Failed Extubation After Lung Transplantation in the United States: A Six-Year National Analysis Using the UNOS...

Early and sustained liberation from mechanical ventilation (MV) is a key marker of postoperative recovery after lung transplantation (LT). We hypothesized that failed extubation reflects higher-risk recipient, donor, and procedural factors and predicts worse outcomes.

We analyzed adult LT recipients in the United Network for Organ Sharing (UNOS) database from 2017 to 2022. Failed extubation was defined as the inability to liberate from MV within 72 h and/or the need for reintubation during the index hospitalization.

Among 14 254 recipients, 37.7% experienced failed extubation. Failure to liberate from MV within 72 h occurred in 30.3%, and 19.4% required reintubation; 11.9% met both criteria. Independent predictors included higher BMI, female sex, frailty, elevated LAS, impaired renal reserve, redo-transplantation, ECMO bridging, older and ECD/DCD donors, ex vivo lung perfusion, bilateral LT, and longer ischemic time. Failed extubation was associated with increased postoperative morbidity, including dialysis need (20.3% vs. 1.3%), stroke (5.3% vs. 1.1%), and longer hospitalization (33 vs. 15 days) (all p < 0.001). Failed extubation independently predicted worse posttransplant survival (adjusted HR 1.79; p < 0.001).

Failed extubation affects over one-third of contemporary LT recipients and is strongly associated with morbidity and mortality, highlighting the need for risk-stratified perioperative management and optimized donor-recipient matching.