the art and science of discontinuing patients from invasive mechanical ventilation continues to attract attention . the discontinuation process consists of two components : weaning ( assessing the need for ventilatory support ) and extubation ( assessing the need for an airway ) . investigators have increasingly focused on the latter component , where 520% of extubations may fail and require reintubation . delayed extubation is associated with increased length of stay , increased risk for ventilator - associated pneumonia , and increased mortality in brain - injured patients . conversely , reintubation ( extubation failure ) after planned extubation is associated with adverse outcomes , including increased hospital mortality , prolonged hospital stay , higher costs , and greater need for tracheotomy and transfer to postacute care [ 2 - 4 ] . although the adverse effects of reintubation could reflect the severity of underlying illness or could result from complications during reintubation , this has not been demonstrated with multivariate analysis [ 2 - 4 ] . rather , delayed timely reinstitution of ventilatory support may allow for deterioration and new organ failure , ultimately contributing to increased mortality and increased costs . in response to this observation , investigators have examined whether postextubation application of noninvasive ventilation ( niv ) can improve outcome . unfortunately , niv did not improve outcome for established postextubation respiratory failure   and was actually associated with increased intensive care unit ( icu ) mortality when used in a large cohort with early signs of extubation failure ( only 10% of whom had chronic obstructive pulmonary disease ) . hence the relevance of the study by seymour and colleagues , who extend previous work by finding that extubation failure ( in a 16-bed medical  surgical icu ) also exacts a devastating toll in the community setting . using a retrospective methodology , these investigators noted that both postextubation icu length of stay and hospital length of stay was significantly longer in patients requiring reintubation ( 9 days and 11 days longer , respectively ) . both icu mortality and hospital mortality were also higher for reintubated patients , although the latter did not achieve statistical significance . using estimates from direct and indirect charges , seymour and colleagues found that total hospital costs increased by an average of nearly $ 34,000 for reintubated patients . although the results of seymour and colleagues ' study are enticing , several issues with the study design will need to be addressed when future investigators examine this issue . a classic case control methodology should ideally be employed , matching controls for sex , age , case type ( e.g. surgical versus medical ) , severity of illness ( or organ failure score ) , etiology of respiratory failure , and duration of mechanical ventilation prior to extubation . in addition , several groups have noted that patients reintubated for airway problems or upper airway obstruction and those patients reintubated more rapidly have a better prognosis than other reintubated patients . with so many potential factors impacting outcome for reintubated patients , multivariate analyses to determine the independent effect of extubation failure are mandatory . how should the results of this study and other studies conducted in tertiary care academic centers affect how we care for ventilated patients ? given the poor outcome of patients failing extubation and the inconsistent benefit for niv to prevent reintubation , clinicians should be more vigilant in identifying who is at high risk for extubation failure . predictors developed to predict weaning outcome have not faired well in accurately predicting extubation outcome . this is not unexpected as extubation failure often occurs for reasons other than an imbalance between work of breathing and the load on the respiratory system , the typical reason for weaning failure . patients often fail extubation because of upper airway obstruction , inadequate cough , excess respiratory secretions , abnormal mental status , or a combination of more than one of these factors . the quantitative cuff leak test ( the difference between inspired and expired tidal volumes during assist - control ventilation with the endotracheal tube cuff deflated ) can identify a cohort at increased risk for postextubation stridor [ 12 - 14 ] . objective , quantitative assessments of cough strength and secretion volume can similarly predict postextubation failure . indeed , decreased peak expiratory flow rates using a calibrated flow meter ( < 60 l / min ) and increased sputum volume ( > 2.5 ml / hour in the 23 hours prior to extubation ) were associated with relative risks for reintubation of 4.8 and 3 , respectively . the same investigators noted a relative risk of extubation failure of 4.3 in patients unable to complete four simple neurological tasks ( open eyes , follow with eyes , grasp hand , stick out tongue ) . combining the three risk factors of decreased peak cough flow , increased sputum volume , and abnormal neurological assessment had a synergistic effect . only 3% of patients without risk factors required reintubation , compared with 100% of patients with all three risk factors . based on these studies , one can recommend delaying extubation if the risk factor ( e.g. excess secretions , abnormal mental status ) can be substantially corrected in 13 days . intuitively , little is gained by waiting for extubation if risk factors are irreversible or would take more than a few days to correct . in the latter instance , the benefits of waiting are offset by the risks of significantly prolonging invasive ventilation . whether the latter group should be extubated despite the elevated risk for reintubation or alternatively be considered for tracheotomy is unclear . a preliminary report suggests that immediate application of niv in such a high - risk cohort may be effective in improving outcome . in conclusion , the study of seymour and colleagues further supports the notion that extubation failure is an outcome to be avoided , wherever it occurs .
extubation failure is an outcome of increasing importance but nearly all studies have been conducted in academic settings . 
 the article by seymour and colleagues demonstrates that extubation failure is an outcome to be avoided in the community hospital setting as well . 
 patients failing extubation experience longer lengths of stay , experience higher intensive care unit mortality , and incur greater hospital costs . 
 investigators have identified tools for predicting extubated patients at highest risk for reintubation . 
 the predictors focus on detecting upper airway obstruction , inadequate cough , excess respiratory secretions , and abnormal mental status . 
 systematic application of these predictors has the potential to improve outcome .