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. 2025 Aug;43(1):243-253.
doi: 10.1007/s12028-024-02198-6. Epub 2025 Jan 7.

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study

Shi Nan Feng  1 , Camilo Diaz-Cruz  2 , Raphael Cinotti  3   4 , Karim Asehnoune  3 , Marcus J Schultz  5   6   7 , Gentle S Shrestha  8 , Paula R Sanches  9 , Chiara Robba  10   11 , Sung-Min Cho  12 ; ENIO collaborators
Affiliations

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study

Shi Nan Feng et al. Neurocrit Care. 2025 Aug.

Abstract

Background: Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI.

Methods: A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings.

Results: Of 1512 patients (median age = 54 years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59 days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30).

Conclusions: In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Keywords: Acute brain injury; Country income level; Extubation failure; Intensive care unit; Invasive mechanical ventilation; Mortality; Neurocritical care; Tracheostomy.

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Conflict of interest statement

Declarations. Conflict of interest: None of the authors has conflicts of interest that are directly relevant to the content of this article. Ethical Approval/Informed Consent: Data management, monitoring, and reporting of the study were performed according to the International Conference on Harmonization Good Clinical Practice Guidelines. Approval to enroll patients in ENIO was obtained from the institutional review board of the promoter center (Groupe Nantais d’Ethique dans le Domaine de la Santé, IRB No. 7/11/2017), and then from each participating site. Informed consent was obtained in accordance with local regulations.

References

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