Admission NT-proBNP as a Prognostic Biomarker for Ventilator Weaning Failure: Implications for Tracheostomy Timing

Background/Objectives: Ventilator weaning imposes profound hemodynamic stress, unmasking cardiopulmonary vulnerability. Since conventional predictors of post-tracheostomy weaning failure remain elusive, biomarker-driven risk stratification offers a translational approach. We evaluated the prognostic utility of admission N-terminal pro-B-type natriuretic peptide (NT-proBNP) as an early triaging tool for weaning failure and explored its therapeutic implications alongside optimal tracheostomy timing. Methods: In this large-scale retrospective cohort study, we analyzed 707 critically ill patients who underwent tracheostomy in a medical intensive care unit. We investigated the association between baseline NT-proBNP levels—measured as a molecular surrogate of cardiovascular stress at ICU admission; echocardiographic parameters; and weaning outcomes. Multivariable logistic regression analysis was utilized to identify independent pathophysiological predictors associated with weaning failure. Results: Patients experiencing weaning failure exhibited significantly elevated admission NT-proBNP levels compared to those successfully weaned (3077.0 vs. 1410.0 pg/mL, p < 0.001). High admission NT-proBNP (>3271 pg/mL) was independently associated with an increased risk of weaning failure (adjusted odds ratio [aOR] 2.86, 95% confidence interval [CI] 1.81–4.53, p < 0.001). Conversely, an early clinical intervention—tracheostomy performed within 10 days of mechanical ventilation initiation—was associated with a significantly lower risk of weaning failure (aOR 0.55, 95% CI 0.35–0.87, p = 0.010). Furthermore, elevated biomarker levels strongly correlated with prolonged intensive care unit stays and higher 90-day mortality. Conclusions: Admission NT-proBNP serves as a powerful biomarker associated with cardiopulmonary vulnerability from the earliest stages of critical illness. Integrating this diagnostic biomarker with interventional strategies like optimal tracheostomy timing has significant prognostic implications. This biomarker-guided approach facilitates personalized risk stratification from ICU admission, potentially optimizing weaning pathways for mechanically ventilated patients.