Ventilator Settings and Monitoring Variables Associated with Extubation Failure in Critically Ill Patients: A Retrospective Cohort Study

Steinberg, Emilio; Garegnani, Luis Ignacio; Steinberg, Damián; Maniás, Emilia; Lovazzano, Pablo; Mazzini, Luca; Nieto, Jesica; Lavítola, Nahuel; Giménez, María Lucía; Setten, Mariano

doi:10.62675/2965-2774.20260327

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Original Article • Crit. Care Sci. 38 • 2026 • https://doi.org/10.62675/2965-2774.20260327 linkcopy

Ventilator Settings and Monitoring Variables Associated with Extubation Failure in Critically Ill Patients: A Retrospective Cohort Study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective Mechanical ventilation is an essential tool in the management of acute respiratory failure. Extubation is a critical event in the clinical course of patients, yet it may fail even in those who successfully complete a spontaneous breathing trial. This study aimed to evaluate which ventilator settings and monitoring variables are associated with extubation failure.

Methods This was a retrospective, multicenter cohort study, including patients from July 2021 to December 2022 across five intensive care units in Argentina. Adult patients (≥ 18 years old) who received at least 48 hours of mechanical ventilation and underwent an extubation were included. A multivariable logistic regression was performed with extubation failure - defined as reintubation or death within 7 days post-extubation– as the outcome variable. The analysis was adjusted for APACHE II score, type of spontaneous breathing trial, use of non-invasive ventilatory support after extubation, and COVID-19 as a reason for mechanical ventilation.

Results A total of 516 patients were analyzed, with an extubation failure rate of 35.8%. Oxygenation, measured by the oxygen saturation/fraction of inspired oxygen ratio prior to extubation was associated with a protective effect (OR 0.99, 95%CI 0.993 - 0.997) while higher positive end-expiratory pressure, fraction of inspired oxygen, and peak pressure showed a significant association with extubation failure (OR 1.26, 95%CI 1.09 - 1.45; OR 1.04, 95%CI 1.01 - 1.07; OR 1.04, 95%CI 1,003 - 1.07 respectively). Additionally, patients who failed had a higher incidence of delirium on the day of extubation and greater use of neuromuscular blocking agents during their intensive care unit stay.

Conclusion In critically ill patients undergoing mechanical ventilation, ventilator settings, monitoring parameters, and oxygenation status at the time of extubation may influence the likelihood of success. Better oxygenation appears protective, whereas elevated positive end-expiratory pressure and fraction of inspired oxygen may indicate increased vulnerability to extubation failure.

Keywords
Respiration, artificial; Weaning; Airway extubation; Respiratory insufficiency; Ventilators, mechanical

	Population (n = 516)	Extubation success (n = 331)	Extubation failure (n = 185)	p value
Age (years)	67.3 [52.4 - 77.1]	63.5 [47.9 - 75.6]	72.6 [60 - 79.48]	< 0.001
Sex, female	253 (49.03)	159 (48.03)	94(50.8)	0.540
Reason for initiation of MV
On chronic respiratory failure	21 (4.07)	15 (4.53)	6 (3.24)	0.690
De novo acute respiratory failure	406 (78.68)	258 (77.95)	148 (80)
Acute neurological disease	81 (15.7)	54 (16.31)	27 (14.59)
Neuromuscular disease	8 (1.55)	4 (1.21)	4 (2.16)
APACHE II	16 [11 - 22]	16 [10 - 22]	16 [12 - 23]	0.160
Charlson	4 [1 - 5]	3 [1 - 5]	4 [2 - 6]	< 0.05
BMI (kg/m₂)	26.5 [22.8 - 30.7]	26.15 [22.8 - 29.7]	27.07 [22.8 - 30.6]	0.390

Variable	OR	95%CI	p value	Adjusted OR	Adjusted 95%CI	Adjusted p value
Ventilatory mode	0.85	0.69 - 1.06	0.17	0.8	0.63 - 1	0.06
Inspiratory pressure	0.97	0.92 - 1.03	0.49	0.98	0.92 - 1.04	0.58
PEEP	1.18	1.04 - 1.35	0.01	1.25	1.08 - 1.44	< 0.05
Peak pressure	1.03	0.99 - 1.06	0.06	1.03	1.002 - 1.07	< 0.05
Set respiratory rate	1.07	0.96 - 1.18	0.17	1.03	0.93 - 1.16	0.51
Monitored respiratory rate	1.03	0.98 - 1.07	0.14	1.02	0.98 - 1.06	0.25
Exhaled V_T	0.99	0.99 - 1	0.4	0.99	0.99 - 1	0.4
ΔP_DYN	1.02	0.98 - 1.06	0.18	1.02	0.99 - 1.06	0.14
SpO₂	0.8	0.72 - 0.88	< 0.001	0.81	0.73 - 0.9	< 0.001
FiO₂	1.05	1.02 - 1.08	< 0.001	1.04	1.01 - 1.08	< 0.05
SpO₂/FiO₂	0.99	0.993 - 0.997	< 0.001	0.99	0.993 - 0.998	< 0.05

	Population (n = 516)	Extubation success (n = 331)	Extubation failure (n = 185)	p value
CAM-ICU the day of 1IS
Positive	219 (42.52)	124 (37.58)	95 (51.35)	0.007
Negative	270 (52.43)	190 (57.87)	80 (43.24)
Not valuable	26 (5.05)	16 (4.85)	10 (5.41)
Use of NMB	90 (17.51)	44 (13.37)	46 (24.86)	< 0.001
Days until 1IS	5 [3 - 8]	5 [3 - 8]	6 [3 - 9]	0.430
Days until extubation	6 [4 - 9]	5 [4 - 8]	7 [4 - 10]	< 0.05
ICU LOS	17 [10 - 29]	14 [10 - 22]	26 [15 - 42]	< 0.001
Mortality	102 (19.84)	21 (6.38)	81 (43.78)	< 0.001

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E-mail: ccs@amib.org.br

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[TFN1] MV- mechanical ventilation; APACHE II - Physiology and Chronic Health Evaluation II; BMI - body mass index. Results expressed as median [interquartile range] or n (%).