Providers Consistently Delay Extubation After Successful Spontaneous Breathing Trials: A Retrospective Cohort Study

Many patients who pass a spontaneous breathing trial (SBT) are not extubated, leaving them at risk for life-threatening ventilator-associated complications. Determining barriers to timely extubation may facilitate shorter overall durations of mechanical ventilation. To identify the patient-related and patient-independent barriers to timely extubation within 6 hours of passing an SBT. We analyzed electronic health record data from adult patients on mechanical ventilation admitted to a medical or cardiac intensive care unit at an academic, tertiary-care center between 1/1/2015 and 12/31/2023. We utilized a mixed-effects multivariate logistic regression model to evaluate the association between timely extubation within 6 hours of first passing an SBT and fifteen potential reasons to delay extubation, accounting for clustering at the attending physician level. Among 3,240 patients, 62.3% underwent timely extubation within 6 hours of first passing an SBT. Patients with delayed extubation experienced a median of 2.0 [IQR: 1.0-3.8] additional days on mechanical ventilation after passing an SBT, for a total of 3,930 days. This delay accounts for 32% of the total time on mechanical ventilation for the study population. Patients were less likely to have timely extubation if they underwent a procedure in the 24 hours after passing an SBT (average marginal effect [AME] -17.7%, 95% CI:-29.2 to -6.3), had lower levels of consciousness (AME -16.5%, 95% CI:-23.2 to -10.0), were on low (AME -12.9%, 95% CI:-19.2 to -4.8), or high dose vasopressors (AME -12.2%, 95% CI:-17.8 to -8.1), or had copious secretions (AME -8.7%, 95% CI:-13.3 to -4.1). However, 55% of patients with delayed extubation experienced none of these top five potential barriers. There was minimal physician variability in the decision to extubate after a successful SBT (median odds ratio: 1.10, 95% CI:1.02-1.78). The most frequent reason documented by respiratory therapists for not extubating a patient after passing an SBT was attending preference (43%). One in 3 patients remain on mechanical ventilation after passing their first SBT, with over half lacking an identifiable barrier to extubation. Future work should be pursued to address this, including consideration of unit-wide interventions to increase timely extubation attempts among patients without contraindications.