CHEST

Original Research
CRITICAL CARE MEDICINE

Risk Factors for Extubation Failure in

Patients Following a Successful
Spontaneous Breathing Trial*
Fernando Frutos-Vivar, MD; Niall D. Ferguson, MD, MSc; Andres Esteban, MD, PhD;
Scott K. Epstein, MD, FCCP; Yaseen Arabi, MD, FCCP; Carlos Apeztegua, MD;
Marco Gonzalez, MD; Nicholas S. Hill, MD, FCCP; Stefano Nava, MD;
Gabriel DEmpaire, MD; and Antonio Anzueto, MD

Background: To assess the factors associated with reintubation in patients who had successfully
passed a spontaneous breathing trial.
Methods: We used logistic regression and recursive partitioning analyses of prospectively
collected clinical data from adults admitted to ICUs of 37 hospitals in eight countries, who had
undergone invasive mechanical ventilation for > 48 h and were deemed ready for extubation.
Results: Extubation failure occurred in 121 of the 900 patients (13.4%). The logistic regression
analysis identified the following associations with reintubation: rapid shallow breathing index
(RSBI) [odds ratio (OR), 1.009 per unit; 95% confidence interval (CI), 1.003 to 1.015]; positive
fluid balance (OR, 1.70; 95% CI, 1.15 to 2.53); and pneumonia as the reason for initiating
mechanical ventilation (OR, 1.77; 95% CI, 1.10 to 2.84). The recursive partitioning analysis
allowed the separation of patients into different risk groups for extubation failure: (1) RSBI of
> 57 breaths/L/min and positive fluid balance (OR, 3.0; 95% CI, 1.8 to 4.8); (2) RSBI of < 57
breaths/L/min and pneumonia as reason for mechanical ventilation (OR, 2.0; 95% CI, 1.1 to 3.6);
(3) RSBI of > 57 breaths/L/min and negative fluid balance (OR, 1.4; 95% CI, 0.8 to 2.5); and (4)
RSBI of < 57 breaths/L/min (OR, 1 [reference value]).
Conclusions: Among routinely measured clinical variables, RSBI, positive fluid balance 24 h prior
to extubation, and pneumonia at the initiation of ventilation were the best predictors of
extubation failure. However, the combined predictive ability of these variables was weak.
(CHEST 2006; 130:1664 1671)
Key words: artificial respiration; extubation; predictive index; reintubation; ventilator weaning
Abbreviations: CI confidence interval; OR odds ratio; RSBI rapid shallow breathing index

delayed and premature discontinuation of

B oth
mechanical ventilation have been associated with
increased mortality.17 Multiple randomized trials2,8 13 have demonstrated that the duration of
ventilation can be reduced safely by a strategy
employing daily assessments for readiness to wean,
followed by prompt extubation after a successful
spontaneous breathing trial. However, this approach
to weaning still results in an extubation failure rate
(ie, the need for reintubation within 48 to 72 h) of 10
to 20%.9 13 Thus, there is a need to determine what
factors may be associated with this failure rate.
Attention has now moved to refining the second
stage in the liberation process, namely, the decision

to extubate after having passed a spontaneous

breathing trial.3 Studies from the past few
years7,14 16 have focused on the association of extubation outcomes with variables that assess the ability
to protect the airway. These studies have reported
that the risk of extubation failure is increased with
ineffective cough, a propensity for aspiration, and
abundant secretions, while a decreased level of
consciousness was not consistently identified as a risk
factor for failure. However, the results of these
studies may not be widely generalizable, as they were
performed at single centers or in specific populations,7,14 16 with relatively small sample sizes. In
addition, many of their specific predictor variables,

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Original Research

such as cough, peak flow, and secretion volume, are

difficult to measure in daily clinical practice.
The objective of our multicenter international
study was to assess prospectively the variables associated with reintubation in a heterogeneous group of
For editorial comment see page 1635
mechanically ventilated patients who were extubated
after having successfully completed a spontaneous
breathing trial.
Materials and Methods
Patients
Between November 1999 and May 2002, consecutive patients
18 years of age, who had undergone invasive mechanical
ventilation for 48 h and had been extubated following a
successful spontaneous breathing trial, were enrolled from the
ICUs of 37 hospitals in eight countries. The research ethics board
at each center approved the study and informed consent was
obtained at the time of enrollment. Patients with a tracheostomy
were excluded. Each of the study ICUs used the same general
methodology for weaning patients from mechanical ventilation.
Patients were assessed daily for the presence of the following
readiness-to-wean criteria: (1) improvement in the underlying
condition that led to acute respiratory failure; (2) alert and able to
communicate; (3) core temperature not 38C; (4) no therapy
with vasoactive drugs (excluding dopamine, 5 g/kg/min); and
(5) adequate gas exchange, as indicated by a Po2 of at least 60
*From the Hospital Universitario de Getafe (Drs. Frutos-Vivar
and Esteban), Madrid, Spain; the Department of Medicine (Dr.
Ferguson), Division of Respirology, and the Interdepartmental
Division of Critical Care Medicine, University Health Network,
University of Toronto, Toronto, ON, Canada; the Department of
Medicine (Dr. Epstein), Caritas-St. Elizabeths Medical Center,
Tufts University School of Medicine, Boston, MA; King Abdulaziz Medical City (Dr. Arabi), Riyadh, Saudi Arabia; Hospital
Profesor Posadas (Dr. Apeztegua), Buenos Aires, Argentina;
Hospital General de Medelln (Dr. Gonzalez), Medelln, Colombia; Pulmonary and Critical Care Division (Dr. Hill), Department
of Medicine, New England Medical Center, Tufts University
School of Medicine, Boston, MA; Respiratory Intensive Care
Unit (Dr. Nava), Fondazione S. Maugeri, Istituto Scientifico di
Pavia, Pavia, Italy; Hospital de Clnicas (Dr. DEmpaire), Caracas, Venezuela; and South Texas Veterans Health Care System
(Dr. Anzueto), San Antonio, TX.
This research was supported by grant 00/315 from the Fondo de
Investigacion Sanitaria; by grants Red Gira G03/063 and Red
Respira C03/11 from the Instituto de Salud Carlos III, Spain; and
by a Canadian Institutes of Health Research-Canadian Lung
Association Post-Doctoral Fellowship (to Dr. Ferguson).
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received July 8, 2006; revision accepted September 2,
2006.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Fernando Frutos-Vivar, MD, Intensive Care
Unit, Hospital Universitario de Getafe, Carretera de Toledo km
12,500, 28905 Getafe, Madrid, Spain; e-mail: ffrutos@ucigetafe.com
DOI: 10.1378/chest.130.6.1664

mm Hg with an inspired fraction of oxygen of 0.40 and a

positive end-expiratory pressure not 5 cm H2O. Patients
meeting these criteria were then weaned using one of the
following techniques: (1) daily trial of spontaneous breathing for
up to 120 min using a T-tube, continuous positive airway
pressure, flow-by, or pressure support of 8 cm H2O; (2)
multiple daily trials of spontaneous breathing, as cited above; or
(3) gradual reductions of pressure support until a level of 7 cm
H2O was reached. All patients ultimately passed a spontaneous
breathing trial and were extubated.
Data Collection
We recorded demographic data and the severity of illness at
the time of ICU admission. The reason for the initiation of
mechanical ventilation was recorded using the same classification system and definitions as those used in another large
international observational study17; specifically, pneumonia
was defined as the presence of new or worsening radiographic
alveolar infiltrates along with fever or hypothermia, and
leukocytosis or leukopenia. The presence of cardiovascular
events (shock or acute coronary syndrome) over the course of
mechanical ventilation, the duration of mechanical ventilation,
and the method of weaning were also documented. We
prospectively collected the following data during the 24 h
before extubation: tracheal secretions volume (none, minimal,
or abundant) and consistency (normal or purulent); subjective
efficacy of cough (poor, moderate, or excellent); WBC count
12,000 per L; temperature 38C; administration of
sedatives; and fluid balance (calculated as fluid input minus
output over the 24-h period). Tracheobronchial aspirates were
sent for semi-quantitative culture. We considered culture
findings to be positive if 105 cfu/mL potentially pathogenic
organisms were isolated. After successful completion of a
spontaneous breathing trial and immediately prior to extubation, investigators documented the following: (1) patients
ability to cooperate (poor, moderate, and excellent); (2) a
1-min observation of respiratory frequency and tidal volume
measured through a spirometer or from the ventilator display
(to calculate the rapid shallow breathing index [RSBI]18); (3)
maximal inspiratory pressure; and (4) oxygen saturation. If
available, the arterial blood gas levels were recorded.
After extubation, patients were followed up for the presence of
postextubation respiratory distress. Patients in whom acute respiratory failure developed were randomized to receive either
noninvasive positive-pressure ventilation or usual care.19 In both
groups, patients were reintubated if they met at least one of the
following criteria: lack of improvement and/or worsening in
arterial pH or Pco2; decreased mental status; decrease in the
oxygen saturation to 85%, despite the use of a high fraction of
inspired oxygen; lack of improvement in signs of respiratory
muscle fatigue; hypotension, with a systolic BP 90 mm Hg for
30 min despite adequate volume loading, the use of vasopressors, or both; and copious secretions that the patient could not
adequately clear.
Statistical Analysis
Results are expressed as the mean and SD, median and
interquartile range, and proportions, as appropriate. We used the
Student t test or the Mann-Whitney U test to compare continuous variables, and the 2 test or the Fisher exact test to compare
proportions, as appropriate. Two-tailed p values of 0.05 were
used to indicate statistical significance.
To estimate the simultaneous effects of multiple variables on
reintubation, a multivariate analysis was performed using a

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1665

conditional logistic regression model and a backward stepwise

selection method to correct for collinearity. We used a significance threshold of p 0.10 for entering tested variables into the
model. A recursive portioning analysis (Answer Tree; SPSS Inc;
Chicago, IL) was subsequently performed using the significant
variables from the multivariable logistic regression, in order to
derive clinically relevant subgroups of patients at different risks
for reintubation. This method identified threshold values for each
variable, which provided the best separation of the study population according to reintubation status. The resultant classification tree grouped patients into distinct groups using combinations of variables that jointly influenced the likelihood of
reintubation. Odds ratios (ORs) and 95% confidence intervals
(CIs) were then calculated for each of these distinct groups using

a dummy variable entered into a logistic regression equation. We

also calculated likelihood ratios for each risk category using
standard methods.20

Results
A total of 980 patients fulfilled the study entry
criteria and were electively extubated. We excluded
from our analysis two patients who required immediate reintubation because of upper airway obstruction (ie, glottic edema), and 78 patients in whom the
data for the predictor variables had not been re-

Table 1Characteristics of the Study Cohort*

Characteristics
Age, yr
Female gender
Simplified acute physiology score II, points
Reason for mechanical ventilation
COPD
Asthma
Coma
Neuromuscular disease
Postoperative acute respiratory failure
ARDS
Congestive heart failure
Pneumonia
Sepsis
Trauma
Complications during mechanical ventilation
Shock
Acute coronary syndrome
Method of weaning
Once-daily spontaneous breathing trial
Multiple daily spontaneous breathing trials
Gradual reduction of pressure support
Duration of mechanical ventilation, d
Arterial blood gas levels at extubation
Arterial pH
Arterial partial pressure of carbon dioxide, mm Hg
Arterial partial pressure of oxygen, mm Hg
Oxygen saturation, %
Parameters previously associated with extubation failure
Culture of tracheobronchial aspirate
Negative
105 cfu/mL potential pathogen microorganism
105 cfu/mL potential pathogen microorganism
Ineffective cough
Poor patient collaboration
Abundant tracheobronchial secretions
Purulent tracheobronchial secretions
Fever in 24 h prior to extubation
Leukocytosis in 24 h prior to extubation
Sedatives in 24 h prior to extubation
Maximal inspiratory pressure, cm H2O
Rapid shallow breathing index, breaths/min/L
Fluid balance, mL

Reintubated
(n 121)

Not Reintubated
(n 779)

p Value

60 (17)
53 (44)
38 (10)

55 (19)
299 (38)
37 (9)

0.006
0.26
0.36

14 (12)
1 (1)
8 (7)
3 (2.5)
21(17)
7 (6)
9 (7)
28 (23)
16 (13)
8 (7)

73 (9)
18 (2)
41 (5)
14 (2)
158 (20)
44 (6)
41 (5)
115 (15)
97 (12.5)
109 (14)

0.45
0.29
0.54
0.61
0.45
0.95
0.33
0.02
0.81
0.03

62 (51)
10 (8)

348 (45)
43 (5.5)

0.18
0.23

67 (55)
22 (18)
29 (24)
5 (712)

465 (60)
91 (12)
183 (23.5)
4 (711)

0.81
0.05
0.90
0.39

7.42 (0.06)
39 (9)
103 (33)
97 (2)

7.43 (0.05)
40 (9)
101 (36)
97 (4)

0.06
0.84
0.62
0.37
0.20

68 (56)
25 (21)
28 (23)
33 (27)
47 (39)
40 (33)
41 (34)
10 (8)
31 (26)
58 (48)
32 (14)
50 (3572)
293 (8041,494)

480 (62)
170 (22)
129 (17)
178 (23)
249 (32)
238 (31)
257 (33)
98 (13)
231 (30)
448 (57)
34 (15)
45 (3363)
109 (1,200888)

0.28
0.13
0.60
0.85
0.17
0.36
0.05
0.28
0.02
0.004

*Values are given as No. (%), unless otherwise indicated.

Values are given as the mean (SD).
Values are given as the median (interquartile range).
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Original Research

corded. Overall, extubation failure occurred in 121 of

the 900 patients included in this analysis (13.4%).
Table 1 shows the baseline characteristics of the
study cohort according to reintubation status. The
reasons for reintubation were lack of improvement in
work of breathing (55 of 121 patients; 45%), hypoxemia (27 of 121 patients; 22%), respiratory acidosis
(13 of 121 patients; 11%), retained secretions (12 of
121 patients; 10%), decreased level of consciousness
(7 of 121 patients; 6%), and hypotension (7 of 121
patients; 6%). Patients who required reintubation
were older and more likely to have had pneumonia as
their reason for receiving mechanical ventilation. In
addition, by univariate analysis these patients had
higher RSBI values (Fig 1) and were more likely to
have a positive fluid balance in the 24 h prior to
extubation (Fig 2).
The logistic regression analysis identified the following variables as being associated with reintubation: RSBI (OR, 1.009 per unit; 95% CI, 1.003 to
1.015); positive fluid balance (OR, 1.70; 95% CI,
1.15 to 2.53); and pneumonia as the reason for
initiating mechanical ventilation (OR, 1.77; 95% CI,
1.10 to 2.84). The recursive partitioning analysis
identified thresholds for these variables that allowed
the greatest separation of patients into different risk
groups for extubation failure (Fig 3). The probability
of reintubation in each distinct risk group defined by

the recursive partitioning analysis and the likelihood

ratios for extubation failure in the defined groups are
shown in Table 2.
Discussion
In a heterogeneous cohort of mechanically ventilated patients who were extubated after a successful
spontaneous breathing trial, we found that reintubation within 72 h was associated with a RSBI value of
57 breaths/min/L, a positive fluid balance within
24 h prior to extubation, and pneumonia as the cause
for initiating mechanical ventilation. In the original
description of the RSBI, Yang and Tobin18 identified
a threshold value of 105 breaths/min/L as a predictor
of weaning failure. Weaning failure was defined as
either the failure of a spontaneous breathing trial (in
which case patients were not extubated) or as the
failure of extubation after a successful spontaneous
breathing trial. Almost 15 years later, we now appreciate that predicting the success or failure of a
spontaneous breathing trial is less important. Spontaneous breathing trials are safe, well-tolerated, and
easy to perform. What now seems more important is
to predict the success of extubation following the
successful completion of a trial of spontaneous
breathing. Thus, several studies have assessed the
RSBI as a predictor of outcome after extubation.

Figure 1. Reintubation rate by RSBI group. Patients were divided into categories according to RSBI
values immediately prior to extubation using arbitrary steps of 25 breaths/min/L. Columns depict the
reintubation rate for each category. The numbers on top of the columns are the numeric reintubation
rates, while the numbers placed inside the columns indicate the number of patients in each category.
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Figure 2. Reintubation rate by fluid balance category. Patients were divided into categories according
to fluid balance in the 24 h prior to extubation using arbitrary steps of 1 L. Columns depict the
reintubation rate for each category. The numbers on top of the columns are the numeric reintubation
rates, while the numbers placed inside the columns indicate the number of patients in each category.

Bien et al21 reported that reintubated patients had a

significantly higher median RSBI (69 vs 45 breaths/
min/mL, respectively; p 0.05). Other studies14,16
have shown similar differences between successful
and failed extubations, but these did not reach
statistical significance. Smina et al,15 however, reported a significant difference in RSBI between
reintubated patients and those who had not been
reintubated (median, 88 vs 60 breaths/min/L, respectively; p 0.03). Furthermore, these investigators found that an RSBI of 100 breaths/min/L was
an independent predictor of extubation failure. Similar results were recently reported by Upadya et al.22
In our study, the RSBI was an independent predictor
of extubation failure, and a value 57 breaths/min/L
increased the risk of reintubation from 11 to 18%.
Congestive heart failure has been suggested as an
important reason for weaning failure. Lemaire et al23
reported a cohort of 15 patients with severe COPD
and cardiovascular disease in whom there was an
increase in pulmonary artery occlusion pressure during weaning that resulted in extubation failure. After
treatment with diuretics, 9 of the 15 patients were
successfully weaned from mechanical ventilation.23
Similarly, Cabello et al24 reported in 2004 that
congestive heart failure was the cause of weaning
failure in 7 of 12 patients (58%) who failed a
spontaneous breathing trial. Epstein and Ciubotaru,25
in a study of 74 patients who required reintubation

within 72 h of extubation, reported that congestive

heart failure was the reason for extubation failure in
23% of the patients. In our study, patients with a
positive fluid balance in the 24 h before extubation
had a higher likelihood of being reintubated. A
limitation of our study is that we did not collect any
hemodynamic or echocardiographic measurements
to be able to correlate positive fluid balance with
ventricular dysfunction. It is possible that patients
who failed extubation due to a positive fluid balance
had poor cardiovascular reserves and were not able
to handle the volume overload. It is also possible,
however, that fluid balance is acting as a general
marker of recovery from acute illness in our study
population. Patients who have an ongoing inability to
regulate the integrity of their vascular space and
achieve a negative fluid balance may also be less
likely to be successfully extubated. Similar results
have been reported by Upadya et al.22 In a prospective study including 87 patients these authors22
observed that a positive cumulative fluid balance
from hospital admission to weaning was associated
with weaning failure. Although in this study the
administration of diuretics was not associated with
improved weaning outcomes, we agree with these
authors that further prospective studies will be necessary to assess the value of hemodynamic monitoring and the role of diuretic therapy in the prevention
of reintubation. In relation to this issue, the recently

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Original Research

Figure 3. Recursive partitioning tree. Results of the recursive partitioning analysis are illustrated,
whereby each patient is ultimately assigned to one of four distinct risk groups for reintubation. Patients
are first divided according to their RSBI, and subsequently either by their fluid balance or the presence
of pneumonia as their reason for the initiation of ventilation. The proportions (percentage) of patients
reintubated in each group are displayed.

published study26 on fluid management in patients

with acute lung injury could support the observation
that fluid restriction is associated with a shorter time
period for needing ventilation.
Pneumonia as the reason to initiate mechanical
ventilation was the third variable related to reintubation in our study. The only other difference that
we identified in these patients was that they were
more likely to have tracheal aspirates positive for
pathogens prior to extubation (30.5% of patients with
pneumonia had 105 microorganisms that were
potentially pathogens in their tracheal aspirates prior
to extubation vs 18% of patients without pneumonia;
p 0.001). Other variables such as fever, leukocytosis or purulent secretions were similar between

patients with and without pneumonia at the time of

extubation. These findings suggest that patients may
not have fully cleared the microbial load from their
pneumonia, and therefore continued to require ventilatory support.
Extubation failure remains a difficult outcome to
predict. We were unable to clearly define a subgroup
of patients who were at very high risk of reintubation
using predictor variables that are measured in routine practice. Studies14 16 have highlighted the importance of cough strength and the amount of
bronchial secretions as factors related to reintubation. On univariate analysis, we identified that tracheal aspirate cultures with positive findings were
more common in patients who required reintuba-

Table 2Risk Subgroups for Reintubation From the Recursive Partitioning Analysis*
Risk Subgroup
RSBI
RSBI
RSBI
RSBI

57
57
57
57

breaths/min/L
breaths/min/L
breaths/min/L
breaths/min/L

and
and
and
and

positive fluid balance

pneumonia as reason for mechanical ventilation
negative fluid balance
not pneumonia as reason for mechanical ventilation

Extubation
Failure

Reintubation

36 (24)
18 (17)
20 (13)
47 (10)

3.0 (1.84.8)
2.0 (1.13.6)
1.4 (0.82.5)
1

Likelihood Ratio
(95% CI)
2.0
1.3
0.9
0.7

(1.52.8)
(0.82.1)
(0.61.5)
(0.50.8)

*Values are given as No. (%) or OR (95% CI), unless otherwise indicated.
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1669

tion, but this variable did not retain statistical significance in the multivariate analysis. Cough strength,
amount of secretions, level of consciousness, or
patient cooperation was not associated with extubation outcome in our study. There are several reasons
that may explain the differences between our findings and those of the previous studies. In our cohort,
the decision to extubate was protocolized; however,
the physician in charge of the patient made the final
decision, and it is possible that some physicians
delayed extubation until patients showed an improvement in some of these variables. Furthermore,
in our study the frequency of weak cough and/or
abundant amount of secretions was lower than previously observed. We also observed differences in
the reintubation rate of patients with the worst-case
clinical scenario, as described by Salam et al.16 These
investigators found that all patients who were unable
to cooperate, and had abundant secretions and a
weak cough required reintubation. In our study,
these three conditions were all present in 5% of the
population, but their reintubation rate was only 17%.
In summary, in a large cohort of mechanically
ventilated patients passing a spontaneous breathing
test and judged clinically appropriate to extubate, we
were able to demonstrate that the RSBI, a positive
fluid balance 24 h prior to extubation, and pneumonia as the cause for initiating mechanical ventilation
were the best predictors of extubation failure. However, the combined predictive ability of these variables was weak, as evidenced by likelihood ratios that
result in only modest changes from the pretest
probability of extubation failure. Future studies are
needed to search for other variables that are predictive of extubation failure while still being widely
applicable in routine care.
Appendix: Participating Study
Investigators
Argentina
S. Bauque and S. Giannasi (Hospital Italiano de Buenos Aires);
L. Bettini and A.R. Diez (Hospital Provincial del Centenario de
Rosario); H.S. Canales (Hospital Interzonal General de Agudos
General San Martin de la Plata de Mar del Plata); M.F. Costa and
H. Solar (Hospital Profesor Posadas de Haedo); P.M. Desmery
and A. Gomez (Sanatorio Mitre de Buenos Aires); P. Gomez and
O. Yunk (Hospital Espanol de Buenos Aires); M. Grill and W.
Vazquez (Hospital Espanol de Mendoza); E. Turchetto (Hospital
Privado de la Comunidad de Mar del Plata); and R. Valentn
(Centro de Estudios Medicos e Investigaciones Clnicas de
Buenos Aires).
Brazil
M.A. Soares and I.M. de Oliveira Rezende (Hospital Universitario Sao Jose, Belo Horizonte).

Colombia
B. Gil (Clnica Medelln de Medelln); M. Granados (Fundacion Valle de Lily de Cali); A. Guerra (Hospital General de
Medelln and Clnica Soma de Medelln); and F. Molina (Clnica
Universitaria Bolivariana de Medelln).
Saudi Arabia
S. Haddad (King Fahad National Guard Hospital of Riyadh).
Spain
A. Abella and M. Prieto (Hospital Universitario de Getafe,
Madrid); J.M. Allegue and S. Rodrguez Fernandez (Hospital
Santa Maria del Rosell, Cartagena); S. Alonso and C. Boque
(Hospital Universitario Joan XXIII, Tarragona); A. Belenguer and
T. Mut (Hospital General de Castellon); S. Benito and A.
Claramunt (Hospital de Santa Creu i Sant Pau, Barcelona); J.
Blanco (Hospital del Ro Hortega, Valladolid); J.L. Buenda and
J.A. Gomez Rub (Hospital Virgen de la Arrixaca, El Palmar); R.
Fernandez Fernandez and M.M. Fernandez Fernandez
(Complejo Hospitalari de Parc Taul, Sabadell); J. Gener and R.
Tomas (Hospital Germans Trias i Pujol, Badalona); S. Macias and
F. Martnez Soba (Hospital General de Segovia); and F. Esteban
and I. Vallverdu (Hospital Universitari de Reus, Tarragona).
United States
J. Houtchens and T. Liesching (Rhode Island Hospital, Brown
University Medical School, Providence, RI); A. Pelaez and D.
Vines (University of Texas Health Science Center, San Antonio);
and N. Singh (New England Medical Center, Tufts University
School of Medicine, Boston).
Venezuela
M. Capdevielle (Hospital Universitario de Caracas); J.M. Espana (Hospital Universitario de Caracas); A. Medina (Hospital
Militar); F. Perez (Hospital de Clnicas de Caracas); and R.A.
Zerpa (Hospital Militar).

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