Effect of failed extubation on the outcome of mechanical ventilation

Objective: To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation. Design: Prospective cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital. The failed extubation group consisted of all patients reintubated within 72 h or within 7 days (if continuous ICU care had been required) of extubation. All others were considered to be successfully extubated. Study end points included hospital death vs survival, the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation, the likelihood of requiring greater than or equal to 7 or greater than or equal to 14 days of ICU care after extubation, and the need for transfer to either a long-term care or rehabilitation facility among the survivors. Results: Of 289 intubated patients, 247 (85%) were successfully extubated, and 42 (15%) required reintubation for failed extubation (time to reintubation 1.5+/-0.2 days). Reintubation for extubation failure resulted in 12 additional days of mechanical ventilation. When compared with successfully extubated patients, reintubated patients were more likely to die in the hospital (43% vs 12%; p<0.0001), spend more time in the ICU (21.2+/-2.8 days vs 4.5+/-0.6 days; p<0.001) and in the hospital (30.5+/-3.3 days vs 16.3+/-1.2 days; p<0.001) after extubation, and require transfer to a long-term care or rehabilitation facility (38% vs 21%; p<0.05). Using multiple logistic regression, extubation failure was an independent predictor for death and the need for transfer to a long-term care facility. Compared with those successfully extubated, patients who failed extubation were seven times (p<0.0001) more likely to die, 31 times (p<0.001) more likely to spend greater than or equal to 14 days in the ICU after extubation, and six times (p<0.001) more likely to need transfer to a long-term care or rehabilitation facility if they survived. Conclusion: After adjusting for severity of illness and comorbid conditions, extubation failure had a significant independent association with increased risk for death, prolonged ICU stay, and transfer to a long-term care or rehabilitation facility. Extubation failure may serve as an additional independent marker of severity of illness. Alternatively, poor outcomes may be etiologically related to extubation failure. If the latter proves to be the case, identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practices may reduce mortality, duration of ICU stay, and need for transfer to a long-term care facility.