Neurocrit Care (2018) 28:93–96
https://doi.org/10.1007/s12028-017-0398-3
ORIGINAL ARTICLE
Extubating the Neurocritical Care Patient: A Spontaneous
Breathing Trial Algorithmic Approach
Naresh Mullaguri1 • Zalan Khan1 • Premkumar Nattanmai1 • Christopher R. Newey1
Published online: 25 May 2017
Ó Springer Science+Business Media New York 2017
Abstract
Background Delaying extubation in neurologically impaired
patients otherwise ready for extubation is a source for sig-
nificant morbidity, mortality, and costs. There is no consensus
to suggest one spontaneous breathing trial (SBT) over another
in predicting extubation success. We studied an algorithm
using zero pressure support and zero positive end-expiratory
pressure (ZEEP) SBT followed by 5-cm H2O pressure support
and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT
in those who failed ZEEP SBT.
Methods This is a retrospective analysis of intubated
patients in a neurosciences intensive care unit. All eligible
patients were initially challenged with ZEEP SBT. If
failed, a 5/5 SBT was immediately performed. If passed
either the ZEEP SBT or the subsequent 5/5 SBT, patients
were liberated from mechanical ventilation.
Results In total, 108 adult patients were included. The
majority of patients were successfully liberated from
mechanical ventilation using ZEEP SBT alone (82.4%;
p = 0.0007). Fifteen (13.8%) patients failed ZEEP SBT
but immediately passed 5/5 SBT (p = 0.0005). One patient
(0.93%) required reintubation. We found high sensitivity of
this extubation algorithm (100; 95% CI 95.94–100%) but
poor specificity (6.67; 95% CI 0.17–31.95%).
Conclusion This study showed that the majority of patients
could be successfully liberated from mechanical ventilation
after a ZEEP SBT. In those who failed, a 5/5 SBT
Naresh Mullaguri, Zalan Khan, Premkumar Nattanmai and
Christopher R. Newey have contributed equally to this work.
& Christopher R. Newey
neweyc@health.missouri.edu
1
Department of Neurology, University of Missouri, 5 Hospital
Drive CE 540, Columbia, MO 65211, USA
increased the successful liberation from mechanical
ventilation.
Keywords Spontaneous breathing trial (SBT)
ZEEP

Neurocritical care
Mechanical ventilation
Extubation
Introduction
Central control of respiration and the unique pathophysi-
ology of a neurocritically ill patient pose a dilemma for
mechanical ventilation and eventual liberation that has both
medical and economic implications [1–4]. There is a need
for an extubation algorithm with robust predictive value.
Delaying extubation has been associated with increased
morbidity in the form of side effects from sedative medi-
cations, nosocomial infections, increased mortality, and
higher financial costs due to extended hospital and inten-
sive care unit stays [1, 5]. It also obfuscates our ability to
frequently monitor the neurological examination of the
patient.
Most intensive care units (ICUs) use algorithms focused
on weaning the medical intensive care unit patient [6–8].
Unfortunately, studies have shown that these traditional
weaning parameters may not be successful in predicting
extubation failure, particularly in the neurocritical setting
[9, 10]. One reason is that detailed neurological and res-
piratory examinations in neurocritically ill patients can be
challenging [11, 12]. Also, this patient population may
have unique breathing patterns that can make extubation
challenging [13]. Other studies focused on respiratory
parameters, such as muscle strength and maintenance of
oxygenation, along with spontaneous breathing trials
(SBTs) lasting up to 120 min [6]. A multipronged decision
tree model employing rapid shallow breathing index
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(RSBI) during a SBT and evaluating minute volume
recovery time has also been used [7, 14]. Specific to the
neurocritically ill patient, predictors of extubation failure
have been identified as low Glasgow Coma Scale (GCS)
score, pneumonia, atelectasis, duration of mechanical
ventilation, location of stroke, and clinical examination
findings such as poor orolingual control, non-intact gag
reflex, and inability to close eyes [1, 9]. Overall up to 20%
of patients undergoing extubation will fail [15]. Proposed
guidelines for weaning and subsequent discontinuation of
ventilator support are generalized and overall not tailored
specifically toward neurocritically ill patients [16].
We aim to study an algorithm of extubating neuro-
critically ill patients using zero pressure support and zero
positive end-expiratory pressure (ZEEP) SBT immediately
followed by 5-cm H2O pressure support (PS) and 5-cm
H2O positive end-expiratory pressure (PEEP) (i.e., 5/5)
SBT in patients who failed the ZEEP SBT.
a 5/5 SBT [17]. If the patient passed this SBT, they were
then extubated. If a patient was extubated but had to be
reintubated within 24 h, they were considered an extubation
failure.
Statistical Analysis
Continuous and categorical data were summarized with
descriptive statistics including means and standard devia-
tion (continuous data) and frequencies (categorical data).
Categorical data were analyzed with Fisher’s test. Matched
case–control data were analyzed using McNemar’s test.
Sensitivity and specificity were calculated for this group.
Using Wilson–Brown method, 95% confidence interval
(CI) was then calculated. Continuous data were analyzed
using t test between the groups. A p value of <0.05 was
considered significant. Data were analyzed using GraphPad
Prism 7 (La Jolla, CA, USA).

Methods Results

Study Population In total, 108 patients were included in this study. The
average age of the patients was 61.6 ± 15.9 years. The
This was an 11-month retrospective review of adult majority were male (n = 60, 55%). Stroke (ischemic or
(>18 years of age) patients admitted to the neurosciences hemorrhagic) was the most common etiology resulting in
intensive care unit at the University of Missouri, Columbia, intubation (n = 51, 47.2%). This was followed by trau-
requiring mechanical ventilation. The neurosciences matic brain injury patients with no extracranial injuries
intensive care unit is a specialized unit at a level 1 (n = 23, 21.3%) and patients with status epilepticus
academic trauma center managing patients with ischemic (n = 10, 9.3%) (Table 1). There were no neuromuscular
and hemorrhagic stroke, status epilepticus, spinal cord patients in our data set.
injury, intracranial tumor, neuromuscular weakness, post-
operative neurosurgery, central nervous system infection,
encephalopathy, hypoxic ischemic injury, intracranial Table 1 Patient characteristics
hypertension, and traumatic brain injury. The Institutional Total 5/5 SBT
Review Board of University of Missouri, Columbia,
approved this study. Age (avg ± SD) 61.6 15.9
No. of male (n, %) 60 55
Ventilator Management Etiologies
ARDs/sepsis/PE 4 3.7 0 0.0
All patients were assessed daily off sedation by standard CNS infection 4 3.7 1 6.7
ventilator weaning criteria as previously described [13]. In CNS tumor 5 4.6 1 6.7
brief, the following criteria had to be met prior to SBT: GCS Post-op 3 2.8 0 0.0
>8t with demonstration of orolingual control, cough with or SAH 8 7.4 1 6.7
without gag reflex, PaO2 >60 mmHg with FiO2 <50%, Status epilepticus 10 9.3 4 26.7
PEEP of <8, hemodynamic stability, and thin secretions Stroke/ICH 51 47.2 5 33.3
with suctioning requirements no more than every 2 h. If a TBI 23 21.3 3 20.0
patient met these criteria, a ZEEP SBT was performed. Tracheostomy (n, %) 4 3.7 NA NA
ZEEP was a SBT using zero PS and zero PEEP. This SBT Duration (avg hr ± SD) NA NA 1.35 1.1
was administered over 30 min. Patients failed if during the
ARDs acute respiratory distress syndrome, CNS central nervous sys-
30 min they became tachypneic (respiration rate >30/min), tem, ICH intracerebral hemorrhage, PE pulmonary embolus, SAH
desaturated (<90%), or became hemodynamically unstable. subarachnoid hemorrhage, SD standard deviation, TBI traumatic brain
If a patient failed the ZEEP SBT, we immediately performed injury

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The majority (n = 89, 82.4%) of the patients included in
this study passed the ZEEP SBT and were successfully
extubated (p = 0.0007). The remaining 15 patients failed
the ZEEP SBT. These patients were intubated on average
4.2 ± 3.0 days. All 15 patients failed secondary to tachyp-
nea. These 15 patients were immediately placed on 5/5 SBT.
All 15 patients passed this SBT. The average duration of this
trial was 1.35 ± 1.1 h. The arterial blood gases (ABGs)
from immediate post-intubation and immediate pre-extuba-
tion are found in Table 2. There were no statistical
differences between the ABGs of these two groups. The
FiO2 immediately post-intubation and immediately prior to
extubation were statistically significant (p < 0.0001). All
15 patients were then extubated. Fourteen of these patients
were successfully extubated. One patient required reintuba-
tion within 8 h of extubation due to tachypnea. The addition
of a 5/5 SBT to those patients who were otherwise ready to
be extubated but failed a ZEEP SBT significantly increased
the number of patients successfully extubated (p = 0.0005).
We found high sensitivity of this extubation algorithm (100;
95% CI 95.94–100%) but poor specificity (6.67; 95% CI
0.17–31.95%).
Discussion
This retrospective analysis of intubated patients in the
neurosciences intensive care unit found that the majority of
patients meeting extubation criteria who passed ZEEP SBT
were successfully extubated. In those who failed, a 5/5
SBT increased the number of patients successfully liber-
ated from mechanical ventilation.
A review of 552 mechanically ventilated neurocritically
ill patients compared to non-neurocritically ill ventilated
patients found similar use of lung-protective strategies (i.e.,
using tidal volumes of <8 cc/kg predicted body weight),
plateau airway pressures (<30 cm H20), mild-to-moderate
levels of PEEP, and ABGs [18]. Despite these similarities,
neurocritically ill patients required longer duration of ven-
tilation and more commonly had tracheostomies [18].
Neurocritically ill patients were extubated less frequently
Table 2 Arterial blood gases
PH
(ABGs)
Post-intubation 7.36 0.09
Pre-extubation 7.42 0.05
p value NS
ABGs post-intubation and pre-extubation are shown. There was no significant difference between the two
groups
Data are expressed as average ± standard deviation
FiO2 fraction of inspired oxygen, HCO3 bicarbonate in mmol/L, NS nonsignificant, pH potential of
hydrogen, pCO2 partial pressure of carbon dioxide in mmHg, pO2 partial pressure of oxygen in mmHg
95
despite passing SBT secondary to reduced levels of arousal
and secretion clearance [18]. Despite these concerns, a study
in 1265 patients over 62 months found that 61% of neuro-
critically ill patients could indeed be successfully extubated
[19]. Only 6.1% of patients failed extubation mostly from
worsening mental status [19]. These findings highlight the
challenges of extubating the neurological patient.
Conventional weaning parameters (i.e., RSBI of <105,
min ventilation, respiratory rate, negative inspiratory force,
tidal volume, and PaO2/FiO2 ratio) do not necessarily
predict extubation failure in the neurocritical care [10].
Anderson et al. [20] showed that patients who could follow
four commands (close eyes, show two fingers, wiggle toes,
and cough to command) could be successfully extubated.
These specific neurological examination findings may be
more predictive than GCS alone. Having a gag reflex or
normal eye movements alone did not retain significance for
extubation success [20]. In this study, patients had thin
secretions, tidal volumes of 500 cc on average, and rela-
tively normal ABGs [20]. Another study showed that
patients who could open eyes, follow observer with eyes,
grasp hand, and stick out tongue on command along with
having a strong cough with minimal secretions had a
synergistic effect for successful extubation [21]. The syn-
ergism was lost with only assessing neurological status and
cough strength [21]. Recently, a meta-analysis of nine
studies involving 928 patients found that factors associated
with extubation failure in the neurocritically ill patient
include pneumonia, atelectasis, duration of mechanical
ventilation, thick secretion (but not secretion volume), poor
GCS (7–9t), inability to follow commands (especially close
eyes), and no gag reflex [9]. The ability to show two fin-
gers, wiggle toes, and cough on command did not predict
extubation failure [9]. Similarly, patients with posterior
fossa strokes with a GCS of <6 at the time of intubation
and intubated for >1 week were likely to fail extubation
[3]. The absence of pneumonia or atelectasis and having a
cough/gag reflex were not predictive of extubation success
[3]. Coplin et al. [1] evaluated extubation criteria in
neurologically impaired patients. This group found that the
presence of a spontaneous cough (gag not required) and
PCO2 PO2 HCO3 FiO2
39.89 9.86 156.23 118.92 21.70 4.32 63.70% 2.17
35.98 5.02 109.22 34.15 22.79 2.88 33.70% 9.05
NS NS NS <0.0001
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less frequent suctioning requirements was significantly
associated with successful extubation despite low GCS [1].
Extubating patients with a GCS of 10 versus 7 had similar
reintubation rates [1]. Delaying extubation in these patients
only because of impaired neurological status, increased
duration on ventilator which led to a higher incidence of
pneumonias (24 vs. 10%), and time in the ICU (8.6 days
versus 3.8 days) [1].
Overall, the neurological examination is important in
liberating neurocritically ill patients from the ventilator.
However, guidance as to which SBT should be used in this
patient population has largely been lacking. Our study
evaluated patients exclusively in the neurocritical care
setting with diverse neurological and neurosurgical
etiologies. We showed that the majority of patients who met
SBT criteria could be liberated from mechanical intubation
if they passed a ZEEP SBT. We further showed that in
patients who failed the ZEEP SBT, the use of a 5/5 SBT
identified additional patients that could be successfully
extubated as pressure-augmented SBT has proven to be
more sensitive in assessing readiness for extubation [22].
This SBT approach may reduce hospital and ICU length of
stay. Additionally, nosocomial infections and unnecessary
tracheostomies may be prevented. Future studies will need
to be designed to assess the cost-effectiveness and reduction
of mortality and morbidity with this algorithm.
We acknowledge limitations of our study. This study
was a retrospective analysis from a single center. Our study
population is highly diverse with regard to the primary
admitting diagnosis spreading across many domains of the
brain injury. However, this algorithm needs to be further
evaluated in a larger, multicenter study.
In conclusion, we showed that the majority of neuro-
critically ill patients who were otherwise ready to be
extubated could safely be extubated after passing a ZEEP
SBT. In those who failed, the use of a 5/5 SBT identified
additional patients who could be liberated from mechanical
ventilation.
Compliance with Ethical Standards
Conflict of interest All authors have no financial disclosures to
report.
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