Early Electroencephalographic Background Evolution as a Predictor of Airway Outcomes in Severe Traumatic Brain Injury: A Pilot Study.

Background and aims: Determining the optimal timing for extubation or tracheostomy in patients with severe traumatic brain injury (TBI) remains challenging. Standard weaning criteria often fail to account for neurological readiness, leading to high rates of extubation failure. This study evaluated whether the evolution of electroencephalography (EEG) background activity over the first 96 hours could predict airway outcomes better than standard clinical assessments. Patients and methods: We conducted a prospective observational study on 43 patients with severe TBI requiring mechanical ventilation. Electroencephalography recordings were obtained on admission to the intensive care unit (ICU) and at 96 hours. Background activity was classified as improving (alpha/beta dominance) or non-improving (theta/delta dominance). The primary outcome was successful extubation vs extubation failure (defined as re-intubation or need for tracheostomy). Results: Of the 43 patients, 25 (58%) were successfully extubated, while 18 (42%) failed. Dominant EEG frequency at 96 hours was a powerful predictor of outcome. Patients with improving alpha/beta backgrounds demonstrated a positive predictive value (PPV) of 92.9% for successful extubation. Conversely, persistent theta/delta slowing was significantly associated with extubation failure [odds ratio (OR): 18.41; 95% confidence interval (CI): 2.1-160.3; Conclusion: Early improvement in EEG background activity is a robust indicator of airway competence in severe TBI. A non-improving EEG warrants caution, while an improving background suggests that tracheostomy may be judiciously deferred to allow for successful extubation. Integrating serial EEG into weaning protocols may prevent unnecessary surgical interventions and reduce extubation failure rates.