What are the criteria for a patient to be considered ready for extubation?

Extubation Criteria for ICU Patients

A patient is ready for extubation when they successfully complete a spontaneous breathing trial (SBT) AND demonstrate adequate airway protection through effective cough, manageable secretions, patent upper airway, and sufficient neurologic function—not just respiratory parameters alone. 1

Mandatory Pre-Screening Requirements

Before attempting an SBT, patients must meet ALL of the following safety criteria 1, 2:

• Oxygenation: FiO₂ ≤0.5, PEEP ≤6 cm H₂O, SpO₂ >92% 1, 2
• Hemodynamic stability: No significant cardiovascular compromise, minimal or stable vasopressor support 1, 2
• Adequate respiratory drive: Spontaneous breathing effort present 1, 2
• Resolution of primary indication: The reason for intubation has improved or resolved 1

The Spontaneous Breathing Trial (Core Assessment)

Perform a 30-minute SBT with pressure support 5-8 cm H₂O plus CPAP for standard-risk patients, as this achieves higher success rates (84.6% vs 76.7% with T-piece) and better extubation outcomes (75.4% vs 68.9%) 3, 1, 4. For high-risk patients (prolonged ventilation >6 days, previous extubation failure, neuromuscular disease), use CPAP alone without pressure support for 60-120 minutes to better assess true readiness 3, 1, 4.

SBT Failure Criteria (Immediate Termination Required)

Stop the trial if ANY of the following occur 1, 4:

• Respiratory rate >30/min or <10/min 1
• SpO₂ <92% or oxygen desaturation 1, 4
• Respiratory distress (accessory muscle use, paradoxical breathing, diaphoresis) 4
• Hemodynamic instability (tachycardia, hypertension, hypotension) 4
• Altered mental status or agitation 1, 4

Critical pitfall: Do NOT perform repeat SBTs on the same day after failure—this causes respiratory muscle fatigue and worsens respiratory mechanics 4. Address the underlying cause and retry the next day 4.

Beyond the SBT: Four Additional Critical Assessments

Approximately 10% of patients who pass an SBT still fail extubation due to non-respiratory factors 3, 1. You MUST assess:

1. Airway Patency (Cuff Leak Test)

Perform a cuff leak test in ALL patients with risk factors for laryngeal edema 3, 1:

• Female gender 3
• Traumatic or difficult intubation 3
• Intubation >6 days 3
• Large endotracheal tube (>8mm men, >7mm women) 3
• Reintubation after unplanned extubation 3

Technique: Deflate the cuff and measure the difference between inspired and expired tidal volumes 3, 2. Absence of a leak around an appropriately sized tube generally precludes safe extubation 3, 2.

If leak volume is low or absent, administer corticosteroids (prednisolone 1 mg/kg/day or equivalent) at least 6 hours before extubation 3. This reduces reintubation risk from laryngeal edema, which causes 15% of early reintubations 3.

2. Cough Effectiveness

Assess cough strength using a 0-5 scale 5. Patients with weak coughs (grade 0-2) are four times more likely to fail extubation compared to those with moderate-to-strong coughs (grade 3-5) 5. The white card test (asking patients to cough onto a card held 1-2 cm from the endotracheal tube) provides objective assessment—negative results triple extubation failure risk 5.

3. Secretion Management

Patients with moderate-to-abundant secretions are more than eight times as likely to fail extubation as those with minimal secretions 5. The combination of poor cough AND excessive secretions is synergistic, increasing failure risk 32-fold 5. Perform thorough oral and tracheal suctioning under direct vision before extubation 3.

4. Neurologic Function and Airway Protection

Assess bulbar function and ability to protect the airway 1, 2. For stroke patients specifically, a Glasgow Coma Scale score ≥8T predicts successful extubation 6. Ensure neuromuscular blockade is fully reversed with train-of-four ratio ≥0.9 using a peripheral nerve stimulator 3.

Algorithmic Decision Framework

1. Daily screening → Does patient meet pre-screening criteria? 1
2. If YES → Perform appropriate SBT (30 min with PS 5-8 for standard-risk; 60-120 min CPAP alone for high-risk) 1, 4
3. If SBT successful → Assess cuff leak test (if risk factors present) 3, 1
4. If adequate leak OR steroids given → Assess cough effectiveness and secretion burden 1, 5
5. If adequate → Assess neurologic status and airway protection 1, 2
6. If ALL criteria met → Proceed with extubation 1

Post-Extubation Management

For high-risk patients (previous extubation failure, prolonged ventilation >14 days, chronic lung disease, heart failure), apply prophylactic noninvasive ventilation immediately after extubation 3, 1. This reduces reintubation rates in this population 3. For children <1 year at high risk, use CPAP over high-flow nasal cannula 3, 1.

Extubation failure is defined as reintubation within 48-72 hours and occurs in 10-20% of patients, with mortality rates of 25-50% 3, 7. The acceptable failure rate should be 5-10%—higher rates suggest inadequate assessment 3, 4.

Pediatric-Specific Modifications

For children, use the same protocolized ERT bundle approach 3, 1. Administer dexamethasone at least 6 hours before extubation in children at high risk of postextubation upper airway obstruction 3, 1. For children at higher risk of extubation failure, use CPAP without pressure support during SBTs 3, 1.