Risk factors and clinical consequences of early extubation failure in lung transplant recipients

Prolonged intubation following lung transplantation is thought to delay recovery, yet a paucity of data exists regarding risk factors and outcomes related to extubation failure.

We performed a single-center, retrospective analysis of 238 lung transplant recipients between January 1, 2018, and December 31, 2022, to identify risk factors for extubation failure (intubation greater than 3 days, reintubation, and/or need for tracheostomy). We also assessed short-term outcomes relative to extubation success.

In this cohort, 144 patients (60%) were extubated successfully while 94 patients experienced extubation failure; 10 (11%) were intubated greater than 3 days, 9 (9%) were reintubated, 34 (36%) required tracheostomy after reintubation, and 41 (44%) underwent empiric tracheostomy. Recipient height and female sex, lung allocation score, 6-minute walk distance, donor ischemic time, ex-vivo perfusion, donor smoking history, intraoperative transfused red blood cells (packed red blood cells (PRBCs)), primary graft dysfunction at time zero, and comatose sedation state at day 2 were associated with extubation failure on univariate analysis (all p < 0.01), whereas comatose state [(odds ratio) OR = 84.95 (95%confidence interval (CI) 17-423), p < 0.01], donor smoking [OR = 5.41 (95%CI 1.73-16.92), p < 0.01], primary graft dysfunction at T0 [OR = 2.02 (95%CI 1.22-3.34), p < 0.01], and PRBCs [OR = 1.19 (95%CI 1.06-1.34, p < 0.01] were independently associated with extubation failure on multivariate analysis. Reintubation and empiric tracheostomy were associated with similarly prolonged intensive care unit and hospital length of stay, while tracheostomy was also associated with protracted inpatient rehabilitation, increased functional impairment, and increased 6-month mortality.

Specific baseline donor and recipient demographics and intraoperative variables are associated with greater risk for post-transplant extubation failure. Patients with extubation failure have worse short-term outcomes.