In Reply

We gratefully acknowledge Dr. Patlak et al. for his constructive comments on our article.¹  We fully agree with our colleague when he states that protracted ventilation is the main issue in brain-injured patients,²  because delaying extubation promotes morbidity and healthcare costs. The VISAGE (visual pursuit, swallowing, age, Glasgow coma scale for extubation) score¹  was developed to help the physician in securing the challenging extubation process in neurocritical care patients. The fear of extubation failure is due to the lack of guidelines for extubation in neurologic patients, and there is a clear need for new clinical evidence to help the attending physician. If the VISAGE score performs well at predicting extubation success based on favorable neurologic clinical signs, it is true that its performance is less accurate in patients with a low score. One obvious explanation stems from the fact that neurologic examination varies considerably within the same day in a single patient. Thus, the VISAGE score, as well as the other prediction score recently published in Anesthesiology,³  add a lot to the field by showing for the first time that a suboptimal level of consciousness and one or two functional aspects of the airway may predict a successful extubation. However, as mentioned by Patlak et al., we need other information for guiding extubation when the value of the VISAGE score is low. Finally, we truly believe that this score is a first step toward improvement of global respiratory management of neurocritical care patients.⁴  Even if it is likely that extubation failure rate, as well as delayed extubation, will remain elevated in these patients over the next few years, this should not be considered a fatal flaw.