Development and Validation of a Machine-Learning Model for Prediction of Extubation Failure in Intensive Care Units

Background: Extubation failure (EF) can lead to an increased chance of ventilator-associated pneumonia, longer hospital stays, and a higher mortality rate. This study aimed to develop and validate an accurate machine-learning model to predict EF in intensive care units (ICUs). Methods: Patients who underwent extubation in the Medical Information Mart for Intensive Care (MIMIC)-IV database were included. EF was defined as the need for ventilatory support (non-invasive ventilation or reintubation) or death within 48 h following extubation. A machine-learning model called Categorical Boosting (CatBoost) was developed based on 89 clinical and laboratory variables. SHapley Additive exPlanations (SHAP) values were calculated to evaluate feature importance and the recursive feature elimination (RFE) algorithm was used to select key features. Hyperparameter optimization was conducted using an automated machine-learning toolkit (Neural Network Intelligence). The final model was trained based on key features and compared with 10 other models. The model was then prospectively validated in patients enrolled in the Cardiac Surgical ICU of Zhongshan Hospital, Fudan University. In addition, a web-based tool was developed to help clinicians use our model. Results: Of 16,189 patients included in the MIMIC-IV cohort, 2,756 (17.0%) had EF. Nineteen key features were selected using the RFE algorithm, including age, body mass index, stroke, heart rate, respiratory rate, mean arterial pressure, peripheral oxygen saturation, temperature, pH, central venous pressure, tidal volume, positive end-expiratory pressure, mean airway pressure, pressure support ventilation (PSV) level, mechanical ventilation (MV) durations, spontaneous breathing trial success times, urine output, crystalloid amount, and antibiotic types. After hyperparameter optimization, our model had the greatest area under the receiver operating characteristic (AUROC: 0.835) in internal validation. Significant differences in mortality, reintubation rates, and NIV rates were shown between patients with a high predicted risk and those with a low predicted risk. In the prospective validation, the superiority of our model was also observed (AUROC: 0.803). According to the SHAP values, MV duration and PSV level were the most important features for prediction. Conclusions: In conclusion, this study developed and prospectively validated a CatBoost model, which better predicted EF in ICUs than other models.