Factors Contributing to Failed Extubation

Primary Risk Factors for Extubation Failure

The British Thoracic Society recommends that impaired neurological function, ineffective airway protection mechanisms, upper airway obstruction, and cardiorespiratory reserve limitations must be systematically assessed beyond the spontaneous breathing trial alone 1, 2, 3
Encephalopathy or delirium is a risk factor for extubation failure, according to the British Thoracic Society 1, 4
Impaired bulbar function leading to aspiration of secretions, impaired gas exchange, or obstructed breathing is a risk factor for extubation failure 1, 2, 4
Ineffective cough, particularly in patients with neuromuscular disease or chest wall deformity, is a risk factor for extubation failure 1, 2, 4
Excessive tracheobronchial secretions or high sputum load is a risk factor for extubation failure 1, 2, 3, 4
Upper airway obstruction, especially from laryngeal edema, is a risk factor for extubation failure 1, 2, 4
Myocardial ischemia or left ventricular dysfunction is a risk factor for extubation failure 1, 2, 4
Cardiac failure is a risk factor for extubation failure 6, 7
Severe abdominal distension is a non-respiratory complication that can contribute to extubation failure 1, 4
Malnutrition is a non-respiratory complication that can contribute to extubation failure 6, 7
Residual neuromuscular blockade is a non-respiratory complication that can contribute to extubation failure 6, 7

A cuff leak test should be performed before extubation, particularly in patients with risk factors for laryngeal edema, according to the Anaesthesia society 8, 3, 9
Risk factors requiring cuff leak testing include female gender, traumatic or difficult intubation, and large endotracheal tube size 8, 3, 9, 7

The Anaesthesia society recommends that the acceptable extubation failure rate should be 5-10% 3, 9
Delayed reintubation worsens outcomes, and rapid recognition and re-establishment of ventilatory support is essential 1, 2, 4
Prophylactic noninvasive ventilation should be considered for high-risk patients immediately after extubation to reduce extubation failure rates 9, 5