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* From the Department of Pulmonary and Critical Care, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT.
Correspondence to: Constantine A. Manthous, MD, FCCP, Bridgeport Hospital, West Tower 6, 267 Grant St, Bridgeport, CT 06610; e-mail: pcmant{at}bpthosp.org
Background: After patients recovering from respiratory failure have successfully completed a spontaneous breathing trial (SBT), clinicians must determine whether an artificial airway is still required. We hypothesized that cough strength and the magnitude of endotracheal secretions affect extubation outcomes.
Methods: We conducted a prospective study of 91 adult patients treated in medical-cardiac ICUs who were recovering from respiratory failure, had successfully completed an SBT, and were about to be extubated. A number of demographic and physiologic parameters were recorded with the patient receiving full ventilatory support and during the SBT, just prior to extubation. Cough strength on command was measured with a semiobjective scale of 0 to 5, and the magnitude of endotracheal secretions was measured as none, mild, moderate, or abundant by a single observer. In addition, patients were asked to cough onto a white card held 1 to 2 cm from the endotracheal tube; if secretions were propelled onto the card, it was termed a positive white card test (WCT) result. All patients were then extubated from T-piece or continuous positive airway pressure breathing trials. If 72 h elapsed and patients did not require reintubation, they were defined as successfully extubated.
Results: Ninety-one
patients with a mean (± SE) age of 65.2 ± 1.6 years, ICU admission
APACHE (acute physiology and chronic health evaluation) II score of
17.7 ± 0.7, and duration of mechanical ventilation of 5.0 ± 0.5
days were studied over 100 extubations. Sixteen patients could not be
extubated, and 2 patients underwent two unsuccessful extubation
attempts, for a total of 18 unsuccessful extubations. Age, severity of
illness, duration of mechanical ventilation, oxygenation, rapid shallow
breathing index, and vital signs during SBTs did not differ between
patients with successful extubations vs patients with unsuccessful
extubations. The WCT result was highly correlated with cough strength.
Patients with weak (grade 0 to 2) coughs were four times as likely to
have unsuccessful extubations, compared to those with
moderate-to-strong (grade 3 to 5) coughs (risk ratio [RR], 4.0; 95%
confidence interval [CI],1.8 to 8.9). Patients with
moderate-to-abundant secretions were more than eight times as times as
likely to have unsuccessful extubations as those with no or mild
secretions (RR, 8.7; 95% CI, 2.1 to 35.7). Patients with negative WCT
results were three times as likely to have unsuccessful extubations as
those with positive WCT results (RR, 3.0; 95% CI, 1.3 to 6.7). Poor
cough strength and endotracheal secretions were synergistic in
predicting extubation failure (Rothman synergy index, 3.7; RR, 31.9;
95% CI, 4.5 to 225.3). Patients with
PaO2/fraction of inspired oxygen (P:F) ratios
of 120 to 200 (receiving mechanical ventilation) were not less likely
to be successfully extubated than those with P:F ratios of > 200, but
those with hemoglobin levels 
10 g/dL were more than five times as
likely to have unsuccessful extubations as those with hemoglobin levels
> 10 g/dL.
Conclusions: After patients recovering from respiratory failure have successfully completed an SBT, factors affecting airway competence, such as cough strength and amount of endotracheal secretions, may be important predictors of extubation outcomes. Also, a majority (89%) of medically ill patients with P:F ratios of 120 to 200 (four of five patients with P:F ratios from 120 to 150), values sometimes used to preclude weaning, were extubated successfully.
Key Words: critical care • critical illness • extubation • mechanical ventilation • weaning
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