The Effect of Reconnection to Mechanical Ventilation for 1 Hour After Spontaneous Breathing Trial on Reintubation Among Patients Ventilated for More Than 12 Hours

A Randomized Clinical Trial


      The resting of the respiratory musculature after undergoing the spontaneous breathing trial (SBT) to prevent extubation failures in critically ill patients needs to be studied further.

      Research Question

      Is the reconnection to mechanical ventilation (MV) for 1 h after a successful SBT able to reduce the risk of reintubation?

      Study Design and Methods

      Randomized clinical trial conducted in four ICUs between August 2018 and July 2019. Candidates for tracheal extubation who met all screening criteria for weaning were included. After achieving success in the SBT using a T-tube, the patients were randomized to the following groups: direct extubation (DE) or extubation after reconnection to MV for 1 h (R1h). The primary outcome was reintubation within 48 h.


      Among the 336 patients studied (women, 41.1%; median age, 59 years [interquartile range, 45-70 years]), 12.9% (22/171) in the R1h group required reintubation within 48 h vs 18.2% (30/165) in the DE group (risk difference, 5.3 [95% CI, –2.49 to 13.12]; P = .18). No differences were found in mortality, length of ICU or hospital stay, causes of reintubation, or signs of extubation failure. A prespecified exploratory analysis showed that among the 233 patients (69.3%) who were ventilated for more than 72 h, the incidence of reintubation was 12.7% (15/118) in the R1h group compared with 22.6% (26/115) observed in the DE group (P = .04).


      Reconnection to MV after a successful SBT, compared with DE, did not result in a statistically significant reduction in the risk of reintubation in mechanically ventilated patients. Subgroup exploratory findings suggest that the strategy may benefit patients who were ventilated for more than 72 h, which should be confirmed in further studies.

      Trial Registry

      Brazilian Clinical Trials Registry; No.: RBR-3x8nxn; URL:

      Key Words


      DE (direct extubation), MV (mechanical ventilation), NIV (noninvasive ventilation), R1h (extubation after reconnection to mechanical ventilation for 1 h), SBT (spontaneous breathing trial)
      To read this article in full you will need to make a payment


      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Esteban A.
        • Frutos F.
        • Tobin M.J.
        • et al.
        A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group.
        N Engl J Med. 1995; 332: 345-350
        • Boles J.M.
        • Bion J.
        • Connors A.
        • et al.
        Weaning from mechanical ventilation.
        Eur Respir J. 2007; 29: 1033-1056
        • Thille A.W.
        • Harrois A.
        • Schortgen F.
        • et al.
        Outcomes of extubation failures in medical intensive care unit patients.
        Crit Care Med. 2011; 39: 2612-2618
        • Peñuelas O.
        • Thille A.W.
        • Esteban A.
        Discontinuation of ventilatory support: new solutions to old dilemmas.
        Curr Opin Crit Care. 2015; 21: 74-81
        • Esteban A.
        • Alia I.
        • Tobin M.J.
        • et al.
        Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation.
        AM J Respir Crit Care Med. 1999; 159: 512-518
        • Frutos-Vivar F.
        • Esteban A.
        • Apezteguia C.
        • et al.
        Outcome of reintubated patients after scheduled extubation.
        J Crit Care. 2011; 26: 502-509
        • Jaber S.
        • Quintard H.
        • Cinotti R.
        • et al.
        Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures.
        Crit Care. 2018; 22: 236
        • Ely E.W.
        • Baker A.M.
        • Dunagan D.P.
        • et al.
        Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.
        N Engl J Med. 1996; 335: 1864-1869
        • Ely E.W.
        • Bennett P.
        • Bowton D.
        • et al.
        Large implementation of a respiratory therapist-driven protocol for ventilator weaning.
        Am J Respir Crit Care Med. 1999; 159: 439-446
        • Ely E.W.
        • Meade M.O.
        • Killef M.H.
        • et al.
        Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines.
        Chest. 2001; 120: 454S-463S
        • MacIntyre N.R.
        • Cook D.J.
        • Ely E.W.
        • et al.
        Evidence-based guidelines for weaning and discontinuing ventilatory support.
        Chest. 2001; 120: 375S-395S
        • Sklar M.
        • Burns K.
        • Rittayamai N.
        • et al.
        Effort to breathe with various spontaneous breathing trial techniques. A physiologic meta-analysis.
        Am J Respir Crit Care Med. 2017; 195: 1477-1485
        • Burns K.E.A.
        • Devlin J.W.
        • Hill N.S.
        Patient and family engagement in designing and implementing a weaning trial: a novel research paradigm in critical care.
        Chest. 2017; 152: 707-711
        • Subirà C.
        • Hernández G.
        • Vázquez A.
        • et al.
        Effect of pressure support vs T-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: a randomized clinical trial.
        JAMA. 2019; 321: 2175-2182
        • Rochwerg B.
        • Brochard L.
        • Elliott M.W.
        • et al.
        Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure.
        Eur Respir J. 2017; 50: 1602426
        • Fernandez M.M.
        • Gonzales-Castro A.
        • Magret M.
        • et al.
        Reconnection to mechanical ventilation for 1 hour after a successful spontaneous breathing trial reduces reintubation in critically ill patients: a multicenter randomized controlled trial.
        Intensive Care Med. 2017; 43: 1660-1667
        • Hernandez G.
        • Fernandez R.
        • Luzon E.
        • et al.
        The early phase of the minute ventilation recovery curve predicts extubation failure better than the minute ventilation recovery time.
        Chest. 2007; 131: 1315-1322
        • Epstein S.K.
        Weaning from ventilatory support.
        Curr Opin Crit Care. 2009; 15: 36-43
        • Bai L.
        • Duan J.
        Use of cough peak flow measured by a ventilator to predict re-intubation when a spirometer is unavailable.
        Respiratory Care. 2017; 62: 566-571
        • Khamiees M.
        • Raju P.
        • DeGirolamo A.
        • et al.
        Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial.
        Chest. 2001; 120: 1262-1270
        • Barbas C.S.V.
        • Ísola A.M.
        • de Carvalho Farias A.M.
        • et al.
        Brazilian recommendations of mechanical ventilation 2013. Part 2.
        Revista Brasileira de Terapia Intensiva. 2014; 26: 215
        • Quintard H.
        • l’Her E.
        • Pottecher J.
        • et al.
        Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF).
        Ann Intens Care. 2019; 9: 13
        • Martínez A.
        • Seymour C.
        • Nam M.
        Minute ventilation recovery time. A predictor of extubation outcome.
        Chest. 2003; 123: 1214-1221
        • Ozdemir B.A.
        • Karthikesalingam A.
        • Sinha S.
        • et al.
        Research activity and the association with mortality.
        PLoS One. 2015; 10e0118253
        • Jonker L.
        • Fisher S.J.
        The correlation between National Health Service trusts’ clinical trial activity and both mortality rates and care quality commission ratings: a retrospective cross-sectional study.
        Public Health. 2018; 157: 1-6
        • Grosu H.B.
        • Im Lee Y.
        • Lee J.
        • et al.
        Diaphragm muscle thinning in patients who are mechanically ventilated.
        Chest. 2012; 142: 1455-1460
        • Jaber S.
        • Petrof B.J.
        • Jung B.
        • et al.
        Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans.
        Am J Respir Crit Care Med. 2011; 183: 364-371
        • Hooijman P.E.
        • Beishuizen A.
        • Witt C.C.
        • et al.
        Diaphragm muscle fiber weakness and ubiquitin-proteasome activation in critically ill patients.
        Am J Respir Crit Care Med. 2015; 191: 1126-1138
        • Schmidt G.A.
        • Girard T.D.
        • Kress J.P.
        • et al.
        Liberation from mechanical ventilation in critically ill adults: executive summary of an official American College of Chest Physicians/American Thoracic Society clinical practice guideline.
        Chest. 2017; 151: 160-165
        • Wang T.H.
        • Wu C.P.
        • Wang L.Y.
        Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units.
        Clin Respir J. 2018; 12: 2613-2621
        • Blackwood B.
        • Alderdice F.
        • Burns K.
        • et al.
        Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients. Cochrane systematic review and meta-analysis.
        BMJ. 2011; 342: c7237
        • Salam A.
        • Tilluckdharry L.
        • Amoateng-Adjepong Y.
        • et al.
        Neurologic status, cough, secretions and extubation outcomes.
        Intensive Care Med. 2004; 30: 1334-1339
        • Smailes S.T.
        • McVicar A.J.
        • Martin R.
        Cough strength, secretions and extubation outcome in burn patients who have passed a spontaneous breathing trial.
        Burns. 2013; 39: 236-242
        • Epstein S.K.
        Putting it all together to predict extubation outcome.
        Intensive Care Med. 2004; 30: 1255-1257
        • Smina M.
        • Salam A.
        • Khamiees M.
        • et al.
        Cough peak flows and extubation outcomes.
        Chest. 2003; 124: 262-268