Ventilator Settings and Monitoring Variables Associated with Extubation Failure in Critically Ill Patients: A Retrospective Cohort Study.

OBJECTIVE

Mechanical ventilation is an essential tool in the management of acute respiratory failure. Extubation is a critical event in the clinical course of patients, yet it may fail even in those who successfully complete a spontaneous breathing trial. This study aimed to evaluate which ventilator settings and monitoring variables are associated with extubation failure.

METHODS

This was a retrospective, multicenter cohort study, including patients from July 2021 to December 2022 across five intensive care units in Argentina. Adult patients (≥ 18 years old) who received at least 48 hours of mechanical ventilation and underwent an extubation were included. A multivariable logistic regression was performed with extubation failure - defined as reintubation or death within 7 days post-extubation- as the outcome variable. The analysis was adjusted for APACHE II score, type of spontaneous breathing trial, use of non-invasive ventilatory support after extubation, and COVID-19 as a reason for mechanical ventilation.

RESULTS

A total of 516 patients were analyzed, with an extubation failure rate of 35.8%. Oxygenation, measured by the oxygen saturation/fraction of inspired oxygen ratio prior to extubation was associated with a protective effect (OR 0.99, 95%CI 0.993 - 0.997) while higher positive end-expiratory pressure, fraction of inspired oxygen, and peak pressure showed a significant association with extubation failure (OR 1.26, 95%CI 1.09 - 1.45; OR 1.04, 95%CI 1.01 - 1.07; OR 1.04, 95%CI 1,003 - 1.07 respectively). Additionally, patients who failed had a higher incidence of delirium on the day of extubation and greater use of neuromuscular blocking agents during their intensive care unit stay.

CONCLUSION

In critically ill patients undergoing mechanical ventilation, ventilator settings, monitoring parameters, and oxygenation status at the time of extubation may influence the likelihood of success. Better oxygenation appears protective, whereas elevated positive end-expiratory pressure and fraction of inspired oxygen may indicate increased vulnerability to extubation failure.