Prediction of post-extubation stridor using ultrasound measurement of subglottic airway diameter.

Background: Endotracheal tube intubation can be associated with laryngeal edema, which may present as post-extubation stridor (PES). PES may prolong length of stay in pediatric intensive care unit, particularly if reintubation was necessary. Objective: To evaluate the efficacy of laryngeal ultrasonography and percent leak volume (PLV) in predicting PES in pediatric patients. Materials and Methods: A prospective study of 43 pediatric patients admitted to pediatric intensive care unit was conducted. Laryngeal ultrasonography was performed to measure air column width (ACW) within 24 hours after intubation. Within four hours before extubation, laryngeal ultrasonography was repeated. Air column width ratio (ACWR) was calculated by ACW before extubation divided by ACW after intubation. PLV was calculated by the difference between inspiratory and expiratory tidal volume divided by inspiratory tidal volume. Both of ACWR and PLV were analyzed to determine the optimal cut-off value for predicting PES. Results: Twenty-two patients (51%), developed PES. Receiver operating characteristics curve (ROC) analysis showed that ACWR at cut-off point ≤0.94 had a sensitivity of 72.7%, specificity of 61.9%, positive predictive value (PPV) of 66.7%, and accuracy of 67.4% in predicting PES. A cut-off point of PLV of less than 9.74% had 59.1% sensitivity, 57.1% specificity, 59.1% PPV, and 58.1% accuracy in predicting PES. ACWR and PLV had an area under the ROC curve (AUC) of 0.722 (p=0.013, 95% CI 0.56 to 0.87) and 0.602 (p=0.253, 95% CI 0.43 to 0.77), respectively. Conclusion: ACWR measured by laryngeal ultrasonography of 0.94 or less may be helpful in predicting PES. ACWR is more accurate than PLV in predicting PES. Keywords: Laryngeal ultrasonography; Percent leak volume; Post-extubation stridor

Post-extubation stridor (PES) is a common problem in the pediatric intensive care unit (PICU) and is associated with extubation failure, longer length of stay, and increased mortality. Infants represent a large proportion of PICU admissions and are at higher risk for PES, making identification and mitigation of factors associated with PES important in this age group. What factors are associated with PES in infants (age less than 1 year) intubated in the PICU? The primary outcome was PES as defined by the need for racemic epinephrine within 6 h of extubation. Secondary outcomes were heliox administration and reintubation. Statistical analyses were performed with Fisher's exact test for univariate analyses and multivariate logistic regression. 518 patient charts were retrospectively reviewed. 24.1% of patients developed PES. Duration of mechanical ventilation greater than 48 h was associated with increased risk of PES (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.13-2.71, P = .01), as was nonelective intubation (OR = 2.92, 95% CI 1.91-4.46, P < .01). The presence of a cuff, gastroesophageal reflux disease, prematurity, and known upper airway abnormality had no association with PES. 4.0 endotracheal tubes (ETTs) had an increased association with PES compared to 3.5 ETTs (OR = 1.96, 95% CI 1.18-3.27, P < .01). There was no difference in risk of PES between 3.5 and 3.0 ETTs. In infants intubated in the PICU, mechanical ventilation greater than 48 h and nonelective intubation were associated with PES. 4.0 ETTs were associated with higher risk of PES compared to 3.5 ETTs. These findings may help providers in ETT selection and to identify infants that may be at increased risk of PES.

Purpose: Weaning from mechanical ventilation (MV) is a complex process that involves clinical aspects, contextual aspects, and the characteristics of health professionals who work in an intensive care service. Regarding the clinical aspects, previous studies have shown great variability of protocols, strategies and criteria used in the process of weaning from MV and extubation in neonatal and pediatric intensive care patients. Furthermore, the management of this process can be influenced by contextual aspects of the intensive care units (ICUs) structure and organization, and professional aspects of the team involved in this scenario. The aim of this study was to describe clinical aspects of the weaning practices in neonatal, pediatric, and mixed (neonatal and pediatric) ICUs in Brazil, as well as the organizational aspects associated with the physiotherapist's performance to conduct this process. Methods: A cross-sectional survey was carried out by sending an electronic questionnaire to 298 neonatal, pediatric, and mixed ICUs in Brazil (January to November 2016). Data on weaning practices and extubation were collected. Only one representative of each unit answered to the questionnaire. Results: This study assessed questionnaires from 146 ICUs (49.3% neonatal, 35.6% pediatric and 15.1% mixed). 57.5% of the ICUs surveyed apply weaning protocols. In neonatal and mixed ICUs using weaning protocols the standardized gradual reduction of ventilator support was the most used method of liberation from MV (60.5% and 50.0%, respectively). In pediatric ICUs using weaning protocols the spontaneous breathing trial (SBT) was the most common (53%). During SBT the most common ventilation mode in all ICUs was PSV+PEEP with PSV=10.03 ± 3.15 cmH2O and the trial lasted from 35.76 ± 29.03 minutes in neonatal ICUS to 76.42 ± 41.09 minutes in pediatric ICUs. The SBT parameters, weaning modes, and time considered for extubation failure varied regardless of ICU age profile. Clinical evaluation and arterial blood gas are frequently criteria used to assess readiness for extubation, regardless of ICU age profile. Regarding the professionals involved in the process of weaning and extubation, the physical therapist frequently conducted this process (66.7%). However, the professional responsible for conducting weaning and extubation decision varied regardless of ICU age profile. The three ICUs age profile frequently had an exclusive physical therapist. However, physiotherapeutic care 24 hour/7 days per week was predominant in pediatric ICUs (56.0%). Moreover, when the physical therapist was 24 hours/7 days per week, he was responsible for the extubation decision and the patients were successfully extubated on the first try. Conclusion: In Brazil, the clinical practice towards weaning from MV and extubation occur according to the ICU age profile. The ICUs with physical therapy assistance 24 hours/7 days per week were more associated with the use of weaning protocol, extubation decision and success of the first attempt of extubation.

Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. Paediatric intensive care units in the UK. Invasively mechanically ventilated children (aged < 16 years). The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded. The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days. The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03). The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined. The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain. Future work should explore intervention sustainability and effects of the intervention in other paediatric populations. This trial is registered as ISRCTN16998143. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.

ObjectivesWe aimed to assess combined predictive ability of ultrasound lung, diaphragm and echocardiography variables, to anticipate failure of spontaneous breathing trial (SBT) and extubation.MethodsWe conducted a prospective observational study in 73 consecutive mechanically ventilated children aged (1month-18years) eligible for SBT as per protocol. Comprehensive USG lung, diaphragm and echocardiography was performed by single trained paediatric intensivist 30 minutes before initiating SBT to measure lung aeration score (LAS), diaphragmatic thickening fraction (DTF-R) preferred right due to ease of access and left ventricular (LV) systolic and diastolic function. Children succeeded SBT were given extubation trial. Outcome variables were analysed individually between success and failure groups of SBT and extubation trial respectively.ResultsAmong 73 subjects enrolled pre SBT, SBT success group(n=65) had significantly high mean DTF-R (%) (34.66 ± 12.70) in comparison to SBT failure group(n=8) (18.95 ± 11.56) (p, 0.004). Children who passed SBT as per clinical protocol and successfully extubated (n=57) had mean DTF-R (%)(35.09 ± 13.17) comparable to (31.59 ± 8.64) extubation failure group(n=8) (p, 0.63). Extubation success group had significantly low LAS (15.98 ± 4.49) in contrast to extubation failure group (21.75 ± 6.30) (p,0.012). LV diastolic dysfunction (LVDD) defined by E/ E’ cutoff (≥10)1 had diagnostic accuracy of 86.2% to predict extubation failure individually. Whereas, combined predictive ability of DTF(R)+LAS+LVDD to predict extubation failure was superior to individual variables (AUROC, 0.82) (p=0.004).Predictor VariableCut-offAUROC95% CIP valueSensitivitySpecificityPPVNPVDiagnostic accuracyDTF-Right (%)<43%0.5540.352–0.7560.632100%26%16%100%35%DTF-Left (%)<24%0.5950.328–0.8630.39062%75%26%94%74%LAS (x/50)>220.7770.604–0.9510.01262%84%36%94%82%DTF (Right)+ LAS+LVDD_0.8200.65–0.990.00475%86%43%96%85%ConclusionThe combined ultrasound evaluation of heart, lung and diaphragm in comparison to individual variables, significantly enhanced prediction accuracy of extubation failure before SBT in children. DTF alone is a non-reliable marker for prediction of extubation failure.

We read with interest the recent Critical Care review of post-extubation laryngeal edema and stridor resulting in respiratory failure [1]. We mostly agree with the authors’ opinion in that article except that the cuff leak test (CLT) was proposed as a standard extubation algorithm. We have two reasons to disagree. First, although the CLT has been widely used for the prediction of post-extubation laryngeal edema, evidence for the predictive value of the CLT is conflicting. Most studies on the CLT document a high specificity and a low sensitivity, and this means that patients with a negative test have a low probability of developing post-extubation stridor (PES) but that patients with a positive CLT may not develop PES. In a recent systematic review, Ochoa et al. evaluated the accuracy of the CLT for reintubation secondary to upper airway obstruction; the sensitivity was 0.63 (95 % confidence interval (CI) 0.38–0.84), and the specificity was 0.86 (95 % CI 0.81–0.90) [2]. Shin et al. report that the CLT does not reliably identify those patients who will require reintubation in a trauma population [3]. Similarly, a recent study by Patel et al. demonstrates that the CLT or a combination with laryngeal parameters failed to accurately predict PES [4]. Second, the CLT is regarded as a simple and non-invasive procedure, but that does not mean this procedure is totally safe for patients. Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections and is associated with higher mortality, morbidity, and costs. Contaminated secretions that spill over the endotracheal tube cuff and leak down to the lungs are considered a significant pathogenic mechanism of VAP [5]. Although the related evidence is lacking, it is reasonable to posit that the CLT should increase the risk of oropharyngeal and subglottic secretions into the airway during cuff deflation and mechanical ventilation. The poor predictive accuracy suggests that the CLT is an unstable clinical prognosticator, and we consider that the CLT should be applied for patients at high risk and that the excessive use of CLT is inappropriate.

The optimal spontaneous breathing trial (SBT) duration is not known for children who are critically ill. The study objective was to evaluate extubation outcomes between cohorts exposed to a 1- or 2-h SBT. This was a retrospective cohort study of a quality improvement project database in a 24-bed pediatric ICU. The intervention was a respiratory therapist-driven SBT clinical pathway across 2 improvement cycles by using a 2- or 1-h SBT. The primary outcomes were extubation failure and rescue noninvasive ventilation in the first 48 h. Secondary outcomes included SBT results and process measures. There were 218 and 305 encounters in the 2- and 1-h cohorts, respectively. Extubation failure (7.3 vs 8.5%; P = .62) and rescue noninvasive ventilation rates (9.3 vs 8.2%; P = .68) were similar. In logistic regression models, SBT duration was not independently associated with either primary outcome. Extubation after 1-h SBT failure was associated with significantly higher odds of rescue noninvasive ventilation exposure (odds ratio 3.94, 95% CI 1.3-11.9; P = .02). SBT results were not associated with odds of extubation failure. There were 1,072 (2 h) and 1,333 (1 h) SBTs performed. The 1-h SBT pass rate was significantly higher versus the 2-h SBT (71.4 vs 51.1%; P < .001). Among all failed SBTs, the top 3 reported failure modes were tidal volume ≤ 5 mL/kg (23.6%), breathing frequency increase > 30% (21%), and oxygen saturation < 92% (17.3%). When considering all failed SBTs, 75.5% of failures occurred before 45 min. A 1-h SBT may be a viable alternative to a 2-h version for the average child who is critically ill. Further, a 1-h SBT may better balance extubation outcomes and duration of invasive ventilation for the general pediatric ICU population.

What is the central question of this study? A transcranial magnetic stimulation (TMS)-induced twitch applied on isolated single breaths over the motor cortex somatotopic representation of the tongue briefly recruits submental muscles and improves airflow dynamics of flow-limited respiratory cycles without arousing sleep apnoea patients. However, the mechanical impact of the TMS-induced twitch applied during consecutive breathing cycles on airflow dynamics remains unknown. What is the main finding and what is its importance? Our results show that application of TMS with the stimulator output set at the sleep submental motor threshold intensity on consecutive respiratory cycles increases inspiratory flow and reduces the turbulent airflow component. These results indicate an improvement of airflow pattern after two single consecutive TMS-induced twitches without arousing sleep apnoea patients. Transcranial magnetic stimulation (TMS)-induced twitches applied on isolated breaths briefly recruit upper airway dilator muscles and improve airflow and inspiratory volume without arousing apnoeic patients from sleep, but the effects of applying such twitches consecutively on airflow dynamics is unknown. The objective of this study was to quantify the effects of five consecutive TMS-induced twitches applied on sleep-induced obstructive hypopnoeic breaths in 10 obstructive sleep apnoea patients. Submental muscle motor threshold (SUBMT) and motor-evoked potential were measured during wakefulness and sleep. The TMS-induced twitches were applied during stable non-rapid eye movement (NREM) sleep, at the beginning of inspiration of consecutive flow-limited respiratory cycles, with the stimulator output set at sleep SUBMT. Maximal inspiratory flow, inspiratory volume, inspiratory time, shifts of electroencephalogram frequency and pulse rate variability were assessed. During sleep, SUBMT increased (wakefulness, 25.3 ± 4.9%; NREM sleep, 27.0 ± 6.2%; P = 0.02). During each series of stimulations there was a rise in maximal inspiratory flow (from 306.7 ± 123.2 to 359.8 ± 154.1 ml s(-1); P = 0.0002) and in inspiratory volume (from 346.1 ± 128.1 to 414.9 ± 171.2 ml; P = 0.02) without differences in thoraco-abdominal efforts and inspiratory time. These responses were observed in the absence of arousals and ceased immediately after TMS interruption. Transcranial magnetic stimulation-induced cortical and/or autonomic arousal was observed in 30.2% of all series of stimulation. Consecutive twitch TMS of submental muscles may lead to arousals in a minority of patients but can be applied on consecutive respiratory cycles during sleep and can significantly improve maximal inspiratory flow and inspiratory volume of flow-limited cycles.

The airleak test is measured with a manometer as the pressure necessary to generate an audible airleak around the endotracheal tube. Our objectives were to determine whether the airleak test predicts postextubation stridor in children and if age affects its sensitivity and specificity. A retrospective study. Pediatric intensive care unit. We studied all intubated patients admitted to our pediatric intensive care unit between July 1998 and December 1999. Patients were excluded if they had acute viral croup, tracheal surgery, hypotonic airway, or vocal cord paralysis or if they died before extubation. Medical records were reviewed for patient demographics, presence of an airleak on the day of extubation, airleak values, presence of postextubation stridor, and extubation failure secondary to upper airway obstruction. One hundred and five patients met our inclusion criteria and had an airleak test at the time of extubation. In children <7 yrs of age, the incidence of postextubation stridor was similar in patients with or without an airleak at >20 mm Hg (50% vs. 67.7%; >.05) with a sensitivity of 65.6% (95% confidence interval, 46.9-80.8). In children >or=7 yrs of age, the incidence of postextubation stridor was greater in patients with an airleak at >20 mm Hg (55.5% vs. 5.8%; p=.01) with a sensitivity of 83.3% (95% confidence interval, 36.8-99) in predicting postextubation stridor. Our study suggests that the airleak test has a low sensitivity when used as a screening test to predict postextubation stridor in young children (<7 yrs old), whereas in older children (>or=7 yrs old) the airleak test may predict postextubation stridor.

Changes in albuminuria during the spontaneous breathing trial: A prospective observational study

Association Between Reduced Cuff Leak Volume and Postextubation Stridor

Timely ventilator liberation is crucial in the pediatric ICU. In many pediatric ICUs, the decision to initiate weaning is driven by the physician, which may lead to delays in ventilator liberation. The objectives of this quality improvement project were to develop and implement a respiratory therapist (RT)-led protocol for screening for spontaneous breathing trial (SBT) readiness, to test protocol feasibility, and to evaluate its impact on SBT timing. A retrospective chart review was performed on all intubated patients in the pediatric ICU for 18 months prior to protocol institution. An RT-driven protocol was developed and implemented, enabling consistent screening for SBT readiness. When criteria were met, an SBT was initiated after order placement. The difference in the timing of the first SBT between physician-directed screening and the RT-driven protocol was evaluated. A total of 219 subjects were included in this project (128 pre-intervention; 91 intervention). Baseline demographic data, including mortality risk and endotracheal tube size, were similar in both groups. The time of the first SBT (median [25th, 75th percentile]) was not significantly different between the intervention and preintervention groups (39.5 [25.3, 85.2] vs 42.6 [26.4, 81.3], respectively). There was no difference in mechanical ventilation duration, or length of hospital and ICU stay. The odds of being placed on noninvasive respiratory support were higher in the intervention group at 1 h (odds ratio [95% CI]: 2.29 [1.10, 4.78], P = .03) and 12 h (odds ratio 2.53 [1.23, 5.20], P = .01) postextubation, but the odds of re-intubation did not reach statistical significance (odds ratio 2.60 [0.73, 9.27], P = .14). RT adherence with patient screening was 56.4%. An RT-driven protocol was successfully introduced in an academic pediatric ICU. However, it did not impact time of SBT initiation, potentially due to the difficulty in maintaining adherence over time. RT-driven protocols require further study.

Introduction: Coordinated Spontaneous Awakening Trials (SAT) & Spontaneous Breathing Trials (SBT) are an important component of the SCCM’s ICU Liberation (ABCDEF) Bundle, a collection of best practices that reduce harmful effects of ICU stays and improve patient outcomes in critically ill patients. SATs & SBTs liberate patients from excess sedation and mechanical ventilation (MV). This quality improvement project describes a multidisciplinary initiative at a large academic medical center to (1) improve performance of SAT and SBT processes & (2) reduce mechanical ventilation days through enhancing knowledge, communication, and protocol adherence. Methods: A multidisciplinary group coordinated efforts across 7 ICUs over several PDSA cycles. Respiratory therapists (RT) piloted SBT data forms to identify gaps between task completion and EMR data and RNs completed a survey to assess knowledge, practice, and communication gaps. RN education focused on ABCDEF bundle and knowledge gaps identified in the survey. RT education emphasized communication with the team and documentation. The “Awake by 8” SAT Campaign promoted expectations for SAT completion time. Team communication was emphasized at multiple stages in the process as applicable for each patient: reason for failing a safety screen or a trial and ensuring a plan is in place post-SAT/SBT completion. Team feedback supported documentation and data requests for ABCDEF work across the healthcare system. Results: More than 80% of RN and RT teammates completed education. Baseline (Q2 2024) and post-intervention (Q2 2025) SAT/SBT data show sustained or improved outcomes in all areas except SAT Completion, which dipped slightly from 84.6% to 83.2%. This may be representative of better capture through screening processes. Improvements were seen in SAT Safety Screen (7.6% to 19.2%), SBT Screening (39.8% to 66.2%), and SBT Performance (67.1% to 73.8%). Baseline MV Days (Apr-Dec 2024) improved from 3.55 to 3.09 YTD in 2025 (May), averaging ~11 hours saved per patient. Conclusions: Spontaneous Awakening and Breathing trials are complex and nuanced, requiring careful coordination and ongoing quality improvement. Addressing these complexities with a multidisciplinary team and a variety of strategies will help to drive improvements to improve patient outcomes.

Spontaneous awakening and breathing trials have been associated with shorter durations of mechanical ventilation and intensive care unit lengths of stay. Inconsistent spontaneous awakening trials and spontaneous breathing trials, mechanical ventilation weaning strategies, and interdisciplinary rounding processes contributed to prolonged mechanical ventilation duration and length of stay in a 44-bed adult medical intensive care unit. Methods A standardized rounding tool that focused on coordinating spontaneous awakening and breathing trials, and on their outcomes, was integrated into daily multidisciplinary rounds in a medical intensive care unit. Aggregated patient data from the 4-month project implementation phase were compared with historical data collected for 2 months before project implementation. During the 2-month preintervention phase, 613 adult patients were managed in the medical intensive care unit and 41 patients required mechanical ventilation, whereas during the 4-month intervention phase, 1271 patients were managed in the unit and 96 patients required mechanical ventilation. The project was associated with a 24% (0.89-day) reduction in the mean length of stay (3.72 vs 2.83 days) and a 46.3% (2.81 day) reduction in mechanical ventilation duration (6.06 vs 3.25 days) when comparing August 2019 to January 2020. A standardized rounding tool emphasizing a coordinated process for spontaneous awakening and breathing trials was associated with a shorter length of stay and duration of mechanical ventilation among patients in the medical intensive care unit. An evidence-based approach to weaning from mechanical ventilation and standardized rounding may be a cost-effective way to reduce mechanical ventilation duration and length of stay in a medical intensive care unit.

Weaning and liberation from mechanical ventilation in pediatric patients with tracheostomy and long-term mechanical ventilation constitute a challenging process due to diagnosis heterogeneity and significant variability in the clinical condition. We aimed to evaluate the physiological response during the first attempt of a spontaneous breathing trial (SBT) and to compare variables in subjects who failed or passed the SBT. This was a prospective observational study in tracheostomized children with long-term mechanical ventilation admitted to the Hospital Josefina Martinez, Santiago, Chile, between 2014-2020. Cardiorespiratory variables such as breathing pattern, use of accessory respiratory muscles, heart rate, breathing frequency, and oxygen saturation were registered at baseline and throughout a 2-h SBT with or without positive pressure depending on an SBT protocol. Comparison of demographic and ventilatory variables between groups (SBT failure and success) was performed. A total of 48 subjects were analyzed (median [IQR] age of 20.5 [17.0-35.0] months, 60% male). Chronic lung disease was the primary diagnosis in 60% of subjects. Eleven (23%) total subjects failed the SBT (< 2 h), with an average failure time of 69 ± 29 min. Subjects who failed the SBT had a significantly higher breathing frequency, heart rate, and end-tidal CO2 than subjects who succeeded (P < .001). In addition, subjects who failed the SBT had significantly shorter duration of mechanical ventilation before the SBT, higher proportion unassisted SBT, and higher rate of deviation SBT protocol in comparison with subjects who succeeded. Conducting an SBT to evaluate the tolerance and cardiorespiratory response in tracheostomized children with long-term mechanical ventilation is feasible. Time on mechanical ventilation before the first attempt and type of SBT (with or without positive pressure) could be associated with SBT failure.