Predicting extubation failure after successful completion of a spontaneous breathing trial.
OBJECTIVE
To derive a clinical prediction rule that uses bedside clinical variables to predict extubation failure (reintubation within 48 h) after a successful spontaneous breathing trial.


METHODS
This prospective observational cohort study was performed at the Northwestern Memorial Hospital in Chicago, Illinois, which is a large tertiary-care university hospital. Among 673 consecutive patients who received mechanical ventilation during a 15-month period, 122 were ventilated for at least 2 days and did not undergo withdrawal of support or tracheostomy. These patients were followed after extubation to identify those who were reintubated within 48 h (extubation failure). We used logistic regression analysis to identify variables that predict reintubation, and we used bootstrap resampling to internally validate the predictors and adjust for overoptimism.


RESULTS
Sixteen (13%) of the 122 patients required reintubation within 48 h. Three clinical variables predicted reintubation: moderate to copious endotracheal secretions (p = 0.001), Glasgow Coma Scale score < or =10 (p = 0.004), and hypercapnia (P(aCO(2)) > or = 44 mm Hg) during the spontaneous breathing trial (p = 0.001). Using logistic regression and bootstrap resampling to adjust for overfitting, we derived a clinical prediction rule that combined those 3 clinical variables (area under the receiver operating characteristic curve 0.87, 95% confidence interval 0.74-0.94).


CONCLUSIONS
With our clinical prediction rule that incorporates an assessment of mental status, endotracheal secretions, and pre-extubation P(aCO(2)), clinicians can predict who will fail extubation despite a successful spontaneous breathing trial.
Mokhlesi
Babak
B
Section of Pulmonary and Critical Care Medicine, University of Chicago Pritzker School of Medicine, Chicago IL 60637, USA. bmokhles@medicine.bsd.uchicago.edu
Tulaimat
Aiman
A
Gluckman
Ty J
TJ
Wang
Yue
Y
Evans
Arthur T
AT
Corbridge
Thomas C
TC
D000328:Adult; D000368:Aged; D001980:Bronchi / Q000378:metabolism; D002641:Chicago; D015331:Cohort Studies; D005260:Female; D006786:Hospitals, Urban; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012119:Respiration; D012131:Respiratory Insufficiency / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000009:adverse effects* / Q000592:standards