Airway management and functional outcomes in intubated patients with ischemic stroke

Abstract

We investigated the functional outcomes in ischemic stroke patients who underwent endotracheal intubation according to airway management (i.e., extubation success, extubation failure, primary tracheostomy) at multiple time points. Patients were classified into three groups: extubation success, extubation failure, and primary tracheostomy. Their functional outcomes were compared at hospital discharge, 3-month, and 1-year. Out of 165 ischemic stroke patients, 84 (50.9%) underwent extubation attempt and 81 (49.1%) underwent primary tracheostomy. Among the patients who underwent extubation, 26 (31.0%) experienced extubation failure. The extubation success group had a higher rate of achieving a favorable functional outcome (modified Rankin Scale 0-4) compared to the extubation failure group at hospital discharge (adjusted odds ratio [aOR] 3.93; 95% CI, 1.33-13.1; p = 0.018) and at 3-month (aOR 5.67; 95% CI 1.79-19.8; p = 0.004), but not at 1-year (aOR 2.99; 95% CI 0.96-9.68; p = 0.061). The primary tracheostomy group had a significantly lower rate of achieving a favorable functional outcome at all time points compared to the extubation failure group. These findings suggest that a condition suitable for an extubation attempt may be a more important 1-year prognostic indicator than extubation failure. Despite its limitations, this study suggests that the clinical condition prompting primary tracheostomy may outweigh extubation failure as a determinant of 1-year prognosis. However, prospective studies are needed to validate it and clarify its clinical implications.

Keywords: Cerebral infarction; Extubation failure; Intensive care unit; Intubation; Neurocritical care.

Fig. 1

Patient selection flow. ICU, intensive care unit.

Fig. 2

Distribution of mRS scores. Comparison of modified rankin scale scores among the study groups at (A) hospital discharge, (B) at 3 months, and (C) at 1 year.

Fig. 3

Flow chart according to the decision of airway management. In intubated stroke patients requiring additional airway management decisions, 50.9% underwent an extubation attempt, and 59.8% of them had a favorable outcome after one year. Out of the 84 patients who had an extubation attempt, 26 (31.0%) experienced extubation failure. Among these, 11 underwent tracheostomy, while 15 attempted a second extubation. There was no significant difference in the proportion of 1-year favorable outcomes between patients who underwent tracheostomy after the first extubation failure and those who attempted a second extubation (p > 0.999). Out of the 15 patients who attempted a second extubation, 8 (53.3%) were successful, and 7 (46.7%) failed. There was no significant difference in the proportion of 1-year favorable outcomes between these groups (p = 0.59).