Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation.

OBJECTIVE To assess whether a systematic approach to weaning and extubation (intervention) is superior to the sole physician's judgment (control) in preventing reintubation secondary to extubation failure in patients with neurologic disorders. DESIGN Randomized controlled trial. SETTING Intensive care unit of a large teaching hospital. PATIENTS Three hundred eighteen intubated patients who had been receiving mechanical ventilation for at least 12 hrs and were able to trigger the ventilator. INTERVENTIONS Patients were randomized to the intervention (n = 165) or control group (n = 153). MEASUREMENTS Rate of reintubation after extubation failure occurring within 48 hrs (primary end point). Duration of mechanical ventilation, length of intensive care unit stay, mortality, rate of tracheotomy (secondary end points). The perception of the research protocol by the intensive care unit staff was also assessed. MAIN RESULTS The rate of reintubation was lower in the intervention (5%) than in the control (12.5%) group (p = 0.047). There was no difference in any of the other outcome variables (secondary end points). Simplified Acute Physiologic Score II (adjusted odds ratio 1.042 per unit; 95% confidence interval 1.006-1.080; p = 0.022) and inclusion in the control group (adjusted odds ratio 2.393; 95% confidence interval 1.000-5.726; p = 0.05) were the only two independent predictive factors for the risk of extubation failure. The protocol was felt by the staff to determine an improvement in patients' clinical outcome, but to increase intensive care unit workload; nurses and physiotherapists considered its impact on their professional role more positively than physicians. CONCLUSIONS In patients with neurologic diseases, a systematic approach to weaning and extubation reduces the rate of reintubation secondary to extubation failure without affecting the duration of mechanical ventilation, and is overall positively perceived by intensive care unit professionals.