Extubation failure in very preterm infants: associations with respiratory outcomes in a nine-year cohort study

Extubation failure is a common event in very preterm infants and has been associated with adverse respiratory and clinical outcomes. However, it remains unclear whether extubation failure independently contributes to subsequent morbidity or primarily reflects underlying respiratory disease severity. We conducted a retrospective cohort study of ventilated infants born at less than 32 weeks of gestation in a tertiary neonatal intensive care unit over a 9-year period. Infants who underwent at least one planned extubation attempt were included. Extubation failure was defined as the need for reintubation within 72 h of planned extubation. Multivariate analyses were performed to identify independent predictors and to evaluate associations with moderate-to-severe bronchopulmonary dysplasia (BPD), duration of invasive ventilation, length of hospital stay, and infection-related morbidity. A total of 877 infants were included, of whom 89 (10.1%) experienced extubation failure. The incidence demonstrated a strong gestational age gradient, decreasing from 22.5% at less than 26 weeks to 4.9% at 30–31 + 6 weeks ( p < 0.001). In multivariate analysis ( n = 858), gestational age remained the only independent predictor of extubation failure among the variables available for analysis (adjusted OR 0.78 per week, 95% CI 0.65–0.94; p = 0.007), while birth weight, Apgar score, antenatal steroid exposure, surfactant requirement, early pulmonary complications, and initial respiratory strategy were not independently associated. Among survivors ( n = 811), extubation failure was associated with a higher incidence of moderate-to-severe BPD (50.6% vs. 18.7%; adjusted OR 3.07, 95% CI 1.79–5.24; p < 0.001). Infants with extubation failure also had significantly greater cumulative exposure to invasive ventilation (median 31 vs. 6 days; adjusted ratio 2.01, 95% CI 1.64–2.45; p < 0.001) and longer hospital stay (median 97 vs. 59 days; adjusted ratio 1.40, 95% CI 1.21–1.63; p < 0.001). Infection-related morbidities were more frequent, including late-onset sepsis (37.1% vs. 18.1%, p < 0.001) and ventilator-associated pneumonia (28.1% vs. 10.0%, p < 0.001). Extubation failure in very preterm infants was most strongly associated with lower gestational age and with a more adverse respiratory course, increased infection-related morbidity, and greater healthcare utilisation. Gestational age should be interpreted as one component of extubation risk assessment rather than as a standalone determinant of extubation readiness. Overall, these findings indicate that extubation failure identifies infants at increased risk of subsequent respiratory morbidity but should not be interpreted as an independent causal determinant of adverse outcomes.