Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial*

Abstract

Objectives: To identify whether factors associated with withholding extubation in the ICU also predict the risk of extubation failure. Design: Retrospective cohort study. Setting: Eight medical-surgical ICUs in Toronto. Patients: Adult patients receiving invasive mechanical ventilation, with a first successful spontaneous breathing trial within 28 days of initial ICU admission. Interventions: None. Measurements and Main Results: The primary end point had three mutually exclusive levels, including: 1) withholding extubation after a successful spontaneous breathing trial, 2) extubation failure within 48 hours, and 3) successful extubation. Among 9,910 patients, 38% of patients were not extubated within 24 hours of their first successful spontaneous breathing trial. A total of 12.9% of patients who were promptly extubated failed within the next 48 hours. Several discrepancies were evident in the association of factors with risk of withholding extubation and extubation failure. Specifically, both age and female sex were associated with withholding extubation (odds ratio, 1.07; 95% CI, 1.03–1.11; and odds ratio, 1.13; 95% CI, 1.02–1.26, respectively) but not a higher risk of failed extubation (odds ratio, 0.99; 95% CI, 0.93–1.05; and odds ratio, 0.93; 95% CI, 0.77–1.11, respectively). Conversely, both acute cardiovascular conditions and intubation for hypoxemic respiratory failure were associated with a higher risk of failed extubation (odds ratio, 1.32; 95% CI, 1.06–1.66; and odds ratio, 1.46; 95% CI, 1.16–1.82, respectively) but not a higher odds of a withheld extubation attempt (odds ratio, 0.79; 95% CI, 0.68–0.91; and odds ratio, 1.07; 95% CI, 0.93–1.23, respectively). Conclusions: Several factors showed discordance between the decision to withhold extubation and the risk of extubation failure. This discordance may lead to longer duration of mechanical ventilation or higher reintubation rates. Improving the decision-making behind extubation may help to reduce both exposure to invasive mechanical ventilation and extubation failure.