High-Flow Nasal Cannula After Extubation in Acute Brain Injury

Patients with acute brain injury after neurosurgery are at increased risk of extubation failure after removal of the endotracheal tube. High-flow nasal cannula (HFNC) may provide better post-extubation respiratory support than conventional oxygen therapy (COT), but evidence in post-neurosurgical patients remains limited. This prospective observational study evaluated adult post-neurosurgical patients with acute brain injury who underwent planned extubation in the Surgical Intensive Care Unit of Bach Mai Hospital, Vietnam. Patients received either HFNC or COT after extubation according to routine clinical practice and the decision of the attending ICU physicians. The primary outcome was treatment failure, defined as reintubation or escalation of respiratory support within 5 days after extubation. Secondary outcomes included tracheostomy, ventilator-associated pneumonia, ICU length of stay, total duration of mechanical ventilation, and time from extubation to reintubation. Propensity score matching was used to reduce baseline imbalance between groups.

Inclusion Criteria: * Patients aged 16 years or older. * Admission to the Surgical Intensive Care Unit after neurosurgery for acute brain injury, including traumatic brain injury, intracerebral hemorrhage, subarachnoid hemorrhage, ischemic stroke, or other acute neurosurgical brain conditions. * Requirement for invasive mechanical ventilation for at least 24 hours. * Undergoing planned extubation after clinical assessment by the treating ICU team. * Successful completion of a spontaneous breathing trial lasting 30 to 120 minutes. * Adequate airway protection, defined as an Airway Care Score less than 8 points. * Neurological readiness for extubation, as assessed by Glasgow Coma Scale score and bedside neurological examination. * Adequate oxygenation before extubation, including PaO2/FiO2 greater than 200 mmHg and PEEP less than 7 cmH2O. Exclusion Criteria: * Pre-existing tracheostomy. * Known upper airway obstruction, including airway stenosis or airway tumor. * Suspected cerebrospinal fluid leak or complex skull base fracture. * Unplanned self-extubation. * Requirement for immediate prophylactic reintubation before initiation of post-extubation oxygen therapy. * Requirement for non-invasive ventilation before initiation of the study exposure. * Missing key clinical data required for outcome assessment or propensity score matching.