Yes, PEEP of 5 cm H₂O is acceptable for extubation if the patient tolerates the weaning trial.
The 2017 ATS/ACCP guidelines explicitly recommend conducting spontaneous breathing trials (SBTs) with inspiratory pressure augmentation of 5-8 cm H₂O, and patients who pass these trials can proceed directly to extubation without requiring a trial at zero PEEP. 1
Evidence-Based Rationale
The guideline evidence demonstrates that:
SBTs conducted with pressure support of 5-8 cm H₂O (which includes PEEP) had higher success rates (84.6% vs 76.7%) and better extubation outcomes (75.4% vs 68.9%) compared to T-piece trials without pressure augmentation 2
There is no requirement to wean PEEP to zero before extubation. The guidelines suggest using pressure augmentation during the SBT itself, and if successful, patients can be extubated directly 1
The conditional recommendation (moderate certainty evidence) supports that most patients who pass an SBT with 5-8 cm H₂O pressure support are ready for extubation 2
Clinical Application Algorithm
If your patient meets these criteria, proceed with extubation:
- Clinically stable and meets readiness criteria for weaning
- Successful SBT at PEEP 5 cm H₂O with pressure support 5-8 cm H₂O for 30 minutes to 2 hours
- No signs of respiratory distress during the trial (tachypnea, accessory muscle use, hypoxemia, hemodynamic instability)
- Adequate cough and airway protection
You do NOT need to:
- Reduce PEEP to zero before extubation
- Perform a separate T-piece trial if the patient passed the SBT with pressure support
Important Caveats
When to Consider Additional Precautions:
- High-risk patients for extubation failure should receive prophylactic NIV after extubation (strong recommendation) 1
- Patients at risk for post-extubation stridor should undergo cuff leak testing, and if failed, receive systemic steroids at least 4 hours before extubation 1
Historical Context vs. Current Evidence:
Older practice (1981-1986) suggested weaning PEEP incrementally before extubation 3, 4, but this approach has been superseded by contemporary evidence showing that maintaining modest PEEP during SBTs actually improves outcomes. The 2017 guidelines represent the current standard of care and explicitly support extubation at PEEP 5 cm H₂O 1, 2.
Physiologic Support:
Research demonstrates that extubating from PEEP 5 cm H₂O maintains functional residual capacity and oxygenation better than reducing to zero PEEP before extubation 3. The endotracheal tube itself imposes work of breathing that is overcome by modest pressure support, making the SBT with 5-8 cm H₂O pressure support actually more physiologic 2.
Common Pitfall to Avoid
Do not delay extubation by unnecessarily weaning PEEP to zero. This outdated practice can actually worsen lung mechanics and oxygenation in the immediate pre-extubation period and is not supported by current guidelines 3. The evidence shows that patients who pass SBTs with pressure augmentation have similar or better extubation success rates compared to those weaned to zero support 2.