Clinical Trial Finder

Inclusion Criteria:

• - Age > 16 years - Acute brain injury (subarachnoid hemorrhage, ischemic stroke, spontaneous intracerebral hemorrhage, seizure, traumatic brain injury, brain tumor, global cerebral anoxia/cardiac arrest, meningitis/encephalitis/cerebral abscess) that occurred within the previous 4 weeks.

• - Receiving invasive mechanical ventilation via endotracheal tube for > 72 hours - Glasgow Coma Scale motor score 3 to 6 with improvement or no change from previous day - passed spontaneous breathing trial (SBT)

  Exclusion Criteria:

  - Previous extubation during this ICU admission - Quadriplegic - Neuromuscular disease that will result in prolong need for mechanical ventilation, including but not limited to Guillain-Barre syndrome, cervical spinal cord injury, advanced multiple sclerosis - Do-Not-Reintubate order in place - Previously randomized in this trial - Underlying pre-existing condition with expected mortality less than 6-months.

- Anticipated/scheduled for surgical procedures within 48 hours - C-spine not yet cleared for activity as tolerated (cleared for activity as tolerated while wearing hard collar is acceptable) - Currently known or suspected to have an difficult airway - Absence of an endotracheal tube cuff leak, if checked - Absence of spontaneous or induced cough - Current enrolment in an RCT that precludes NEURO-ETT co-enrollment

Thousands of patients suffer severe brain injuries every year, from causes such as trauma, stroke, and infection. Extensive clinical research in weaning from mechanical ventilation has led to recommendations for prompt extubation following a successful trial of spontaneous breathing in general intensive care unit (ICU). However, little evidence exists to guide decisions about when to remove the breathing tube in patients with severe brain injury. It is unclear which of the following strategies would optimize important patient outcomes: prompt extubation vs.#46; waiting and extubating or performing a tracheostomy, timed according to physicians' discretion. Each strategy has associated risks: prompt extubation may lead to higher rates of extubation failure and reintubation, whereas waiting longer may expose patients to complications from prolonged mechanical ventilation and tracheostomy may lead to procedural complications (or unnecessary procedures, if prompt extubation would be successful). This trial in brain-injured patients will test which of the following will lead to better patient outcomes:

• (1) removing the endotracheal tube promptly once a spontaneous breathing trial is passed; or (2) usual care, with the airway management strategy selected according to the preference of the treating physician.

Arms

Active Comparator: Extubation

Extubation by removal of endotracheal tube.

Active Comparator: Usual care

The usual clinical practice is removal of the endotracheal tube (extubation), or insertion of tracheostomy, timed according to physicians' discretion

Interventions

Procedure: - Extubation

This is an extubation by removal of endotracheal tube which must be done on the day of randomization or the following day. Any decision to subsequently reintubate the patient will be left to the discretion of the clinical team. Similarly, if a tracheostomy is deemed necessary in a patient who fails the extubation attempt, this will be managed at the discretion of the treating team. If for any reason the patient is not extubated according to the randomized schedule, the reason(s) will be recorded on a protocol violation form and the site investigator will be notified. If a patient receives a tracheostomy instead of being extubated we will again record reasons for this, but the patient will be analysed in the extubation group according to the intention-to-treat principle.

Procedure: - Usual Care

Patients in this group will be treated according to usual care, which may include extubation (removal of endotracheal tube) or insertion of a tracheostomy, timed according to physicians' discretion. The inclusion of this arm will allow prompt extubation to be compared to usual practice, which often involves further observation and delayed decision-making due to clinician uncertainty about the optimal airway management strategy. Incorporation of usual care arms has been promoted as a design feature to improve the safety and interpretability of critical care clinical trials.