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Research ArticleConference Proceedings

Should Patients Be Able to Follow Commands Prior to Extubation?

Christopher S King, Lisa K Moores and Scott K Epstein
Respiratory Care January 2010, 55 (1) 56-65;
Christopher S King
Pulmonary Critical Care and Sleep Medicine Division, Walter Reed Army Medical Center, Washington DC.
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Lisa K Moores
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
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  • For correspondence: [email protected]
Scott K Epstein
Office of Educational Affairs, Tufts University School of Medicine, Tufts Medical Center Boston, Massachusetts.
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Abstract

The determination of optimal timing of liberation from mechanical ventilation requires a thorough assessment of multiple variables that can result in extubation failure. It is estimated that 5–20% of extubations fail. Traditional weaning parameters fail to predict extubation failure accurately, and attention has thus turned to improvements in extubation decision making through assessment of elements that may result in inability to protect the airway, such as excessive respiratory secretions, inadequate cough, and depressed mental status. Extubation is particularly controversial in patients with depressed mental status and inability to follow commands. When looking at univariate analyses, the reported studies are relatively evenly divided among those that did and did not find that inability to follow commands (ie, abnormal mental status) increases the risk of extubation failure. In addition, although extubation failure is a risk factor for poor overall outcome in heterogeneous populations, its impact on the patient failing with neurologic dysfunction has not been adequately determined. One limiting factor in all reported studies is how “inability to follow commands” is defined. The majority of studies use the Glasgow coma score, but this is difficult to determine in the intubated patient. Moreover, using the cutoff of Glasgow coma score ≥ 8, favored by many authors, is questionable, as some patients with higher scores may be unable to follow commands. Currently it is agreed that many patients who are unable to follow commands, but have the ability to clear pulmonary secretions, can be safely extubated. A prospective, randomized trial using a more specific definition of “following commands” would certainly help remove some of the uncertainty in this patient population.

  • mechanical ventilation
  • extubation
  • weaning

Footnotes

  • Correspondence: Lisa K Moores MD COL MC USA, Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda MD 20814. E-mail: lmoores{at}usuhs.mil.
  • Drs Moores and Epstein presented a version of this paper at the 44th Respiratory Care Journal Conference, “Respiratory Care Controversies II,” held March 13-15, 2009, in Cancún, Mexico.

  • The views expressed in this paper are those of the authors and do not necessarily reflect those of the United States Army, Department of Defense, or the United States government.

  • The authors have disclosed no conflicts of interest.

  • Copyright © 2010 by Daedalus Enterprises
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Respiratory Care: 55 (1)
Respiratory Care
Vol. 55, Issue 1
1 Jan 2010
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Should Patients Be Able to Follow Commands Prior to Extubation?
Christopher S King, Lisa K Moores, Scott K Epstein
Respiratory Care Jan 2010, 55 (1) 56-65;

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Should Patients Be Able to Follow Commands Prior to Extubation?
Christopher S King, Lisa K Moores, Scott K Epstein
Respiratory Care Jan 2010, 55 (1) 56-65;
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Keywords

  • mechanical ventilation
  • extubation
  • weaning

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