Journal of Critical Care 48 (2018) 56–62

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Journal of Critical Care

journal homepage: www.journals.elsevier.com/journal-of-critical-care

Predictive factors of weaning from mechanical ventilation and

extubation outcome: A systematic review
Antuani Rafael Baptistella a,b,c,⁎, Fabio Junior Sarmento a, Karina Ribeiro da Silva a, Shaline Ferla Baptistella a,b,c,
Marcelo Taglietti d, Radamés Ádamo Zuquello e, João Rogério Nunes Filho a,c
a
Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil
b
Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil
c
Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
d
Centro Universitário FAG, Cascavel, PR, Brazil
e
Jackson Memorial Hospital, Miami, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Purpose: To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation
Mechanical ventilation and extubation outcomes.
Weaning Methods: Systematic review of scientific articles using four electronic databases: PubMed, Embase, PEDro and
Extubation Cochrane Library. Search terms included “weaning”, “extubation”, “withdrawal” and “discontinuation”, com-
Predictive parameters, outcome bined with “mechanical ventilation” and “predictive factors”, “predictive parameters” and “predictors for suc-
cess”. In this study, we included original articles that presented predictive factors for weaning or extubation
outcomes in adult patients and not restricted to a single disease. Articles not written in English were excluded.
Results: A total of 43 articles were included, with a total of 7929 patients and 56 different parameters related to
weaning and extubation outcomes. Rapid Shallow Breathing Index (RSBI) was the most common predictor,
discussed in 15 studies (2159 patients), followed by Age and Maximum Inspiratory Pressure in seven studies.
The other 53 parameters were found in less than six studies.
Conclusion: There are several parameters used to predict weaning and extubation outcomes. RSBI was the most
frequently studied and seems to be an important measurement tool in deciding whether to wean/extubate a pa-
tient. Furthermore, the results demonstrated that weaning and extubation should be guided by several parame-
ters, and not only to respiratory ones.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction less, e) patient's ability to initiate an inspiratory effort, f) a non-positive

Although invasive mechanical ventilation (IMV) is a cornerstone in
critical care medicine, shortening the duration of this support reduces
the risk of ventilator-associated complications, morbidity, mortality
and hospitalization costs [1-4]. As soon as the inciting factor causing
the respiratory failure starts to improve, weaning from mechanical ven-
tilation may be initiated. Weaning is the gradual process of transition
from full ventilatory support to spontaneous breathing, including, in
most patients, the removal of the endotracheal tube [5].
The identification of patients' readiness for IMV discontinuation is
evaluated daily and includes numerous parameters: a) improvement
in the condition that caused the respiratory failure, b) a partial pressure
of arterial oxygen higher than 60 mmHg, c) fraction of inspired oxygen
lower than 0.4, d) positive end-expiratory pressure of 5 cm of water or
⁎ Corresponding author at: Travessa Domingos Bonato, 37 – CEP, 89600-000 Joaçaba,
Santa Catarina/SC, Brazil.
E-mail address: antuani.baptistella@unoesc.edu.br (A.R. Baptistella).
fluid balance, and g) a normal acid-base equilibrium [6-8].
Subsequently, patients undergo a spontaneous-breathing trial (SBT)
for 30 min. During the SBT, patients who do not experience tachypnea
(N35 breaths per minute), tachycardia (N140 beats per minute),
desaturation (oxygen saturation of b90%), hypertension (systolic
blood pressure N 180 mmHg) or hypotension (b90 mmHg), diaphore-
sis, altered mental status or anxiety are candidates for extubation. Addi-
tionally, it is necessary to evaluate the patients' ability to protect their
airway, the amount of airway secretions, the strength of the cough,
and their level of consciousness [5,9-11].
Even with this algorithm being used worldwide, N10% of extubations
fail, and IMV has to be reinitiated [12]. The Brazilian Recommendation
of Mechanical Ventilation [13] defines “weaning success” when a
patient successfully passes an SBT and “extubation success” when a pa-
tient is extubated after the SBT and is not reintubated during the next
48 h. Patients who fail extubation are seven times more likely to die
and 31 times more likely to spend 14 days or more in the intensive
care unit (ICU) compared to patients in whom discontinuation of IMV

https://doi.org/10.1016/j.jcrc.2018.08.023
0883-9441/© 2018 Elsevier Inc. All rights reserved.
 A.R. Baptistella et al. / Journal of Critical Care 48 (2018) 56–62
is successful [14]. Several scores have been proposed that try to identify
patients who will be successful in weaning and extubating from IMV.
However, disparities amongst studies are evident. Therefore, the objec-
tive of this systematic review is to identify the most reliable parameters
for predicting weaning and extubation success, which is essential to re-
duce the risk of death in these patients.
2. Methods
This review was performed following the Cochrane Handbook for
Systematic Reviews of Interventions (Version 5.1.0) [15], also registered
and published at the International prospective register of systematic re-
views (PROSPERO - n° CRD42018092338).
2.1. Data sources and searching strategy
Initially, three authors (ARB, FJS and KRS) performed the search in
electronic databases (PubMed [1950-2018], EMBASE [1980-2018],
PEDro [2000-2018] and Cochrane Library[1999-2018]) to identify po-
tentially relevant articles, using a pre-planned systematic comprehen-
sive and reproducible search strategy with the terms “weaning”,
“extubation”, “withdrawal” and “discontinuation”, combined with “me-
chanical ventilation” and “predictive factors”, “predictive parameters”
and “predictors for success”. The searching period was from May to Sep-
tember 2017.
2.2. Study selection
Two authors (ARB and FJS) screened title, abstract and full-text arti-
cles in a standardized manner to assess the eligibility of the articles. Dis-
agreement was defined by consensus with a third author (JRNF) when
needed. Original articles published in English were included. These arti-
cles presented predictive factors for weaning or extubation outcomes
amongst adult patients and were not restricted to a single disease.
2.3. Data extraction
Data extraction was performed by an author (FJS) and cross-checked
by a second author (ARB). Data items included author details, year pub-
lished, aims, study design, methods, participants' characteristics, the
predictive parameters, and results. A meta-analysis was not possible be-
cause of the heterogeneity in methods, design, and measurements of
the studies. The studies were grouped by the predictive parameter pre-
sented. Discrepancies were discussed between authors (FJS and ARB),
and a consensus was achieved on all occasions. A third author (JRNF)
cross-checked the data to ensure the relevant parameter was accurately
captured and integrated into the appropriate group.
In the Supplementary Table 1 we present a list of all articles included
in this review, showing the predictive parameters found, the study de-
sign, the number of patients included, outcome, success rate, statistical
analyses and p value, and the definition of weaning and extubation suc-
cess used in the article.
3. Results
The initial search in four electronic databases identified 132 studies.
Nineteen were found to be duplicates and were excluded. From the 113
studies remaining, 44 were excluded after an abstract conference, nine
of which were not published in English. From the 60 remaining articles,
five were excluded because were restricted to a single patient popula-
tion and twelve were excluded because were restricted to a single dis-
ease, resulting in the final inclusion of 43 studies into our analysis
(Fig. 1) [16]. Most of the studies were performed with a prospective co-
hort of patients (n = 37). Four articles used a retrospective cohort and
two studies were clinical trials. A total of 7929 patients were included
57
in these 43 articles with a mean weaning success rate of 63.9% and
mean extubation success rate of 73.4%.
Table 1 presents the parameters reported as predictors of weaning
and extubation success listed according to the number of articles
reporting each parameter. The most cited parameter was the Rapid
Shallow Breathing Index (RSBI), defined as the ratio of respiratory rate
to tidal volume (f/VT), which showed to be a predictor for weaning or
extubation in 15 studies, involving 2159 patients [17-31]. Age
[18,20,23,24,32-34] and Maximum Inspiratory Pressure (MIP)
[18,23,27,30,34-36] were reported as predictors of weaning or
extubation success in 7 articles each. Respiratory rate (RR) was found
in 6 articles [20,24,26,31,34,37]. The Acute Physiology and Chronic
Health Evaluation II (APACHE II) score [35,38-40] and days on mechan-
ical ventilation [22,23,34,35] were reported in 4 articles each. Cough
strength [28,38,41,42] and tidal volume [24,27,31,43] were reported in
4 article each but only as predictors of extubation success. Hemoglobin
level [41,44,45], partial pressure of arterial CO2 (PaCO2) [19,44,45], and
the ratio of partial pressure of arterial oxygen to fractional inspired ox-
ygen (PaO2/FiO2) [20,24,35] were reported as predictors of weaning or
extubation success in 3 articles each. Diaphragmatic thickness
[39,46,47] was reported as a predictor only for extubation success.
Fig. 2 presents the 12 most discussed parameters used to predict
weaning and/or extubation outcomes.
Some parameters were discussed in two articles: level of conscious-
ness [23,35], natriuretic peptide (BNP) [48,49], partial pressure of arte-
rial oxygen (PaO2) [19,24], and heart failure [20,23]. Specific predictors
for weaning success include the CORE index [19,50] (calculated as [Cdyn
x (PImax/P0.1) x (PaO2/PAO2)]/f), arterial pH [19,20], blood urea nitro-
gen (BUN) level [32,35], the Integrative Weaning Index (IWI) [51,52],
and the Oxygen Cost of Breathing (OCOB) [37,53]. Specific predictors
of extubation success include the Occlusion Pressure (PO.1) [18,34],
fluid balance [22,44], chronic obstructive pulmonary disease (COPD)
[22,23], and lung compliance [23,31].
Parameters cited in only one article as specific predictors of weaning
success include: Tension Time Index (TTI) [17], gastric intramural pH
[54], female gender [32], the alveolar-arterial gradient of oxygen [P
(A-a)] [32], Burns Wean Assessment Program (BWAP) [33], creatinine
[35], albumin [35], Power of the Respiratory Flow Signal (Pi) [55], ener-
gy expenditure (EE) [37], Creatinine Height Index [45] and total protein
[45].
Parameters cited in only one article as specific predictors of
extubation success include: Vital Capacity [18], Venous oxygen satura-
tion (SvO2) [56], PO.1/MIP [18], neuroventilatory efficiency [57], the
type and amount of endotracheal secretion [41], HCO3 [44], absence of
need of vasopressor support and hemodialysis [58], the Charlson Co-
Morbidity Index [39], the modified Burns Wean Assessment Program
(m-BWAP) [23], the absence of interstitial lung diseases [23], endotra-
cheal tube size [24], SatO2 [24], CROP Index [24] (which integrates com-
pliance, respiratory rate, oxygenation, and maximum inspiratory
pressure ([CD x (PaO2/PAO2) x PImax]/F)), heart rate [24], the mea-
surement of the liver and spleen displacement [27], the length of stay
in the Intensive Care Unit (ICU days) [28], Weaning Index, calculated
as RSBI x Elastance Index x VDI (Elastance Index = peak pressure/neg-
ative inspiratory force; and VDI = minute ventilation/10) [59], and in-
spiratory time and expiratory time [31].
4. Discussion
In this review, we included 43 articles which reported 56 parameters
or scores assessing ideal conditions to wean and extubate patients. We
found different definitions for weaning and extubation success in the ar-
ticles evaluated. Furthermore, the pathogenesis of weaning failure may
differ significantly from that of extubation failure [41]. Thus, parameters
were separated between those that predict weaning success from those
that predict extubation success.
58 A.R. Baptistella et al. / Journal of Critical Care 48 (2018) 56–62
Fig. 1. PRISMA flow diagram of study selection process ((Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009).
RSBI is the most extensively studied index and seems to be the most
important single parameter to predict weaning and extubation success
[60]. Even when measured independently, the respiratory frequency
[20,24,26,31,34,37] and the tidal volume [24,27,31,43] were reported
to be different in patients who have weaning success from those who
do not. It has been reported that an RSBI b105 breathes per minute
per liter (breaths min-1L-1) is a good predictor for weaning [6]. Howev-
er, other studies have shown that patients who are successfully
extubated have an RSBI around 50 breaths min-1 l-1, while those who
failed in the extubation process have the RSBI around 80 breaths min-
1 l-1 [22,24], which points a discrepancy in the ideal RSBI score to pre-
dict weaning or extubation success.
Most of the studies measured RSBI during the SBT but do not specify
the most appropriate moment to extubate. A study with 100 patients
showed that the RSBI measured at the beginning of the SBT did not cor-
relate with the outcome, but the RSBI measured at 30 to 60 min of SBT
predicted the weaning outcome more effectively (92.2 ± 24.7 and
132.0 ± 57.4 for weaning success and weaning failure group respective-
ly; p b 0.05) [21]. A similar result was observed by Kuo et al. (2006),
where there were no differences in RSBI between success and failure
group at 1 min SBT, but RSBI at 120 min was significantly higher in pa-
tients with extubation failure (95.9 ± 20.6) and trial failure (98.0 ±
50.0) than in patients with weaning success (64.6 ± 26.3) [25]. In an-
other study, RSBI was measured every 30 min during 2 h of SBT. Initial
RSBI was similar in extubation success and extubation failure groups
(77.0 ± 4.8 and 77.0 ± 4.8). Nevertheless, RSBI remained unchanged
or decreased in the extubation success group, while it increased in the
extubation failure group [26].
On the other hand, a study with 500 patients demonstrated that
both, RSBI at the first minute of an SBT (success group: 59 ± 32;
and failure group: 72 ± 36; p = .002) and after 30 min of an SBT
(success group: 63 ± 36; and failure group: 82 ± 47; p = 0
0.000004) can predict the extubation outcome [24]. Another study
showed that the RSBI at the first minute of SBT in the success
group was statistically lower (60 [30–161]) than in the failure
group (116 [68–277], p = 0.005) [31], corroborating the hypothesis
that the RSBI value at the beginning of the SBT can be useful to pre-
dict extubation outcome. Even with many articles showing the im-
portance of RSBI as a predictor for weaning and extubation
outcome, this parameter alone does not have the power to predict
them in all cases.
Weaning parameters conventionally used may not be applicable in
deciding when to discontinue the MV in elderly patients [61]. Some
studies presented an important difference between the age of those pa-
tients successfully weaned (SW) and those that failed (FW) (SW =
48.4 ± 20.2 x FW = 69.8 ± 7.7 [18]; SW = 43.2 x FW = 59.6 [20];
SW = 43 ± 13 x FW = 73 ± 13 [34]; SW = 56 ± 19 x FW = 62 ± 19
[24]), which is justified by physiological changes caused by aging. An-
other study showed a small but statistically significant difference be-
tween these groups of patients (SW = 68.2 ± 0.9 x FW = 71.4 ± 0.9),
despite the small biological difference between ages 68 and 71 years
[32]. A study, with age split into quartiles (≤42, 43–54, 55–62, and
63+ years), demonstrated that the percentages of successful attempts
decrease with increasing age (91%, 91%, 87%, and 84%, respectively)
[33]. Considering these results, several authors have recommended
that age N65 [23,24] or 70 [32] years is a negative predictor of weaning
and extubation success. It has also been reported that in patients with
an age of 80 years or older, if the age is added to days of mechanical ven-
tilation, a sum of 100 or more predicted a poor outcome [62]. Moreover,
different studies [23,34,35] have demonstrated that the longer the
 A.R. Baptistella et al. / Journal of Critical Care 48 (2018) 56–62 59

Table 1
Predictors of weaning or extubation success.

Parameter Number Predictor of weaning success Predictor of extubation success

of studies

RSBI 15 Vassilakopoulos et al., 1998;Mabrouk et al., Capdevila et al., 1995; Chatila et al., 1996; Upadya et al., 2005; Jiang
2015; Papanikolaou et al., 2011; Kuo et al., et al.,2014; Savi et al., 2012; Segal et al., 2009; Jiang et al., 2004; Smina et al.,
2006; Bien et al., 2015 2003; Cohen et al., 2002; Wysocki et al., 2006
Age 7 Scheinhorn et al., 1994; Papanikolaou et al., Capdevila et al., 1995; Montgomery et al. 1987; Jiang et al., 2014; Savi et al.,
2011; Burns et al., 2010 2012
pressure (MIP)
Maximum inspiratory 7 Wu et al., 2009; Bien et al., 2015 Capdevila et al., 1995; Montgomery et al., 1987; Jiang et al., 2014; Jiang et al.,
2004; Bruton et al., 2002
Respiratory rate (RR) 6 Papanikolaou et al., 2011; Miwa et al., 2004 Montgomery et al., 1987; Savi et al., 2012; Segal et al. 2009; Wysocki et al.,
2006
Cough strength 4 Khamiees et al., 2001; Beuret et al., 2009; Su el at, 2010; Smina et al., 2003
APACHE II 4 Wu et al., 2009; Islam, 2013 Su el at, 2010; Farghaly and Hasan, 2016
Days on mechanical ventilation 4 Wu et al., 2009 Montgomery et al. 1987; Upadya et al., 2005; Jiang et al., 2014
Tidal volume 4 Savi et al., 2012; Jiang et al., 2004; Martinez et al. 2003; Wysocki et al., 2006
Hemoglobin 3 Datta et al., 2016 Khamiees et al., 2001; Boniatti et al., 2013
PaCO2 3 Mabrouk et al., 2017; Farghaly et al., 2015 Boniatti et al., 2013
PaO2/FiO2 3 Papanikolaou et al., 2011; Wu et al., 2009 Savi et al., 2012
Diaphragmatic thickness 3 Blumhof et al., 2016; Farghaly and Hasan, 2016; Dinino et al., 2014
Consciousness 2 Wu et al., 2009 Jiang et al., 2014
Natriuretic peptide (BNP)s 2 Farghaly et al., 2015 Chien et al., 2008
Occlusion pressure (PO.1) 2 Capdevila et al., 1995; Montgomery et al., 1987
CORE 2 Mabrouk et al., 2015; Delisle et al., 2011
PaO2 2 Mabrouk et al., 2015 Savi et al., 2012
Arterial pH 2 Mabrouk et al., 2016; Papanikolaou et al., 2011
Blood urea nitrogen (BUN) 2 Scheinhorn et al., 1994; Wu et al., 2009
Integrative weaning index (IWI) 2 Nemer et al., 2009; El-Baradey et al., 2015
Heart failure 2 Papanikolaou et al., 2011 Jiang et al., 2014
Fluid balance 2 Boniatti et al., 2013; Upadya et al., 2005
COPD 2 Upadya et al., 2005; Jiang et al., 2014
Lung compliance 2 Jiang et al., 2014; Wysocki et al., 2006
Oxygen cost of breathing (OCOB) 2 Miwa et al., 2004; Shikora et al., 1994
Vital capacity 1 Capdevila et al., 1995
Tension time index (TTI) 1 Vassilakopoulos et al., 1998
Gastric intramural pH 1 Mohsenifar et al., 1993
Venous oxygen saturation (SvO2) 1 Jubran et al., 1998
Gender 1 Scheinhorn et al., 1994
PO.1/MIP 1 Capdevila et al., 1995
Neuroventilatory efficiency 1 Liu et al., 2012
P (A-a) 1 Scheinhorn et al., 1994
Endotracheal secretion 1 Khamiees et al., 2001
Burns wean assessment program 1 Burns et al., 2010
(BWAP)
HCO3 1 Boniatti et al., 2013
Creatinine 1 Wu et al., 2009
Albumin 1 Wu et al., 2009
Vasopressor support 1 Muzaffar et al., 2017
Hemodialysis 1 Muzaffar et al., 2017
Charlson co-morbidity index 1 Farghaly and Hasan, 2016
Power of the respiratory flow 1 Chaparro et al., 2014
signal (Pi)
m-BWAP 1 Jiang et al., 2014
Interstitial lung diseases 1 Jiang et al., 2014
Endotracheal tube size 1 Savi et al., 2012
SatO2 (%) 1 Savi et al., 2012
CROP 1 Savi et al., 2012
Heart rate 1 Savi et al., 2012
Liver and spleen displacement 1 Jiang et al., 2004
Energy expenditure (EE) 1 Miwa et al., 2004
ICU days 1 Smina et al., 2003
Creatinine height index 1 Datta et al., 2016
Total protein 1 Datta et al., 2016
WI (RSBI x EI x VDI) 1 Huaringa et al., 2013
Inspiratory time 1 Wysocki et al., 2006
Expiratory time 1 Wysocki et al., 2006

duration (in days) of IMV, the lower the chance of success in weaning
and extubating.
It is known that mechanical ventilation causes rapid diaphragmatic
wasting, weakening the very muscle strength required to generate an ad-
equate tidal volume to supply the physiological needs of the body [63,64].
The maximum inspiratory pressure (MIP) is a good parameter to deter-
mine respiratory muscular capacity, a predictive factor for weaning suc-
cess [30]. A previous study reported that a successful weaning outcome
was likely if MIP values were b −30 cm H2O and a weaning failure was
likely if MIP values were N −20 cm H2O [65]. However, some authors
point out the wide range of normal values that have been reported,
which can be closely related to the voluntary effort. This score is therefore
difficult to use in uncooperative patients. Furthermore, the MIP is more
reflective of diaphragmatic contractile strength in deep rather than
quiet respiration [27], resulting in an unsatisfactory ability to predict out-
come since it generally has a high sensitivity but low specificity [36].
60 A.R. Baptistella et al. / Journal of Critical Care 48 (2018) 56–62
Fig. 2. Predictors of weaning and extubation success ordered by the number of articles.
In Trying to improve the capacity of MIP to predict weaning out-
comes, a study demonstrated that the ratio of occlusion pressure
(P0.1)/MIP was a better predictor of extubation success compared to
standard weaning indices [18]. Yet, another study showed that
sustained maximal inspiratory pressures (SMIP) has higher sensitivity
and specificity than the MIP to predict weaning success [36]. As the di-
aphragm is the major contributor to unassisted breathing, assessment of
diaphragmatic function should theoretically predict extubation out-
comes [46]. Different articles have demonstrated that ultrasound (US)
evaluation of the diaphragm can be a marker for diaphragmatic function
and directly affect weaning and extubation outcomes [39,46,47]. The
percent change in diaphragm thickness (TDI) ≥ 30%, between end-
expiration and end-inspiration (Δtdi%), evaluated in the zone of apposi-
tion, has a sensitivity and specificity for extubation success of 88% and
71%, respectively [47]. Another study showed that Δtdi% N 20 is a robust
predictor of extubation success within 48 h of US [46]. A more recent
work presented that a Δtdi% N 34.2 is a cutoff value associated with suc-
cessful extubation [39].
Another parameter of respiratory mechanics presented as a predic-
tor of extubation outcome is the lung compliance [23,31], which reflects
the required pressure to produce the appropriate volume for the phys-
iological needs.
Airway parameters, such as cough strength and endotracheal secre-
tions can reflect the patient's ability to generate an effective cough to ex-
pectorate endotracheal secretions and maintain a patent airway, which
is related to weaning and extubation success [28,41]. Different methods
were used to show the relationship of cough strength with weaning/
extubation outcomes. A study with 150 patients measured the involun-
tary cough peak flow (CPFi) induced by 2 mL of normal saline solution
at the end of inspiration and found that cough reflex has the potential
to predict successful extubation in patients who pass an SBT [38].
These results showed a moderate correlation with a cough strength
scale (0 = no cough response, 1 = audible movement of air through
the endotracheal tube but no audible cough, 2 = strong cough with
phlegm under the end of endotracheal tube, 3 = strong cough with
phlegm coming out of the end of endotracheal tube) which, together
with the amount of endotracheal secretions, demonstrated to be impor-
tant predictors of extubation outcomes [41]. However, there is no scale
that considers the type and amount of secretion and categorizes it in a
reproducible score. Two other studies [28,42] demonstrated that the
trough in the peak cough expiratory flow can be a useful parameter to
predict the weaning and extubation outcome.
In addition to cough ability and the amount of endotracheal secre-
tion, consciousness is another parameter relating to a patient's capacity
to protect the airway, thus ensuring safe extubation. Level of conscious-
ness is evaluated using the Glasgow Coma Scale (GCS) [23] and the
modified-GCS [35]. Despite these results, is important to mention that
the GCS cannot be completely assessed in intubated patients, and the
modified-GCS considers the verbal score to be equal 1 for all such pa-
tients. An important tool to evaluate consciousness in a more reliable
way is to use the estimated-GCS, where the verbal score is calculated
based on motor and eye responses.
Beyond respiratory status, researchers have shown that weaning can
be influenced by general conditions such as the degree of physiologic
derangement, nutrition, and consciousness [35,40]. The APACHE II scor-
ing system was originally designed for use in the ICU to assess the sever-
ity of disease/relative morbidity and provide a guide for treatment
intervention. However, in the last decade, it has been shown to be a
good predictor of weaning outcome, since different studies [35,38-40]
demonstrated that the APACHE II scores were statistically higher in
the weaning/extubation failure group compared to the success groups.
However, this score may not always reflect the current state of a patient,
as the score is applied within 24 h of patient's admission to the ICU, and
weaning can start several days later, resulting in an inaccurate score.
The Sequential Organ Failure Assessment (SOFA) is an important score
developed to quantify the severity of a patient's illness based on the de-
gree of organ dysfunction calculated from data on six organ failures [66].
Different from APACHE II, the SOFA score is normally used continuously
during patients' ICU stay, which accounts for the severity of a patient's
illness at the moment of weaning or extubation, suggesting that SOFA
can be studied as a more reliable predictor of weaning outcome [67].
Nutrition is another factor that can affect weaning capacity, as
malnutrition can result in increased fatigue, decreased inspiratory and
expiratory muscle strength, decreased endurance, depletion of dia-
phragmatic muscle mass, and impairment in respiratory function [68].
In this review, this relation between nutrition and weaning has been
demonstrated through undirected measurements, as total protein
[45], creatinine height index [45] and albumin [35] correlated with the
weaning outcome. Moreover, anemia, measured through the hemoglo-
bin level, demonstrated to be a predictor of weaning [44,45], with he-
moglobin levels b10 g/dL more than five times as likely to have
unsuccessful extubations as those with hemoglobin levels N10 g/dL
[41]. The mechanism by which a low concentration of hemoglobin in-
creased the risk of extubation failure is not clear, but anemia can exac-
erbate the insufficient global oxygen delivery and myocardial
ischemia, both observed in patients who fail weaning [56,69].
The arterial blood gas test (ABG) is widely used to monitor patients'
arterial pH, gases, and bicarbonate concentration, and is essential in
evaluating ventilator settings. In addition, it has been demonstrated
that PaCO2 [19,44,48], PaO2 [19,24], the ratio of PaO2/FiO2 [20,24,35],
the pH [19,20], HCO3 [44] and oxygen saturation [24] can be helpful
to predict the weaning/extubation outcome.
One possible side effect of IMV is hypotension, caused by a reduction
in venous return and commonly treated with fluid administration. Fluid
balance, often a treatment for many critical illnesses, has an impact on
extubation success. A study showed that positive fluid balance in the
24 h prior to extubation can predict the extubation failure [44]. Another
study demonstrated that positive fluid balance not only from the last 24
h but also from the last 48 h, 72 h and even in accumulation since hos-
pital admission is a significantly greater predictor of weaning failures
[22].
It is important to consider renal function as well, since authors have
demonstrated that parameters linked to renal function, such as BUN
[32,35], creatinine [35] and the patients' need for hemodialysis [58],
can also predict the weaning and extubation outcome.
Trying to improve the predictive capacity of many single parameters,
some researchers have proposed scores that consider several parame-
ters systematically joined. Initially, Monganroth [70] created a score
composed of two tables: the first table evaluated ventilator parameters
totaling 27 points, while the second table evaluated adverse factors to-
taling 48 points. In 1996, Gluck proposed the Gluck and Corgian Scoring
System [71], composed of 5 respiratory parameters, scored from 0 to 2,
with a lower score more indicative of weaning success. Yang and Tobin
 A.R. Baptistella et al. / Journal of Critical Care 48 (2018) 56–62
[60] described the respiratory compliance, respiratory rate, oxygena-
tion, and pressure (CROP) index that is calculated by the formula
[Cdyn x PImax x (PaO2/PAO2)]/f. More recently, data supports that
this index is higher amongst successfully extubated patients compared
to those who failed [24]. Delisle [50] found that P0.1 has a high enough
sensitivity and specificity to better guide IMV weaning, and developed
the CORE index, calculated as [Cdyn x (PImax/PO.1) × (PaO2/PAO2)]/f.
Delisle demonstrated that the CORE index is a more accurate predictor
of weaning outcome than the CROP index. In 2009, Nemer [51] present-
ed the integrative weaning index (IWI) which evaluates, in a single
equation, respiratory mechanics, oxygenation, and respiratory pattern
through the formula Cst,rs x SaO2/(f/Vt). Results showed that IWI has
a high accuracy to predict weaning outcome [51,52]. Huaringa [59]
published a study comparing the Weaning Index (WI), which integrates
3 indexes (RSBI × EI × VDI), compared to RSBI alone. Results demon-
strated that WI has a sensitivity of 98%, specificity of 89%, and is more
accurate than RSBI. In 2010, Burns [33] proposed the Burns Wean
Assessment Program (BWAP), a 26-factor weaning assessment
worksheet and scoring instrument. Results showed that patients
with BWAP scores N50 were significantly more likely to be weaned
successfully than were patients with lower scores. Thereafter,
Jiang [23] published an article showing results of the modified Burns
Wean Assessment Program (m-BWAP), where factors including age,
cardiac function, consciousness level, lung compliance (LCs), airway
resistance (Raw) and minute ventilation (MV) were added in the
modified version. Results showed that the m-BWAP score was higher
in patients with successful weaning trials and extubation outcomes.
Using a cut-off value of 60, the sensitivity and specificity of the
m-BWAP to predict successful extubation were 81.4% and 82.1%,
respectively.
In future studies, a scale that considers the most important and stud-
ied parameters discussed here, scored with different weight according
to the scientific evidence, and including some important aspects of pa-
tient status which are not considered until this moment, can be elabo-
rated and tested to improve the predictive capacity of the scores
currently used.
This review has some limitations, as the different study designs, the
different statistical analyses, and the different protocols used by authors
to define “weaning success” and “extubation success”. Nevertheless,
this review can help clinicians maintain a global view of the parameters
used to select patients for extubation and develop guidelines for IMV
weaning and extubation in the future.
5. Conclusions
In this review, we found 56 parameters or scores that can predict
weaning or extubation outcomes. RSBI was the most studied and relied
upon parameter for weaning and extubation success. Furthermore, the
results demonstrated that parameters beyond respiratory ones can pre-
dict weaning and extubation outcome.
Data regarding the weaning process has improved significantly in
the last 3 decades. With it, there has been an evolution from single
parameters in the respiratory system to a more global perspective
which combines systemic parameters and overall patient status
to predict the success of weaning and extubation. Nevertheless, fur-
ther clinical studies utilizing these comprehensive and global param-
eters need further evaluation prior to being relied up in clinical
settings.
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jcrc.2018.08.023.
Conflict of interest
The authors declare that they have no conflict of interest.
61
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