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

Rationale: 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. Objectives: We sought to identify the patient-related and patient-independent barriers to timely extubation within 6 hours of passing an SBT. Methods: We analyzed electronic health record data from adult patients on mechanical ventilation who had been admitted to a medical or cardiac intensive care unit at an academic, tertiary-care center between January 1, 2015, and December 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 15 potential reasons to delay extubation, accounting for clustering at the attending-physician level. Results: 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 (interquartile range = 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% confidence interval [CI] = -29.2 to -6.3); had lower levels of consciousness (AME, -16.5%; 95% CI = -23.2 to -10.0); were on low-dose vasopressors (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 to 1.78). The most frequent reason documented by respiratory therapists for not extubating a patient after passing an SBT was attending-physician preference (43%). Conclusions: 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 the consideration of unitwide interventions to increase timely extubation attempts among patients without contraindications.