Failed weaning carried 78% ICU mortality, and the first failed attempt often set the course

Design

Secondary analysis of an international prospective cohort (WEAN SAFE)

Population

5,664 invasively ventilated patients; 664 with failed weaning

Primary outcome

ICU mortality

Effect

78% in failed weaning vs 2% in successful weaning; three failure phenotypes

WEAN SAFE was an international cohort of patients on invasive ventilation. This secondary analysis of 5,664 patients examined those who entered weaning but never came off the ventilator.

Of 4,394 patients with at least one separation attempt, 664 (15%) had failed weaning at day 90. They had the longest ventilation and ICU stays, more tracheostomies and reintubations, but fewer extubation attempts. ICU mortality was 78%, against 2% in those who weaned. Three phenotypes emerged: a single attempt followed by a decision to withhold or withdraw life support, a single attempt without such a decision, and repeated attempts. A failed first attempt was strongly associated with a subsequent decision to limit treatment.

The association between the first failure and limitation of care deserves reflection. A failed first trial is common and not always a sign of futility. Teams should be clear about whether a limitation decision reflects the patient's prognosis and wishes, or the momentum of one bad day.

• A failed first spontaneous breathing trial is common; reassess the cause before drawing conclusions about prognosis.
• Patients who failed weaning had 78% ICU mortality — discuss goals of care early and honestly.
• Look for reversible causes after a failed attempt: fluid overload, weakness, delirium, secretions.
• Document the reasoning behind any decision to withhold or withdraw life support.

Why it matters

It raises the question of whether one failed trial is driving end-of-life decisions faster than the evidence warrants.

Don't overread it

This is observational — the link between failed first attempts and limitation decisions does not show that either causes the deaths.

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