Pharyngeal electrical stimulation (PES) is a neurostimulation intervention that can improve swallowing and facilitate decannulation in tracheotomised stroke patients with dysphagia. The PHAryngeal electrical stimulation for treatment of neurogenic Dysphagia European Registry (PHADER) study found that PES can reduce dysphagia severity in patients with neurogenic (non-stroke) dysphagia who required mechanical ventilation and tracheotomy. However, the predictive factors for treatment success among these patients remain unclear.

We conducted a subgroup analysis using data from PHADER, with a focus on non-stroke participants who had required mechanical ventilation and tracheotomy. Multiple linear regression was performed to predict treatment success, as measured in improvement in dysphagia severity rating scale (DSRS) total score, accounting for age, sex, time from diagnosis to PES, PES perceptual threshold and PES stimulation intensity at the first session.

Fifty-seven participants (mean[standard deviation] age: 63.6[15.5] years; male: 70.2%) were included in the analysis. These comprised traumatic brain injury (22[38.6%]), critical illness polyneuropathy (15[26.4%]), and other neurological conditions that caused dysphagia (20[35.0%]). Regression analyses identified that a lower PES perceptual threshold at the first session (p = 0.027) and early intervention (p = 0.004) were significant predictors associated with treatment success at Day 9 and 3 months post PES respectively.

We identified two predictive factors associated with successful PES treatment in patients with neurogenic (non-stroke) dysphagia requiring mechanical ventilation and tracheotomy: a lower PES perceptual threshold at the first session and early intervention. These predictors provide critical guidance for optimizing clinical decision-making in managing non-stroke neurogenic dysphagia patients in critical care settings.

The aging of the Israeli population along with a shortage of ICU beds have led to hospitalization of invasive mechanical ventilation patients in internal medicine departments, where, as opposed to ICU, the treatment is less than optimal. The aims of the study were to evaluate the predictive factors for successful weaning from mechanical ventilation in ventilated patients admitted to internal medicine departments. A retrospective study that included non-COVID 19 ventilated patients in internal medicine departments in a university affiliated hospital in Israel between the years 2018-2019. We compared datapoints between patients who were weaned from ventilators versus those who remained ventilated during the hospitalization, and defined demographic and clinical predictive factors for successful weaning. Data were collected from electronic medical records and included demographic, clinical, laboratory and ventilator information. The study group included 348 patients. The rate of successful weaning was 19%; patients who were successfully weaned were primarily functionally independent prior to ventilation, ventilated with low PEEP values, had high hemoglobin and albumin levels alongside with low CRP and lactate levels. Those who remained ventilated either required vasopressor treatment, had positive blood cultures or had lower GFR levels. The overall in-hospital mortality rate was 60%, while the 30-day mortality rate was lower in the extubated group [214 (76%) vs. 6 (9%), P < 0.0001]. Our findings highlight the low rate of weaning from ventilation in the department of medicine, with higher mortality rate among the remained ventilated patients. Various favorable clinical parameters might predict successful weaning.

Weaning of patient from ventilator and finally extubation is a challenge, especially in critical care setup. Though many parameters are available, based on which, the decision of extubation is taken but still many times, there is failure of weaning.

We conducted a prospective observational study to look for diaphragm and abdominal muscle thickness, contraction, and lung ultrasound as indicator for weaning and extubation.

Patients of either gender aged between 20-50 years, who were on invasive mechanical ventilation for more than 48 hrs. and put on spontaneous breathing trial. A bedside ultrasound examination was performed. Abdominal expiratory muscle thickness, diaphragmatic excursion (DE), diaphragmatic thickness fraction (DTF) and lung ultrasound score (LUS) were measured.

12 patients had simple weaning pattern whereas 5 patients had difficult weaning and 8 patients had prolonged weaning. The mean value of DE was 1.97 cm, DTF- 2.3 mm. The mean value of SOFA score is significant between simple, difficult, prolonged weaning (2.24, 4.56, 7.33 respectively). The DE, which is 2.52, 1.26, 1.81 in simple difficult and prolonged weaning respectively is highly significant. The mean value of LUS was 8.34 and is significant in all weaning patterns. The highest sensitivity is found for SOFA score (84.62) with AUC of 0.88.

Evaluation of patient with diaphragm thickness fraction (mean DTF of 26%) and diaphragm excursion (2.52 cm) with mean LUS score of 4.67 opens a new dimension to predict weaning in critically ill patients who are put on spontaneous breathing trial. The sequence of thickness of abdominal expiratory muscles adds to accuracy in successful weaning. Larger muti-center trials are required to make these parameters as a standard practice for weaning patients in critical care setup.

To identify risk factors of failing endotracheal extubation among neurocritical care patients with endotracheal intubation for more than 48 h and passing the autonomous breathing test (SBT) and establish a prediction model accordingly.

This study included the clinical data of patients who received standardized monitoring and treatment in the neurocritical care unit of the First Affiliated Hospital of Anhui Medical University from April 2020 to August 2024. Based on the outcomes of extubation after 5 days, data were divided into the success group and the failure group. Clinical features of two groups were compared and accordingly taken into multivariate logistic regression analysis, eventually generating a scoring model with its receiver operating characteristic curve (ROC). The area under the curves (AUC) of other previous scores was compared by Z-test.

Of 116 recorded cases, 92 (79.3%) were successfully extubated, while 24 (20.7%) required re-intubation within 5 days. Univariate analysis revealed significant differences between two groups in state of consciousness, Glasgow Coma Scale (GCS) total score, GCS motor score (GCS-M), muscle strength, swallowing ability, coughing response, body temperature, oxygenation index, Apache II score, and APS score (all p < 0.05). Multivariate analysis was further carried out, and a scoring model was established accordingly (including GCS-M, coughing ability, and oxygenation index) with a total score of 4 points. The model demonstrated good predictive value, with a cut-off ≥1 distinguishing extubation success with 79.2% sensitivity and 69.6% specificity according to ROC (AUC = 0.79; 95% CI, 0.68-0.90).

This clinical predictive scoring model could provide guidance for extubation decisions in neurocritical care units but requires further external validation.

Timely successful liberation from invasive ventilation has the potential to minimise critically ill patients' exposure to invasive ventilation, save costs and improve outcomes; yet no trials have evaluated strategies to better inform extubation decision-making. The Liberation from mechanical ventilation using Extubation Advisor (EA) Decision Support (LEADS) Pilot Trial will assess the feasibility of a trial of a novel extubation decision support tool on feasibility metrics. The primary feasibility outcome will reflect our ability to recruit the desired population. Secondary feasibility outcomes will assess rates of (1) consent, (2) randomisation, (3) intervention adherence, (4) bidirectional crossovers and the (5) completeness of clinical outcomes collected. We will also evaluate physicians' perceptions of the usefulness of the EA tool and measure costs related to EA implementation.

We will include critically ill adults who are invasively ventilated for ≥48 hours and who are ready to undergo a spontaneous breathing trial (SBT) with a view to extubation. Patients in the intervention arm will undergo an EA assessment that measures respiratory rate variability to derive an estimate of extubation readiness. Treating clinicians (respiratory therapists, attending physicians and intensive care unit fellows) will receive an EA report for each SBT conducted. The EA report will assist, rather than direct, extubation decision-making. Patients in the control arm will receive standard care. SBTs will be directed by clinicians, using current best evidence, without EA assessments or reports. We aim to recruit 1 to 2 patients/month in approximately 10 centres, and to achieve >75% consent rate, >95% randomisation among consented patients, >80% of EA reports generated and delivered (intervention arm), <10% crossovers (both arms) and >90% of patients with complete clinical outcomes. We will also report physician point-of-care perceptions of the usefulness of the EA tool.

The LEADS Pilot Trial is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (4008). We will disseminate the LEADS trial findings through conference presentations and publication.

NCT05506904.

24 April 2024.

Decannulation in tracheotomized neurological patients is often complicated by severe dysphagia, which compromises airway safety and delays weaning. Additional challenges, including reduced cough strength, excessive bronchial secretions, and altered airway anatomy exacerbate weaning issues, thereby increasing morbidity and mortality. This review summarizes diagnostic procedures and therapeutic options crucial for the rehabilitation of tracheotomized patients.

Key diagnostic strategies for assessing decannulation readiness focus on airway protection, airway patency, bronchial secretion management, and cough function. These are collectively introduced as the A2BC criteria in this review. Advanced tools such as flexible endoscopic evaluation of swallowing, endoscopic assessment of airway anatomy, measurement of cough strength, and intrathoracic pressure are essential components of a systematic evaluation. Therapeutic interventions encompass restoring physiological airflow, behavioral swallowing treatment, secretion management, and pharyngeal electrical stimulation. The proposed decannulation algorithm integrates two pathways: the "fast-track" pathway, which facilitates rapid decannulation based on relevant predictors of decannulation-success, and the "standard-track" pathway, which progressively increases cuff deflation intervals to build tolerance over time.

Successful decannulation in neurological patients demands a multidisciplinary, patient-centered approach that combines advanced diagnostics, targeted therapies, and structured management pathways. The proposed algorithm integrates fast-track and standard-track pathways, balancing rapid diagnostics with gradual weaning strategies. This framework promotes flexibility, enabling clinicians to tailor interventions to individual patient needs while maintaining safety and optimizing outcomes.

Rationale: Whether extubation immediately after a successful spontaneous breathing trial is associated with clinical benefits in adult patients with acute brain injury is unknown. Objectives: We sought to estimate the association between a prompt extubation attempt and ventilator-free days among adult patients with acute brain injury. Methods: We performed an emulation of a previously designed randomized controlled trial using data from the Toronto Intensive Care Observational Registry in eight ICUs in Toronto, Ontario, Canada. We included mechanically ventilated adult patients with acute brain injury who had a first successful spontaneous breathing trial. Our main exposure was prompt extubation (i.e., on the same calendar day after the first successful spontaneous breathing trial). The primary outcome was ventilator-free days up to 28 days. We used inverse probability of treatment weighting to adjust for confounding and reported treatment effects using incidence rate ratios and 95% confidence intervals. Measurements and Main Results: A total of 1,406 patients from April 2014 through March 2023 met inclusion criteria. The main reasons for admission were traumatic brain injury (40%), stroke (ischemic or hemorrhagic; 20%), seizures (11%), and subarachnoid hemorrhage (9%). Over half (57%) of patients underwent prompt extubation after their first successful spontaneous breathing trial. Prompt extubation was associated with more ventilator-free days (incidence rate ratio, 1.24; 95% confidence interval, 1.19-1.29) when compared with no prompt extubation. Conclusions: Prompt extubation after a first successful spontaneous breathing trial was associated with more ventilator-free days (up to 28 d) among adults with acute brain injury receiving invasive mechanical ventilation. The original trial protocol was registered with www.clinicaltrials.gov (NCT04291235).

Critically ill patients frequently require mechanical ventilation and often receive sedation to control pain, reduce anxiety, and facilitate patient-ventilator interactions. Weaning from mechanical ventilation is intertwined with sedation management. In this review, we analyze the current evidence for sedation management during ventilatory weaning, including level of sedation, timing of sedation weaning, analgesic and sedative choices, and sedation management in acute respiratory distress syndrome (ARDS).

Despite a large body of evidence from the past 20 years regarding the importance of light sedation and paired spontaneous awakening and spontaneous breathing trials (SATs/SBTs) to promote ventilator weaning, recent studies show that implementation of these strategies lag in practice. The recent WEAN SAFE trial highlights the delay between meeting weaning criteria and first weaning attempt, with level of sedation predicting both delays and weaning failure. Recent studies show that targeted interventions around evidence-based practices for sedation weaning improve outcomes, though long-term sustainability remains a challenge.

Light or no sedation strategies that prioritize analgesia prior to sedatives along with paired SATs/SBTs promote ventilator liberation. Dexmedetomidine may have a role in weaning for agitated patients. Further investigation is needed into optimal sedation management for patients with ARDS.

Postextubation respiratory support treatment approaches, indications, and subgroups of patients with different responses to those therapies are rapidly changing. Planning optimal therapy in terms of choosing devices, timing of application and selecting settings with the goal of minimizing extubation failure is becoming a challenge. This review aims to analyze all the available evidence from a clinical point of view, trying to facilitate decision making at the bedside.

There is evidence for high flow nasal cannula support in patients at low risk of extubation failure. Noninvasive ventilation based strategies should be prioritized in patients at very high risk, who are obese or are hypercapnic at the end of a spontaneous breathing trial. Patients not included in the previous groups merit a tailored decision based on more variables.Optimizing the timing of therapy can include facilitation of extubation by transitioning to noninvasive respiratory support or prolonging a planned preventive therapy according to clinical condition.

Planning postextubatin respiratory support must consider the risk for failing and the presence of some clinical conditions favoring noninvasive ventilation.Extubation can be safely accelerated by modifying screening criteria and spontaneous breathing trial settings, but there is room to increase the role of postextubation noninvasive respiratory support for this indication, always keeping in mind the dangers of delaying a needed intubation.

To assess the predictive capacity of the Rapid Shallow Breathing Index (RSBI) for success in spontaneous breathing trials (SBT) and extubation in critically ill patients. We evaluated the association between RSBI, duration of mechanical ventilation, and ventilator-free time at 28 days.

Prospective multicenter observational study. Secondary analysis of the COBRE-US study.

Intensive care unit (ICU).

367 patients in the ICU receiving invasive mechanical ventilation.

Assessment of RSBI at the end of SBT.

RSBI, SBT, duration of mechanical ventilation, and ventilator-free time at 28 days were evaluated.

367 patients in the ICU under invasive mechanical ventilation were evaluated, of whom 59.7% were male with a median age of 61 years (IQR: 49-72). A total of 456 SBT were conducted with a success rate of 76.5%. RSBI had a ROC-curve of 0.53 for SBT success and a ROC-curve of 0.48 for extubation. The Spearman correlation coefficient between RSBI and duration of ventilation was 0.117 (p = 0.026), while for ventilator-free time at 28 days, it was -0.116 (p = 0.028).

RSBI was not associated with success in SBT or extubation, regardless of the cutoff point used. Correlation analyses showed weak associations between RSBI and both the duration of ventilation and ventilator-free time at 28 days.

The purpose of this study was to evaluate the predictive value of the cough peak flow (CPF) for successful extubation in postcraniotomy critically ill patients.

This was a single-centre prospective diagnostic study.

The study was conducted in three intensive care units (ICUs) of a teaching hospital.

Postcraniotomy patients who were 18 years or older, stayed in ICU for more than 24 hours and underwent mechanical ventilation for more than 24 hours were eligible for the study. Patients were excluded if one of the following was present: no extubation attempt during the ICU stay; underwent tracheostomy without extubation attempt; pregnant or lactating women; enrolled in other clinical trials; declined to participate in the study. A total of 4879 patients were screened and 1037 were eligible for the study, among whom 785 were included in the study.

CPF, including involuntary (CPF-invol) and voluntary CPF (CPF-vol), were measured before extubation. The area under the receiver operating characteristic curve (AUC) was calculated to explore the diagnostic accuracy of CPF in predicting successful extubation.

There were 641 successful extubation cases (81.7%). The AUC of CPF-invol for predicting successful extubation was 0.810 (95% CI 0.766 to 0.854), with a cut-off value of 63.2 L/min, a sensitivity of 87.4% and a specificity of 66.7%. For conscious patients, the AUC of CPF-invol for the prediction of successful extubation was 0.849 (95% CI 0.794 to 0.904), with a cut-off value of 63.2 L/min and the AUC of CPF-vol was 0.756 (95% CI 0.696 to 0.817), with a cut-off value of 68.2 L/min.

The CPF was much higher in patients with successful extubation than that in patients with failed extubation. CPF might be valuable for the prediction of extubation outcomes in postcraniotomy critically ill patients. Multicentre studies could be carried out to further validate the results of this study.

NCT04000997.

Microsurgical resection of tumor is an important treatment for children with fourth ventricular tumors. There is a lack of data describing risk factors for postoperative extubation failure (EF) in these children. We aimed to identify risk factors for EF in children with fourth ventricular tumors and to determine the association between EF and clinical outcomes.

A retrospective study review of children after fourth ventricular tumors surgery who had an extubation attempt between January 2020 to December 2023. Extubation failure was defined as re-intubation within 7 days of extubation. Multivariate logistic regression analysis was performed to explore the risk factors for EF. Bivariate statistical analysis was performed to determine associations between EF and clinical outcomes. Only the first extubation attempt was included in the analysis.

We included 103 children, of whom 10 (9.7%) experienced EF. In the logistic regression analysis, a weak/absent cough reflex was independently associated with EF (p < 0.001). Compared to those with a fair/ strong cough, patients with a weak/absent cough had a odds ratio (OR) of 41.25 for EF (95% CI,8.01-212.37; p < 0.001).Glasgow Coma Score(GCS), the obvious adhesion between the tumor and the fourth ventricle floor, and pulmonary variables were not associated with EF. Children who failed extubation had longer durations of mechanical ventilation [13 days (IQR 6.8-22.8) vs. 1 days (IQR 0.5-3), p < 0.001]; longer PICU lengths of stay [16.5 days (IQR 9.4-27.5) vs. 2 days (IQR1.5-4.3), p < 0.001] and longer hospital lengths of stay [27 days (IQR 21-31.8) vs. 20 days (IQR16-29), p = 0.05] than successfully extubated children.

Children with weak/absent cough reflex after surgery are at increased risk for extubation failure. Extubation failure is associated with significant adverse outcomes in our setting.

Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.

Continuous waveform monitoring is standard-of-care for patients at risk for or with critically illness. Derived from waveforms, heart rate, respiratory rate and blood pressure variability contain useful diagnostic and prognostic information; and when combined with machine learning, can provide predictive indices relating to severity of illness and/or reduced physiologic reserve. Integration of predictive models into clinical decision support software (CDSS) tools represents a potential evolution of monitoring.

We perform a review and analysis of the multidisciplinary steps required to develop and rigorously evaluate predictive clinical decision support tools based on monitoring.

Development and evaluation of waveform-based variability-derived predictive models involves a multistep, multidisciplinary approach. The stepwise processes involves data science (data collection, waveform processing, variability analysis, statistical analysis, machine learning, predictive modelling), CDSS development (iterative research prototype evolution to commercial tool), and clinical research (observational and interventional implementation studies, followed by feasibility then definitive randomized controlled trials), and poses unique challenges (including technical, analytical, psychological, regulatory and commercial).

The proposed roadmap provides guidance for the development and evaluation of novel predictive CDSS tools with potential to help transform monitoring and improve care.

Globally, skull base tumors are among the most challenging tumors to treat and are known for their significant morbidity and mortality. Hence, this study aimed to identify robust associated factors that contribute to mortality of patients following surgical resection for a variety of skull base tumors at the 3-month follow-up period. This in turn helps devise an evidence-based meticulous treatment strategy and baseline input for quality improvement work.

A retrospective cohort study of patients undergoing skull base tumor resection was conducted at two large-volume neurosurgery centers in Ethiopia. The categorical variables were expressed in frequencies and percentages. Normal distribution of continuous data was checked by histogram and the Shapiro-Wilk test. Median with interquartile range (IQR) was calculated for skewed data, while mean with standard deviation (SD) was used for normally distributed data. Odds ratio and adjusted odds ratio (AOR) were used to express the result of univariate and multivariate binary logistic analyses, respectively. A p-value <0.005 was considered statistically significant at 95% confidence interval (CI).

The study involved 266 patients. Of this, women accounted for 63.5% of patients. The median age of patients was 37 (±IQR = 17) years while the median size of the tumor in this study was 4.9 (±IQR 1.5) cm. The mean duration of symptoms at time of presentation was 17.3 (±SD = 11.1) months. Meningioma, pituitary adenoma, and craniopharyngioma contributed to 68.4%, 19.2%, and 9% of the skull-based tumors, respectively. Mortality following skull base tumor resection was 21.1%. On multivariable binary logistic regression analysis, intraoperative iatrogenic vascular insult (AOR = 28.76, 95% CI: 6.12-135.08, p = 0.000), intraventricular hemorrhage (AOR = 6.32, 95% CI: 1.19-33.63, p = 0.031), hospital-associated infection (AOR = 6.96, 95% CI: 2.04-23.67, p = 0.002), and extubation time exceeding 24 h (AOR = 12.89, 95% CI: 4.89-40.34, p = 0.000) were statistically significant with 3-month mortality.

Mortality from skull base tumor resection remains high in our setting. Holistic pre-operative surgical planning, meticulous intraoperative execution of procedures, and post-operative dedicated follow-up of patients in a neurointensive care unit alongside quality improvement works on identified risks of mortality are strongly recommended to improve patient outcomes. The urgent need for setup improvement and further training of neurosurgeons is also underscored.

Spontaneous cerebellar hemorrhage (SCH) patients have a low success rate in extubation, but there are currently no guidelines establishing specifically for SCH patients extubation. The study included 68 SCH patients who received mechanical ventilation for more than 24 h, with 39 cases (57.3%) resulting in successful extubation. The multivariate analysis identified four factors significantly associated with extubation success: patient age under 66 years, an Intracerebral Hemorrhage (ICH) score less than 4 points, the presence of tissue shift, and a Glasgow Coma Scale (GCS) score (excluding language) above 6 points at extubation. By simplifying the prediction model, we obtained the Spontaneous Cerebellar Hemorrhage Extubation Success scoring system (SCHES-SCORE). Within the scoring system, 2 points were allocated for a GCS score (excluding language) above 6 at extubation, 1 point each for age under 66 years and an ICH score below 4, while tissue shift was assigned a negative point. A score of Grade A (SCHES-SCORE = 3-4) was found to correlate with a 92.9% success rate for extubation. The area under the receiver operating characteristic curve was 0.923 (95% CI, 0.863 to 0.983). Notably, successful extubation was significantly linked to reduced durations of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay. In conclusion, the scoring system developed for assessing extubation outcomes in SCH patients has the potential to enhance the rate of successful extubation and overall patient outcomes.

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care, because it is the first step through which a respiratory failure patient begins to transition out of the intensive care unit, and return to normal life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider scientific and systematic approaches, as well as the individual experiences of healthcare professionals. Recently, numerous studies have investigated methods and tools to identify when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians for liberation from the ventilator.

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. These evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved the recommendations.

Recommendations for nine questions on ventilator liberation about Population, Intervention, Comparator, and Outcome (PICO) are presented in this document. This guideline presents seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Weaning from invasive mechanical ventilation is an important part of the management of respiratory failure patients. Patients can be classified into those who wean on the first attempt (simple weaning), those who require up to three attempts (difficult weaning) and those who require more than three attempts (prolonged weaning). The process of weaning includes adequately treating the underlying cause of respiratory failure, assessing the readiness to wean, evaluating the response to a reduction in ventilatory support, and eventually liberation from mechanical ventilation and extubation or decannulation. Post-extubation respiratory failure is a contributor to poorer outcomes. Identifying and addressing modifiable risk factors for post-extubation respiratory failure is important; noninvasive ventilation and high-flow nasal cannulae may be useful bridging aids after extubation. Factors to consider in the pathophysiology of prolonged mechanical ventilation include increased respiratory muscle load, reduced respiratory muscle capacity and reduced respiratory drive. Management of these patients involves a multidisciplinary team, to first identify the cause of failed weaning attempts, and subsequently optimise the patient's physiology to improve the likelihood of being successfully weaned from invasive mechanical ventilation.

This study aimed to explore the influence of different spontaneous breathing trials (SBTs) on regional ventilation distribution in patients with prolonged mechanical ventilation (PMV).

A total of 24 patients with PMV were analyzed retrospectively. They received three different SBT modes which are automatic tube compensation (ATC), continuous positive airway pressure (CPAP), and T-piece (TP), over three days, and every SBT lasted two hours. Electrical impedance tomography (EIT) was used to monitor the SBT process and five-minute EIT data from five periods (pre-SBT which is t0, at the beginning and the end of the first hour SBT are t1 and t2, at the beginning and the end of the second hour SBT are t3 and t4) were analyzed.

In all PMV patients, the temporal skew of aeration (TSA) values at t3 were significantly different in three SBTs (ATC: 18.18±22.97; CPAP: 20.42±17.01; TP:11.26±11.79; p=0.05). In the weaning success group, TSA (t1) values were significantly different too (ATC: 11.11±13.88; CPAP: 19.09±15.77; TP: 9.09±12.74; p=0.04). In the weaning failure group, TSA (t4) values were significantly different in three SBTs (ATC: 36.67±18.46; CPAP: 15.38±11.69; TP: 17.65±17.93; p=0.04). The patient's inspiratory effort (Global flow index at t1) in patients with weaning failure under CPAP (3.51±4.31) was significantly higher than that in the ATC (1.15±1.47) and TP (0.89±1.28). The SBT mode with the best ventilation uniformity may be the one that activates the respiratory muscles the most which may be the optimal SBT. The SBT mode of most uniform ventilation distribution settings varies from patient to patient.

The regional ventilation distribution was different for each individual, making the SBT with the best ventilation distribution of patients need to be personalized. EIT is a tool that can be considered for real-time assessment.

The purpose of this study was to determine the effects of combining proprioceptive neuromuscular facilitation (PNF) with threshold inspiratory muscle training (TIMT), compared with TIMT alone, on respiratory function in neurocritical patients who experienced a weaning failure. Forty-seven participants (mostly after a stroke), were randomly divided into the experimental group ( n  = 24) and the control group ( n  = 23). The control group received usual care and TIMT, whereas the experimental group, in addition, underwent four 90-s periods of manual PNF. Both groups performed training in the ICU twice a day for 5 consecutive days. The main outcome measures included maximum inspiratory pressure, diaphragmatic excursions, diaphragm thickening fraction, oxygenation index, and forced expiratory volume in 1 s/forced vital capacity. The results showed a significant group-by-time interaction effect for maximum inspiratory pressure [ F (1, 45) = 17.84, η2  = 0.328, P  < 0.001] and oxygenation index [ F [1, 45) = 5.58, η2  = 0.11, P  = 0.023]. When compared with the control group, the experimental group showed overall significantly higher maximum inspiratory pressure [mean difference = 4.37 cm H 2 O, 95% confidence interval (CI) 0.25-8.50, P  = 0.038]. No other significant group differences were found. Combining PNF with TIMT may improve respiratory function in neurocritical patients with weaning failure. This combination approach may increase the likelihood of survival of neurocritical patients in the ICU.

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia.

Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation.

Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003).

In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.

To evaluate the association between the pre-extubation sum of eye and motor components of the Glasgow Coma Score (GCS-EM) and odds of extubation failure in patients with acute brain injury being liberated from mechanical ventilation.

Secondary analysis of a prospective, multicenter observational study ( ClinicalTrials.gov identifier NCT03400904).

Sixty-three hospital sites worldwide, with patient recruitment from January 2018 to November 2020.

One thousand one hundred fifty-two critically ill patients with acute brain injury, with a median age of 54 years, of whom 783 (68.0%) were male, 559 (48.5%) had traumatic brain injury, and 905 (78.6%) had a GCS-EM greater than 8 before extubation (scores range from 2 to 10).

None.

GCS-EM was computed in intubated patients on the day of extubation. The main outcome was extubation failure, defined as unplanned reintubation within 5 days of extubation. Analyses used multilevel logistic regression with adjustment for patient characteristics and a random intercept for hospital site. In the primary analysis, GCS-EM was not associated with extubation failure (odds ratio, 1.07 per additional point; 95% CI, 0.87-1.31). Findings were consistent in sensitivity analyses that: 1) used different adjustment covariates, 2) included a verbal estimate to derive an overall GCS, 3) accounted for missing data, 4) considered a 2-day time interval to define extubation failure, 5) accounted for competing risks, and 6) used a propensity score-based model. There was no association between GCS-EM and extubation outcome in subgroups defined by brain injury diagnosis or age.

In this large, contemporary, multicenter cohort of patients with acute brain injury, we found no association between the GCS-EM and odds of extubation failure. However, few patients had a pre-extubation GCS-EM less than or equal to 8, and the possibility of a true prognostic association in patients with low scores is not excluded.

The aim of this study was to investigate the predictive value of the ratio of oxygen saturation (ROX) index calculated during mechanical ventilation (MV) and the weaning period in evaluating readiness to weaning and the success of the spontaneous breathing trial (SBT), extubation, and mortality. We also compared the results of the ROX index calculated with partial arterial oxygen pressure (PaO2), arterial oxygen saturation (SaO2%), and probe oxygen saturation (SpO2%). In this retrospective cohort study, the ROX index was calculated by SpO2%, PaO2, and SaO2% separately using the ROX index formula (PaO2 or SaO2 or SpO2 /FiO2)/respiratory rate. ROX was calculated during the first three days of MV treatment and the weaning period daily (SBT). Positive end-expiratory pressure and peak inspiratory pressure values were also recorded during these measurements. These ROX values were used to analyze whether they predict weaning readiness, SBT, extubation failure (EF), and mortality. The study included 107 mechanically ventilated patients. Weaning could be tried in 64 (60%) of the 107 patients; 44 (69%) of the 64 patients succeeded, and extubation was performed. 19 (43%) of 44 patients had EF. ROX values calculated with PaO2 during MV and SBT predicted readiness to wean, EF, and mortality better than ROX values calculated with SaO2 and SpO2. ROX values calculated with PaO2 during the third day of MV had the highest sensitivity and specificity for EF (sensitivity: 81%, specificity: 70% for the ROX<11 value). The results of this study suggest that the calculation of ROX index, not only with SpO2% but also with arterial blood gas PaO2 and SaO2% values, may be helpful in predicting the weaning readiness evaluation, SBT, and extubation success and mortality. Further studies with more patients are necessary to verify and standardize these results.

Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke.

This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6-12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0-2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death).

This will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia.

The study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients.

This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias.

We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure.

The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.

Traumatic brain injury is one of the leading causes of morbidity and mortality worldwide and is one of the major public healthcare burdens in the US, with millions of patients suffering from the traumatic brain injury itself (approximately 1.6 million/year) or its repercussions (2-6 million patients with disabilities). The severity of traumatic brain injury can range from mild transient neurological dysfunction or impairment to severe profound disability that leaves patients completely non-functional. Indications for treatment differ based on the injury's severity, but one of the goals of early treatment is to prevent secondary brain injury. Hemodynamic stability, monitoring and treatment of intracranial pressure, maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis are the mainstays of medical treatment for severe traumatic brain injury. Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain. Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents, among others.

Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.

This meta-analysis aimed to assess the predictive value of the rapid shallow breathing index for extubation outcomes.

We conducted a systematic review of literature (inception to March 2023) and a meta-analysis. Statistical analysis was performed using Meta-Disc 1.4 software, RevMan 5.4 software and Stata 14.0 software to evaluate the predictive value of RSBI for extubation outcomes.

A total of 1,987 studies were retrieved, and after applying the inclusion criteria, 79 studies were included in the final analysis, involving 13,170 patients undergoing mechanical ventilation. The random-effects model was employed for statistical analysis. The summary receiver operating characteristic curves (SROC) area under the curve (AUC) was 0.8144. The pooled sensitivity was 0.60 (95% CI: 0.59, 0.61), the pooled specificity was 0.68 (95% CI: 0.66, 0.70).

The Rapid Shallow Breathing Index demonstrated moderate accuracy, poor pooled sensitivity and specificity in predicting successful extubation, however the study does not present adequate data to support or reject the use of this tool as a single parameter that predicts extubation outcome. Future studies should explore the combination of The Rapid Shallow Breathing Index with other indicators and clinical experience to improve the success rate of extubation and reduce the risk of extubation failure.

Premature and delayed extubation in mechanically ventilated patients can have a negative impact on prognosis and prolong hospital stay. The Rapid Shallow Breathing Index is a simple, cost-effective, and easily monitored objective evaluation index, which can be used to predict the outcome of extubation, especially in primary hospitals. Our study comprehensively evaluated the value of this tool in predicting extubation outcomes, which can help clinicians combine subjective experience with objective indicators to improve the accuracy of extubation time decisions.

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Spontaneous intracerebral hemorrhage (ICH) is a condition associated with high mortality and morbidity. Survivors may require prolonged intubation with mechanical ventilation (MV). The aim of this study was to analyze the predictors of extubation failure and prolonged MV in patients who undergo surgical evacuation.

This retrospective study was conducted on adult patients with ICH who underwent MV for at least 48 h and survived > 14 days after surgery. The demographics, clinical characteristics, laboratory tests, and Glasgow Coma Scale score were analyzed.

A total of 134 patients with ICH were included in the study. The average age of the patients was 60.34 ± 15.59 years, and 79.9% (n = 107) were extubated after satisfying the weaning parameters. Extubation failure occurred in 11.2% (n = 12) and prolonged MV in 48.5% (n = 65) patients. Multivariable regression analysis revealed that a white blood cell count > 10,000/mm3 at the time of extubation was an independent predictor of reintubation. Meanwhile, age and initial Glasgow Coma Scale scores were predictors of prolonged MV.

This study provided the first comprehensive characterization and analysis of the predictors of extubation failure and prolonged MV in patients with ICH after surgery. Knowledge of potential predictors is essential to improve the strategies for early initiation of adequate treatment and prognosis assessment in the early stages of the disease.

Early extubation, defined as removal of the endotracheal tube at the end of surgery before transfer to a designated postoperative care area, is associated with better outcomes after elective infratentorial craniotomy. The Predicting Infratentorial Craniotomy Extubation (PRICE) project was an international survey designed to estimate the rate of early extubation after elective infratentorial craniotomy, as reported by neuroanesthesiologists, neurosurgeons, and neurocritical care specialists.

Following research ethics board waiver, the 15-question online PRICE survey was circulated to the members of 5 international medical societies over a 15-week period.

One hundred and ninety of 5453 society members completed the survey (3.5% response rate). Respondents represented a total of 99 institutions from 92 cities, in 27 countries. While 84 of 188 (44.7%) respondents reported achieving early extubation in more than 95% of cases, 43 of 188 (22.9%) reported extubating fewer than 75% of cases early. The proportion of physicians who reported extubating at least 75% of cases early was greater in high-volume compared with low-volume institutions (73.5% vs. 50.9%, respectively; P =0.003) and among anesthesiologists compared with other specialties (75.6% vs. 45.6%, respectively; P <0.001). Preoperative bulbar dysfunction, preoperative altered consciousness and the course of surgery were the 3 factors with the biggest impact on the decision to extubate early versus late among respondents.

The reported rate of early extubation after elective infratentorial craniotomy varies widely between institutions, with respondents from high-volume institutions reporting greater rates of early extubation than those from lower-volume centers. The course of surgery, evidence of bulbar dysfunction, and altered consciousness, appear to affect the decision to extubate early more than other predictors.