Approximately 200 000 patients per year will require mechanical ventilation secondary to neurological injury or disease. The associated mortality, morbidity, and costs are significant. The neurological patient presents a unique set of challenges to airway management, mechanical ventilation, and defining extubation readiness. Neurological injury and disease can directly or indirectly involve the process involved with respiration or airway control. This article will review the basics of airway management and mechanical ventilation in the neurological patient. The current state of the literature evaluating extubation criteria in the neurological patient will also be reviewed.
MayerSACopelandDBernardiniGLCost and outcome of mechanical ventilation for life threatening stroke. Stroke. 2000;31(10):2346–2353.
2.
GujjarARDeibertEMannoEMDuffSDiringerMN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology. 1998;51(2):447–451.
3.
SouterMJ.Airway management in the neurological and neurosurgical patient. In: MannoEM, ed. Emergency Management in Neurocritical Care. Oxford, UK: Wiley-Blackwell; 2012.
4.
Chen-GadolAAPichelmanMAMannoEM.Management of head trauma and spinal cord injury in adults. In: NoseworthyJH, ed. Neurological Therapeutics Principals and Practice. London, UK: Martin Dunitz; 2003:1221–1237.
5.
MarshallLFBeckerDPBowersSAThe national traumatic coma data bank. part 1: design, purpose, goals and results. J Neurosurg. 1983;59(2):276–284.
6.
HollandMCMackersieRCMorabitoD. The development of acute lung injury is associated with worse neurological outcome in patients with severe brain injury. J Trauma. 2003;55:106–111.
7.
HollyLTKellyDFCounelisGJBlinmanTMcArthurDLCryerHG. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg. 2002;96(3 suppl):285–291.
8.
WetschWACarlitscheckMSpeltenOSuccess rates and endotracheal tube insertion times of experienced emergency physicians using five video laryngoscopes: a randomised trial in a simulated trapped car accident victim. Eur J Anaesthesiol. 2011;28(12):849–858.
9.
LangeronOMassoEHurauxCPrediction of difficult mask ventilation. Anesthesiology. 2000;92(5):1229–1236.
10.
ReedMJDunnMJMcKeownDW.Can an airway assessment score predict difficulty at intubation in the emergency department?Emerg Med J. 2005;22(2):99–102.
11.
HimmelseherSDurieuxME. Revising a dogma: ketamine for patients with neurological injury?Anesth Analg. 2005;101(2):524–534.
12.
MuenchEBauhufCRothHEffects of positive end-expiratory pressure on regional cerebral blood flow, intracranial pressure and brain tissue oxygenation. Crit Care Med. 2005;33(10):2367–2372.
RopperAH.Critical care of Guillian-Barre syndrome. In: RopperAH, ed. Neurological and Neurosurgical Intensive Care. 3rd ed. New York, NY: Raven Press; 1993:363-382.
15.
SeneviratneJMandrekarJWijdicksEFRabinsteinAA. Noninvasive ventilation in myasthenia crisis. Arch Neurol. 2008;65(1):54–58.
16.
WijdicksEFRoyTK. BiPAP in early guillian – barre syndrome may fail. Can J Neurol Sci. 2006;33(1):105–106.
17.
RikerRRShehabiYBokeschPMSEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489–499.
18.
RobertsDJHallRIKramerAHRobertsonHLGallagherCNZygunDA.Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011;39(12):2743–2751.
19.
VivienBDiMariaSOuattaraALangeronOCoriatPRiouB. Overestimation of Bispectral Index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology. 2003;99(1):9–17.
20.
SchneiderGGelbAWSchmellerBTschakertR.KochsE.Detection of awareness in surgical patients with EEG based indicis – bispectral index and patient state index. Br J Anaesth. 2003;91(3):329–335.
21.
GehlbachBKKressJP. Sedation in the intensive care unit. Curr Opin Crit Care. 2002;8(4):290–298.
22.
EstebanAAliaITobinMJEffect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation: the Spanish lung failure collaborative group. Am J Respir Crit Care Med. 1999;159(2):512–518.
23.
VallverduICalafNSubiranaMNetABenitoSManceboJ. Clinical characteristics, respiratory functional parameters, and outcome of a two hour T- piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med. 1998;158(6):1855–1862.
24.
ElyEWBakerAMEvansGWHaponikEF. The prognostic significance of passing a daily screen of weaning parameters. Intensive Care Med. 1999;25(6):581–587.
25.
LiuYWeiLQLiGQA decision –tree model for predicting extubation outcome in elderly patients after a successful spontaneous breathing trial. Anesth Analg. 2010;111(5):1211–1218.
26.
SeymourCWHalpernSChristieJDGallopRFuchsBD. Minute ventilation recovery time measured using a new simplified methodology predicts extubation outcome. J Intensive Care Med. 2008;23(1):52–60.
27.
MacIntyreNR.Evidenced based guidelines for weaning and discontinuing ventilatory support: a collected task force facilitated by the American College of chest physicians; the American Association of respiratory care; in the American College of critical care medicine. Chest. 2001;120(6 suppl):375S–395S.
28.
OchoaMEMarin MdelCFrutos-VivarFCuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med. 2009;35(7):1171–1179.
29.
RobertsRJWelchSMDevlinJW. Corticosteroids for prevention of post extubation laryngeal edema and adults. Ann Pharmacother. 2008;42(5):686–691.
30.
NamenAMElyEWTatterSBPredictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001;163(3 pt 1):658–664.
31.
CoplinWMPiersonDJCooleyKDNewellDWRubenfeldGD. Implications of extubation delay in brain injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161(5):1530–1536.
32.
KhamieesMRajuPDeGirolamoAAmoateng-AdjepongYManthusCA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120(4):1262–1270.
33.
MannoEMRabinsteinAAWijdicksEFMA perspective trial of elective extubation in brain injured patients meeting extubation criteria for ventilatory support: a feasibility study. Crit Care. 2008;12(6):R138.
34.
SeneviratneJMandrakerJWijdicksEFRabinsteinAA. Predictors of extubation failure in myasthenic crisis. Arch Neurol. 2008;65(7):929–933.
35.
Gandia-MartinezFMartinez-GilIAndaluz-OjedaDBobillo de LamoFParra-MoraisLDiez-GutierrezF.Analysis of early tracheostomy and its impact on development of pneumonia, use of resources, and mortality in neurocritically ill patients [in Spanish]. Neurocirugia (Astur). 2010;21(3):211–221.
