Antoine Roquilly, Raphaël Cinotti, Samir Jaber, Mickael Vourc’h, Florence Pengam, Pierre Joachim Mahe, Karim Lakhal, Dominique Demeure Dit Latte, Nelly Rondeau, Olivier Loutrel, Jérôme Paulus, Bertrand Rozec, Yvonnick Blanloeil, Marie-Anne Vibet, Véronique Sebille, Fanny Feuillet, and Karim Asehnoune Am. J. Resp. Crit. Care Med. Oct 15, 2013, vol. 188 (8): 958-966
Rationale: Mechanical ventilation is associated with morbidity in patients with brain injury.
Objectives: This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in patients with brain injury.
Methods: Before-after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated more than 24 hours were evaluated during two phases (a 3-yr control phase followed by a 22-mo intervention phase). Bundle components were protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia, and systematic approach to extubation. The primary endpoint was the duration of mechanical ventilation.
Measurements and Main Results: A total of 299 and 200 patients, respectively, were analyzed in the control and the intervention phases of this before-after study. The intervention phase was associated with lower tidal volume (P < 0.01), higher positive end-expiratory pressure (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The duration of mechanical ventilation was 14.9 ± 11.7 days in the control phase and 12.6 ± 10.3 days in the intervention phase (P = 0.02). The hazard ratio for extubation was 1.28 (95% confidence interval [CI], 1.04–1.57; P = 0.02) in the intervention phase. Adjusted hazard ratio was 1.40 (95% CI, 1.12–1.76; P < 0.01) in multivariate analysis and 1.34 (95% CI, 1.03–1.74; P = 0.02) in propensity score–adjusted analysis. ICU-free days at Day 90 increased from 50 ± 33 in the control phase to 57 ± 29 in the intervention phase (P < 0.01). Mortality at Day 90 was 28.4% in the control phase and 23.5% in the intervention phase (P = 0.22).
Conclusions: The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in patients with brain injury.
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