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meaning that the actual goal of artificial ventilation is to avoid fatal secondary damage factors such as hypoxemia&#44; hypercapnia and hypocapnia&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;4</span></a> In the second place&#44; neurocritical patients usually remain long periods of time with MV and artificial airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;4</span></a> Lastly&#44; because it is not unusual to find&#44; during ventilatory support and artificial airway withdrawal&#44; several degrees of compromise of the state of consciousness followed by an inability to follow commands and move in order to obtain the classical parameters of MV and&#47;or extubation withdrawal&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;8</span></a> So&#44; because of all these controversial issues we will be trying to expose our point of view through the following questions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Question&#35;1&#46; What is the clinical evidence on weaning from MV in the neurocritical patient&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">The data available today is scarce if we take into consideration the high susceptibility of this population when it comes to developing respiratory complications&#46; Also&#44; the neurocritical condition ranks second on the need for MV&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#8211;3</span></a> On the other hand&#44; one universally accepted criterion before initiating MV withdrawal is resolving the condition that triggered it &#8211; a situation that in neurocritical patients rarely happens&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;9</span></a> One multicenter prospective observational study revealed that neurocritical patients are ventilated for longer periods of time and have higher rates of ventilator-induced pneumonia and mortality compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> MV withdrawal was difficult in almost 50&#37; of the cases&#44; and prolonged in 10&#37; of the cases&#46; Both the methods and duration of withdrawal and the rates of reintubation were similar to those of populations without neurological conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> In the prospective randomized controlled study conducted by Navalesi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> it was determined that approaching the process of withdrawal and extubation from a protocolized&#44; multidisciplinary and controlled fashion reduces the rate of failure&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Question&#35;2&#46; Do conventional criteria apply when weaning from MV and extubation&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">There are different approaches here&#44; since most criteria used cannot be obtained through the adequate technique or are impossible to implement because the state of consciousness has been compromised&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#8211;9</span></a> Recent studies confirm the systemic failure of the usual criteria of withdrawal&#47;extubation in neurocritical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;7&#44;9&#44;12&#44;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When analyzing the predictors of failure in the process of withdrawal&#47;extubation&#44; we find that some of them are associated with characteristics of the critically ill patient per se such as age&#44; heart failure&#44; high levels of the b-type natriuretic peptide&#44; or a positive hydric balance<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a>&#59; while others may be considered specific of neurocritical patients such as low scores on the Glasgow scale &#40;GS&#41;&#44; inadequate functioning of the cough reflex&#44; weak cough and&#47;or presence of abundant tracheal secretions&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;7&#44;9&#44;12&#44;13</span></a> The evidence supporting these predictors is low&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> Recently&#44; one prospective multicenter study determined&#44; through multivariate analyses&#44; the predictors of successful extubations in subjects with severe brain damage&#44; from which they developed the VISAGE score including age &#40;&#60;40 years of age&#41;&#44; capacity to swallow&#44; trouble maintaining fixation with both eyes and GS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#46; Each item was given one &#40;1&#41; point&#59; 90&#37; of the patients extubated successfully scored &#8805;3 in this scale&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Question&#35;3&#46; Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Extubation is a controversial issue in individuals with mental disorders or who &#8220;do not follow commands&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> The &#8220;incapacity to follow commands&#8221; has not been fully described and any assessments conducted among intubated patients using the GS are subject to error&#46; Also&#44; the cut-off point to establish the capacity to be extubated is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;9&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Namen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> confirmed that in a heterogeneous neurocritical population of patients who scored &#8805;8 on the GS&#44; failed extubation happened 25&#37; of the times&#44; and it went up to 63&#37; in those who scored &#60;8&#46; Scoring &#8805;10 on the GS was associated with successful extubation procedures in another study&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The actual recommendations suggest that to initiate the withdrawal of MV&#44; the patient should be awake and capable of following commands&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> However&#44; in the case of brain injuries&#44; this parameter is not strictly necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#8211;7&#44;9</span></a> Coplin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> reported successful extubation rates in 80&#37; of the patients who scored &#8804;8 on the GS and in 91&#37; of those who scored &#8804;4 on such scale&#46; Ko et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> used the Four Score to assess the patients&#8217; neurological state&#44; but they did not find any significant differences in the average score between those whose extubation failed and those whose extubation was successful&#46; Similar results were reported by Anderson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> using the GS&#46; McCredie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> confirmed that the GS is not associated with successful extubations&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Question&#35;4&#46; What are factors associated with successful extubation processes&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Both the control of the airway and post-extubation complications play a key role in the success or failure of the entire process&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The airway care score &#40;ACS&#41; assesses the capacity to protect and maintain patent airways by checking on the vomiting reflex&#44; the color and number of secretions&#44; and the need for aspirations prior to the extubation procedure<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Scores &#8804;6 predicted successful extubations&#59; but yet despite the fact that the ACS is very practical&#44; neither the original ACS nor any of its modifications have been validated externally or through a large scale study&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;13</span></a> Anderson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> reported that the capacity of coughing effectively and the presence of the vomiting reflex are associated with successful extubation procedures&#46; Spontaneous or provoked cough is an independent predictor factor of successful extubation procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">When it comes to post-extubation complications&#44; the incidence of stridor is between 1&#46;5 and 26&#46;3&#37; while the rates of laryngeal swelling are somewhere between 5 and 54&#46;4&#37;&#44; which can be explained by the lack of clear diagnostic criteria for this situation&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In general&#44; the rates of reintubation in critically ill patients are between 18 and 69&#37; for stridor and 15&#37; for laryngeal swelling&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> Such complications can be predicted very accurately using the Cuff Leak Test&#46; Different systematic reviews and clinical guidelines confirm this&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">17&#8211;22</span></a> The actual recommendations suggest using steroids whenever the Cuff Leak Test is positive&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Question&#35;5&#46; What is the extubation failure rate&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In one &#40;1&#41; out of every five &#40;5&#41; patients the extubation procedure fails&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows data from the extubation failure rates in neurocritical patients available today at the actual medical literature&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Question&#35;6&#46; Tracheostomy&#58; is it necessary&#63; If so&#44; when and how&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Controversial issue with uncertain benefits&#46; Two retrospective database studies conducted on severe brain trauma&#44; one of them with associated thoracic trauma recommend conducting early tracheostomy procedures based on fewer pneumonias&#44; days on MV and stay at the intensive care unit &#40;ICU&#41;&#46; Nevertheless&#44; the mortality rate was similar in the group that underwent late tracheostomy procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a> Other than the limitations of the methodological design of both studies per se&#44; the reason why the tracheostomy was indicated was not specified&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a> In another open randomized controlled study with a small sample of ischemic and hemorrhagic stroke victims&#44; early tracheostomies did not reduce the stay at the ICU&#44; but they did reduce the mortality rate&#44; although this was a secondary outcome measure&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> One recent systematic review and one meta-analysis including 10 studies with 503 patients with acute brain injuries showed that early tracheostomies did reduce the long-term mortality rate&#44; the duration of the MV&#44; and the stay at the ICU&#59; however&#44; in the sensitivity analysis conducted&#44; when excluding one biased study&#44; statistical significance went down&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> Even though the Panamerican Iberian consensus does not deal with neurocritical patients&#44; it does not recommend conducting early tracheostomies because&#44; even though this shortens the duration of MV&#44; it does not reduce the rates of pneumonia&#44; days at the ICU&#44; or long-term mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> The percutaneous tracheostomy is preferred to the surgical one due to its lower rate of infections&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> Certain situations favor conducting early tracheostomies&#58; &#40;a&#41; severe cervical spine injuries&#59; &#40;b&#41; infratentorial severe injuries&#59; &#40;c&#41; repeated failed extubations&#59; &#40;d&#41; prolonged MV and &#40;e&#41; poor neurological state&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;27</span></a> The role played by primary tracheostomies is still controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#8211;28</span></a> In our own opinion&#44; most individuals meet the necessary conditions to be extubated before attempting primary tracheostomies&#46; This is why we firmly believe that conducting one tracheostomy procedure with an organized protocol and team work is a valid option&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Question&#35;7&#46; Early mobility&#58; does it really help&#63;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Traditionally&#44; neurocritical patients used to remain at rest during the acute phase of their disease&#46; One binational multicenter study backs up this statement&#44; since 84&#37; of individuals could not move during such phase&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> We are standing at the doors of what will be a change of paradigm and cultural approach when it comes to the early mobility of critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30&#8211;32</span></a> The available evidence today states that this new therapeutic approach is safe and feasible if conducted under controlled multidisciplinary programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30&#8211;32</span></a> One recent meta-analysis conducted among individuals who required prolonged intensive care confirmed that implementing early mobility protocols reduced the duration of MV&#44; the stay at the hospital and mortality rate&#44; and improved the functional state&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> Specific programs implemented among patients who have not moved for long periods of time confirm their positive effect on the final outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> These results are encouraging and require large-scale validation among different populations of patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As far as we know no study today has been able to establish a correlation between early mobility and MV&#47;extubation withdrawal&#44; let alone among neurocritical patients&#46; In patients with brain injuries&#44; one prospective randomized observational uncontrolled Italian cohort reported better clinical and functional outcomes after implementing programs of early mobility&#44; which opens promising approaches in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">We need to conduct large scale studies that will allow us to make recommendations with a higher degree of certainty&#46; In the meantime&#44; we hereby present that&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Since we need one protocolized organized multidisciplinary algorithm for every neurocritical patient based on their individual needs when it comes to MV and extubation withdrawals&#44; we hereby propose an algorithm we can use when having to deal with all these issues &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The usual criteria to initiate the withdrawal of MV and extubation cannot be extrapolated to neurocritical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Not answering to verbal commands or low scores on the GS does not mean delaying or contraindicating MV and&#47;or extubation withdrawal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The airway care score &#40;ACS&#41; is a useful tool to predict the capability of keeping an open airway safely&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The Cuff Leak Test predicts the odds of postoperative swelling and stridor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Conducting one primary tracheostomy is advisable in groups at risk&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest associated with this article whatsoever&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "titulo" => "Question&#35;1&#46; What is the clinical evidence on weaning from MV in the neurocritical patient&#63;"
        ]
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          "identificador" => "sec0015"
          "titulo" => "Question&#35;2&#46; Do conventional criteria apply when weaning from MV and extubation&#63;"
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          "identificador" => "sec0020"
          "titulo" => "Question&#35;3&#46; Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation&#63;"
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          "identificador" => "sec0025"
          "titulo" => "Question&#35;4&#46; What are factors associated with successful extubation processes&#63;"
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          "identificador" => "sec0030"
          "titulo" => "Question&#35;5&#46; What is the extubation failure rate&#63;"
        ]
        6 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Question&#35;6&#46; Tracheostomy&#58; is it necessary&#63; If so&#44; when and how&#63;"
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          "identificador" => "sec0040"
          "titulo" => "Question&#35;7&#46; Early mobility&#58; does it really help&#63;"
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          "titulo" => "Conclusion"
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    "fechaRecibido" => "2018-04-14"
    "fechaAceptado" => "2018-04-24"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Jibaja M&#44; Sufan JL&#44; Godoy DA&#46; Controversias en la retirada de la ventilaci&#243;n mec&#225;nica y extubaci&#243;n en el paciente neurocr&#237;tico&#46; Med Intensiva&#46; 2018&#59;42&#58;551&#8211;555&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for weaning from MV and extubation in neurocritical patients&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source&#58; adapted from Coplin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cough during the aspiration maneuver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of secretions &#40;need for passes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Color of secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Viscosity of secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interval of aspiration of secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vomiting reflex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vigorous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aqueous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More than 3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vigorous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clear brown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frothy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Every 2&#8211;3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yellow&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asehnoune &#40;2017&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
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Controversies in weaning from mechanical ventilation and extubation in the neurocritical patient
Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico
M. Jibajaa,b,
Corresponding author
mjibaja79@gmail.com

Corresponding author.
, J.L. Sufanc, D.A. Godoyd,e
a Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
b Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
c Unidad de Paciente Crítico, Clínica Indisa, Santiago de Chile, Chile
d Unidad de Cuidados Neurocríticos, Sanatorio Pasteur, Catamarca, Argentina
e Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina
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        "titulo" => "Controversias en la retirada de la ventilaci&#243;n mec&#225;nica y extubaci&#243;n en el paciente neurocr&#237;tico"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for weaning from MV and extubation in neurocritical patients&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The information available on the processes of weaning from mechanical ventilation &#40;MV&#41; and extubation after severe neurological injury is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#8211;4</span></a> The strategies used have been extrapolated from researches and protocols obtained from populations of patients without neurocritical conditions<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2</span></a> &#8211; situations that cannot be compared for several reasons&#46; In the first place&#44; most individuals with a brain injury are not ventilated because of a primary respiratory failure but because they show an altered state of consciousness due to their incapacity to keep their airways patent&#44; meaning that the actual goal of artificial ventilation is to avoid fatal secondary damage factors such as hypoxemia&#44; hypercapnia and hypocapnia&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;4</span></a> In the second place&#44; neurocritical patients usually remain long periods of time with MV and artificial airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;4</span></a> Lastly&#44; because it is not unusual to find&#44; during ventilatory support and artificial airway withdrawal&#44; several degrees of compromise of the state of consciousness followed by an inability to follow commands and move in order to obtain the classical parameters of MV and&#47;or extubation withdrawal&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;8</span></a> So&#44; because of all these controversial issues we will be trying to expose our point of view through the following questions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Question&#35;1&#46; What is the clinical evidence on weaning from MV in the neurocritical patient&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">The data available today is scarce if we take into consideration the high susceptibility of this population when it comes to developing respiratory complications&#46; Also&#44; the neurocritical condition ranks second on the need for MV&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#8211;3</span></a> On the other hand&#44; one universally accepted criterion before initiating MV withdrawal is resolving the condition that triggered it &#8211; a situation that in neurocritical patients rarely happens&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;9</span></a> One multicenter prospective observational study revealed that neurocritical patients are ventilated for longer periods of time and have higher rates of ventilator-induced pneumonia and mortality compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> MV withdrawal was difficult in almost 50&#37; of the cases&#44; and prolonged in 10&#37; of the cases&#46; Both the methods and duration of withdrawal and the rates of reintubation were similar to those of populations without neurological conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> In the prospective randomized controlled study conducted by Navalesi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> it was determined that approaching the process of withdrawal and extubation from a protocolized&#44; multidisciplinary and controlled fashion reduces the rate of failure&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Question&#35;2&#46; Do conventional criteria apply when weaning from MV and extubation&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">There are different approaches here&#44; since most criteria used cannot be obtained through the adequate technique or are impossible to implement because the state of consciousness has been compromised&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#8211;9</span></a> Recent studies confirm the systemic failure of the usual criteria of withdrawal&#47;extubation in neurocritical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;7&#44;9&#44;12&#44;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When analyzing the predictors of failure in the process of withdrawal&#47;extubation&#44; we find that some of them are associated with characteristics of the critically ill patient per se such as age&#44; heart failure&#44; high levels of the b-type natriuretic peptide&#44; or a positive hydric balance<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a>&#59; while others may be considered specific of neurocritical patients such as low scores on the Glasgow scale &#40;GS&#41;&#44; inadequate functioning of the cough reflex&#44; weak cough and&#47;or presence of abundant tracheal secretions&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;7&#44;9&#44;12&#44;13</span></a> The evidence supporting these predictors is low&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> Recently&#44; one prospective multicenter study determined&#44; through multivariate analyses&#44; the predictors of successful extubations in subjects with severe brain damage&#44; from which they developed the VISAGE score including age &#40;&#60;40 years of age&#41;&#44; capacity to swallow&#44; trouble maintaining fixation with both eyes and GS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#46; Each item was given one &#40;1&#41; point&#59; 90&#37; of the patients extubated successfully scored &#8805;3 in this scale&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Question&#35;3&#46; Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Extubation is a controversial issue in individuals with mental disorders or who &#8220;do not follow commands&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> The &#8220;incapacity to follow commands&#8221; has not been fully described and any assessments conducted among intubated patients using the GS are subject to error&#46; Also&#44; the cut-off point to establish the capacity to be extubated is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;9&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Namen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> confirmed that in a heterogeneous neurocritical population of patients who scored &#8805;8 on the GS&#44; failed extubation happened 25&#37; of the times&#44; and it went up to 63&#37; in those who scored &#60;8&#46; Scoring &#8805;10 on the GS was associated with successful extubation procedures in another study&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The actual recommendations suggest that to initiate the withdrawal of MV&#44; the patient should be awake and capable of following commands&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> However&#44; in the case of brain injuries&#44; this parameter is not strictly necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#8211;7&#44;9</span></a> Coplin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> reported successful extubation rates in 80&#37; of the patients who scored &#8804;8 on the GS and in 91&#37; of those who scored &#8804;4 on such scale&#46; Ko et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> used the Four Score to assess the patients&#8217; neurological state&#44; but they did not find any significant differences in the average score between those whose extubation failed and those whose extubation was successful&#46; Similar results were reported by Anderson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> using the GS&#46; McCredie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> confirmed that the GS is not associated with successful extubations&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Question&#35;4&#46; What are factors associated with successful extubation processes&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Both the control of the airway and post-extubation complications play a key role in the success or failure of the entire process&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The airway care score &#40;ACS&#41; assesses the capacity to protect and maintain patent airways by checking on the vomiting reflex&#44; the color and number of secretions&#44; and the need for aspirations prior to the extubation procedure<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Scores &#8804;6 predicted successful extubations&#59; but yet despite the fact that the ACS is very practical&#44; neither the original ACS nor any of its modifications have been validated externally or through a large scale study&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;13</span></a> Anderson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> reported that the capacity of coughing effectively and the presence of the vomiting reflex are associated with successful extubation procedures&#46; Spontaneous or provoked cough is an independent predictor factor of successful extubation procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">When it comes to post-extubation complications&#44; the incidence of stridor is between 1&#46;5 and 26&#46;3&#37; while the rates of laryngeal swelling are somewhere between 5 and 54&#46;4&#37;&#44; which can be explained by the lack of clear diagnostic criteria for this situation&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In general&#44; the rates of reintubation in critically ill patients are between 18 and 69&#37; for stridor and 15&#37; for laryngeal swelling&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> Such complications can be predicted very accurately using the Cuff Leak Test&#46; Different systematic reviews and clinical guidelines confirm this&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">17&#8211;22</span></a> The actual recommendations suggest using steroids whenever the Cuff Leak Test is positive&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Question&#35;5&#46; What is the extubation failure rate&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In one &#40;1&#41; out of every five &#40;5&#41; patients the extubation procedure fails&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows data from the extubation failure rates in neurocritical patients available today at the actual medical literature&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Question&#35;6&#46; Tracheostomy&#58; is it necessary&#63; If so&#44; when and how&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Controversial issue with uncertain benefits&#46; Two retrospective database studies conducted on severe brain trauma&#44; one of them with associated thoracic trauma recommend conducting early tracheostomy procedures based on fewer pneumonias&#44; days on MV and stay at the intensive care unit &#40;ICU&#41;&#46; Nevertheless&#44; the mortality rate was similar in the group that underwent late tracheostomy procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a> Other than the limitations of the methodological design of both studies per se&#44; the reason why the tracheostomy was indicated was not specified&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a> In another open randomized controlled study with a small sample of ischemic and hemorrhagic stroke victims&#44; early tracheostomies did not reduce the stay at the ICU&#44; but they did reduce the mortality rate&#44; although this was a secondary outcome measure&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> One recent systematic review and one meta-analysis including 10 studies with 503 patients with acute brain injuries showed that early tracheostomies did reduce the long-term mortality rate&#44; the duration of the MV&#44; and the stay at the ICU&#59; however&#44; in the sensitivity analysis conducted&#44; when excluding one biased study&#44; statistical significance went down&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> Even though the Panamerican Iberian consensus does not deal with neurocritical patients&#44; it does not recommend conducting early tracheostomies because&#44; even though this shortens the duration of MV&#44; it does not reduce the rates of pneumonia&#44; days at the ICU&#44; or long-term mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> The percutaneous tracheostomy is preferred to the surgical one due to its lower rate of infections&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> Certain situations favor conducting early tracheostomies&#58; &#40;a&#41; severe cervical spine injuries&#59; &#40;b&#41; infratentorial severe injuries&#59; &#40;c&#41; repeated failed extubations&#59; &#40;d&#41; prolonged MV and &#40;e&#41; poor neurological state&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;27</span></a> The role played by primary tracheostomies is still controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#8211;28</span></a> In our own opinion&#44; most individuals meet the necessary conditions to be extubated before attempting primary tracheostomies&#46; This is why we firmly believe that conducting one tracheostomy procedure with an organized protocol and team work is a valid option&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Question&#35;7&#46; Early mobility&#58; does it really help&#63;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Traditionally&#44; neurocritical patients used to remain at rest during the acute phase of their disease&#46; One binational multicenter study backs up this statement&#44; since 84&#37; of individuals could not move during such phase&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> We are standing at the doors of what will be a change of paradigm and cultural approach when it comes to the early mobility of critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30&#8211;32</span></a> The available evidence today states that this new therapeutic approach is safe and feasible if conducted under controlled multidisciplinary programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30&#8211;32</span></a> One recent meta-analysis conducted among individuals who required prolonged intensive care confirmed that implementing early mobility protocols reduced the duration of MV&#44; the stay at the hospital and mortality rate&#44; and improved the functional state&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> Specific programs implemented among patients who have not moved for long periods of time confirm their positive effect on the final outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> These results are encouraging and require large-scale validation among different populations of patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As far as we know no study today has been able to establish a correlation between early mobility and MV&#47;extubation withdrawal&#44; let alone among neurocritical patients&#46; In patients with brain injuries&#44; one prospective randomized observational uncontrolled Italian cohort reported better clinical and functional outcomes after implementing programs of early mobility&#44; which opens promising approaches in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">We need to conduct large scale studies that will allow us to make recommendations with a higher degree of certainty&#46; In the meantime&#44; we hereby present that&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Since we need one protocolized organized multidisciplinary algorithm for every neurocritical patient based on their individual needs when it comes to MV and extubation withdrawals&#44; we hereby propose an algorithm we can use when having to deal with all these issues &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The usual criteria to initiate the withdrawal of MV and extubation cannot be extrapolated to neurocritical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Not answering to verbal commands or low scores on the GS does not mean delaying or contraindicating MV and&#47;or extubation withdrawal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The airway care score &#40;ACS&#41; is a useful tool to predict the capability of keeping an open airway safely&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The Cuff Leak Test predicts the odds of postoperative swelling and stridor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Conducting one primary tracheostomy is advisable in groups at risk&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest associated with this article whatsoever&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for weaning from MV and extubation in neurocritical patients&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source&#58; adapted from Coplin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cough during the aspiration maneuver&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Viscosity of secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interval of aspiration of secretions&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aqueous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More than 3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vigorous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clear brown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frothy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dense&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Every 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Green&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sticky&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;1<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Airway care score &#40;ACS&#41;&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author &#40;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients included&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coplin &#40;2000&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">146&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Namen &#40;2001&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manno &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ko &#40;2009&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Karanjia &#40;2011&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1265&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anderson &#40;2011&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">285&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">McCredie &#40;2017&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">152&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asehnoune &#40;2017&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Extubation failure rate of neurocritical patients in different studies&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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          "bibliografiaReferencia" => array:33 [
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                            1 => "F&#46; Frutos-Vivar"
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                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
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                      "autores" => array:1 [
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                          "etal" => false
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                            1 => "A&#46; Roquilly"
                            2 => "R&#46; Cinotti"
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                      "Revista" => array:5 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Mechanical ventilation in neurocritical care patients&#58; a systematic literature review"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "B&#46; Borsellino"
                            1 => "M&#46; Schultz"
                            2 => "M&#46; Gama de Abreu"
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                  "contribucion" => array:1 [
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                      "titulo" => "Conventional weaning parameters do not predict extubation failure in neurocritical care patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            1 => "L&#46; Ramos"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Anderson"
                            1 => "J&#46; Bartscher"
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1007/s12028-010-9369-7"
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                        "tituloSerie" => "Neurocrit Care"
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                        "volumen" => "15"
                        "paginaInicial" => "490"
                        "paginaFinal" => "497"
                        "link" => array:1 [
                          0 => array:2 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway management strategies for brain-injured patients meeting standard criteria to consider extubation&#58; a prospective cohort study"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46; McCredie"
                            1 => "N&#46; Ferguson"
                            2 => "R&#46; Pinto"
                            3 => "N&#46; Adhikari"
                            4 => "R&#46; Fowler"
                            5 => "M&#46; Chapman"
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                  ]
                  "host" => array:1 [
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                      "doi" => "10.1513/AnnalsATS.201608-620OC"
                      "Revista" => array:6 [
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                        "fecha" => "2017"
                        "volumen" => "14"
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