Noninvasive and invasive mechanical ventilation for neurologic disorders

Association of age with extubation failure in neurocritical intensive care unit patients--Insight from an international prospective study named ENIO

OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

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.

MAIN RESULTS

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).

CONCLUSIONS

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.

REGISTRATION

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

Compassionate Ventilator Release in Patients With Neuromuscular Disease: A Two-Case Comparison

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease.

Ventilatory targets following brain injury

PURPOSE OF REVIEW

Recent studies have focused on identifying optimal targets and strategies of mechanical ventilation in patients with acute brain injury (ABI). The present review will summarize these findings and provide practical guidance to titrate ventilatory settings at the bedside, with a focus on managing potential brain-lung conflicts.

RECENT FINDINGS

Physiologic studies have elucidated the impact of low tidal volume ventilation and varying levels of positive end expiratory pressure on intracranial pressure and cerebral perfusion. Epidemiologic studies have reported the association of different thresholds of tidal volume, plateau pressure, driving pressure, mechanical power, and arterial oxygen and carbon dioxide concentrations with mortality and neurologic outcomes in patients with ABI. The data collectively make clear that injurious ventilation in this population is associated with worse outcomes; however, optimal ventilatory targets remain poorly defined.

SUMMARY

Although direct data to guide mechanical ventilation in brain-injured patients is accumulating, the current evidence base remains limited. Ventilatory considerations in this population should be extrapolated from high-quality evidence in patients without brain injury - keeping in mind relevant effects on intracranial pressure and cerebral perfusion in patients with ABI and individualizing the chosen strategy to manage brain-lung conflicts where necessary.