Association of Extubation Timing and Treatment Failure After Successful Extubation Readiness Trial in Pediatric Patients

Background: Protocolized mechanical ventilation weaning and extubation readiness trials (ERTs) reduce mechanical ventilation duration, but the optimal timing of extubation after a successful ERT remains unclear. We aimed to assess whether early extubation—defined as occurring within 6 h of passing ERT—is associated with treatment failure, defined as respiratory support escalation or re-intubation within 48 h. We hypothesized that early extubation would not increase treatment failure. Methods: This was a retrospective cohort study of subjects (<18 years) who underwent mechanical ventilation and were extubated after a successful ERT between January 1, 2021, and July 10, 2023, at a single quaternary care pediatric ICU (PICU). The primary exposure was extubation timing, dichotomized as early (<6 h) or late (≥6 h) after successful ERT. The primary outcome was treatment failure, defined as re-intubation or escalation of planned postextubation respiratory support within 48 h. We compared groups using Wilcoxon rank-sum and chi-squared testing. We used univariable and inverse probability of treatment weighting (IPTW) with a doubly robust outcome model to estimate the association between extubation timing and treatment failure. Secondary outcomes included extubation failure, mechanical ventilation duration, and ICU stay. Results: Among 261 subjects, 102 were extubated early (median 2 h post-ERT, interquartile range [IQR] 0–3) and 159 late (median 17 h, IQR 10–35, P < .01). Age, maximal oxygen saturation index, preadmission respiratory functional status, and PELOD-2 were not significantly different between the 2 groups. Early extubation was not associated with increased treatment failure in univariable (odds ratio [OR] 1.10, 95% CI 0.55–2.20) or IPTW analysis (adjusted OR 1.30, 95% CI 0.66–2.57). Early extubation was associated with reduced postextubation ICU stay (55.5 vs 98.5 h, P < .01). Conclusions: Early extubation was associated with decreased mechanical ventilation duration and ICU stay and not associated with treatment failure or re-intubation.