Timing of Extubation in Adult Patients with Acute Brain Injury

<b>Rationale:</b> Whether extubation immediately after a successful spontaneous breathing trial is associated with clinical benefits in adult patients with acute brain injury is unknown. <b>Objectives:</b> We sought to estimate the association between a prompt extubation attempt and ventilator-free days among adult patients with acute brain injury. <b>Methods:</b> We performed an emulation of a previously designed randomized controlled trial using data from the Toronto Intensive Care Observational Registry in eight ICUs in Toronto, Ontario, Canada. We included mechanically ventilated adult patients with acute brain injury who had a first successful spontaneous breathing trial. Our main exposure was prompt extubation (i.e., on the same calendar day after the first successful spontaneous breathing trial). The primary outcome was ventilator-free days up to 28 days. We used inverse probability of treatment weighting to adjust for confounding and reported treatment effects using incidence rate ratios and 95% confidence intervals. <b>Measurements and Main Results:</b> A total of 1,406 patients from April 2014 through March 2023 met inclusion criteria. The main reasons for admission were traumatic brain injury (40%), stroke (ischemic or hemorrhagic; 20%), seizures (11%), and subarachnoid hemorrhage (9%). Over half (57%) of patients underwent prompt extubation after their first successful spontaneous breathing trial. Prompt extubation was associated with more ventilator-free days (incidence rate ratio, 1.24; 95% confidence interval, 1.19-1.29) when compared with no prompt extubation. <b>Conclusions:</b> Prompt extubation after a first successful spontaneous breathing trial was associated with more ventilator-free days (up to 28 d) among adults with acute brain injury receiving invasive mechanical ventilation. The original trial protocol was registered with www.clinicaltrials.gov (NCT04291235).