Neurocritical Care Division, Neurology, Anesthesia/Critical Care Medicine, Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Meyer 8-140, Baltimore, MD 21287, USA.
Neurocrit Care. 2011 Aug;15(1):4-12. doi: 10.1007/s12028-011-9528-5.
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 injury who were reintubated.
We conducted a retrospective review of patients admitted to the neurocritical care unit of a tertiary care hospital from January 2002 to March 2007.
Of 1,265 patients who were intubated because of primary neurological injury of brain, spinal cord, or peripheral nerve, 25 (2%) died before extubation and 767 (61%) were successfully extubated. Tracheostomies were placed in 181 (14%) patients, of which, 77 (6.1%) were completed before a trial of extubation and 104 (8.2%) after extubation failure. A total of 129 (10%) patients were reintubated; 77 (6.1%) were reintubated within 72 h, meeting the definition of extubation failure. The other 52 (4.1%) were intubated after 72 h usually in the setting of pneumonia or decreased mental status. Ninety-nine of the patients reintubated had primary brain injury and resulting encephalopathy. All were successfully reintubated. Most patients intubated as a result of a primary brain injury (981) were successfully extubated. The most common clinical scenario leading to reintubation in these encephalopathic patients was respiratory distress associated with altered mental status [59 patients (59%)]. These patients usually had atelectasis and decreased minute ventilation, independent of fever, pneumonia, aspiration, and increased work of breathing [39 patients (39%)].
The extubation failure rate in our neurocritical care unit is low. In patients with encephalopathy and primary brain injury who were reintubated, respiratory distress caused by altered mental status was the most common cause of reintubation. These patients demonstrated signs disrupted ventilation usually with periods of prolonged hypoventilation. Increased work of breathing from lung injury due to pneumonia or aspiration was not the most common cause of reintubation in this population.
急性脑损伤但肺功能正常的患者通常需要进行气管插管以保护气道，但拔管经常失败。目前，尚无临床数据描述此类人群中导致拔管失败的事件。我们检查了因原发性神经损伤而插管的患者的拔管失败率、再插管率和临床特征。然后，我们确定了再插管的原发性脑损伤患者的临床特征。
我们对 2002 年 1 月至 2007 年 3 月入住三级医院神经重症监护病房的患者进行了回顾性研究。
在因原发性脑、脊髓或周围神经损伤而插管的 1265 例患者中，25 例（2%）在拔管前死亡，767 例（61%）成功拔管。181 例（14%）患者进行了气管切开术，其中 77 例（6.1%）在尝试拔管前完成，104 例（8.2%）在拔管失败后完成。共有 129 例（10%）患者再次插管；77 例（6.1%）在 72 小时内再次插管，符合拔管失败的定义。另外 52 例（4.1%）在 72 小时后插管，通常是在肺炎或精神状态下降的情况下。再次插管的 99 例患者有原发性脑损伤和由此导致的脑病。所有患者均成功再插管。大多数因原发性脑损伤而插管的患者（981 例）成功拔管。这些脑病患者再次插管最常见的临床情况是伴有精神状态改变的呼吸窘迫[59 例（59%）]。这些患者通常有肺不张和分钟通气量减少，与发热、肺炎、误吸和呼吸功增加无关[39 例（39%）]。
我们的神经重症监护病房的拔管失败率较低。在因脑病和原发性脑损伤而再次插管的患者中，精神状态改变引起的呼吸窘迫是再次插管的最常见原因。这些患者表现出通常伴有长时间通气不足的通气障碍迹象。由于肺炎或误吸导致的肺部损伤而增加的呼吸功并不是该人群中再次插管的最常见原因。
