Identifying the optimal time of extubation in a brain injured population should improve
patient outcome. Brain injured patients usually remain intubated due to concerns of airway
maintenance. Current practice argues that unconscious patients need to remain intubated to
protect their airways. More recent data however suggests that delaying extubation in this
population increases pneumonias and worsens patient outcomes.
We designed a safety and feasibility study of randomizing brain injured patients into early
or delayed extubation. The purpose was to gain insight into patient safety concerns and to
obtain estimates of sample size needed for a larger study.
1. Resolution or improvement of any pulmonary process requiring mechanical ventilation.
2. Adequate gas exchange.
3. Adequate ventilation.
4. Respiratory rate to tidal volume ratio <105.
5. Core body temperature < 38 degrees celsius.
6. Hemoglobin > 8 grams per deciliter.
7. No sedative medications for 2 hours.
Neurological requirements included:
1. GCS ≤ 8.
2. Intracranial pressure (ICP) < 15 cm of water and a cerebral perfusion pressure (CPP)
> 60 mm Hg for patients with intracranial pressure monitors.
1. Age < 18 years.
2. Lack of informed consent by the patients' surrogate.
3. Dependence on mechanical ventilation for at least two weeks prior to enrollment.
4. Patients with tracheostomies.
5. Intubation instituted for therapeutic hyperventilation.
6. Planned surgical or radiological intervention within the next 72 hours.
7. Anticipated neurological or medically worsening conditions (i.e develop cerebral
edema or vasospasm).
8. Patients intubated for airway preservation due to airway edema (cervical neck
injuries or surgery) as opposed to airway protection.