Tracheal reintubation: caused by "too much of a good thing"?

William Shakespeare coined the phase when he wrote in As You Like It: “Can one desire too much of a good thing?” For many years now we have concentrated our efforts on liberating the patient from ventilatory support. The removal of the endotracheal tube (ETT) has been seen as a mere afterthought at the end of the liberation process. However, this approach results in an extubation failure rate (ie, the need for reintubation within 48–72 h) exceeding 30% in some studies.1 Did we desire too much of a good thing? Liberation from the ventilator and liberation from the ETT are 2 different processes that should be separated. With a greater appreciation of the adverse outcomes, attention has now moved to refining liberation from the ETT, namely, the decision to extubate after having passed a spontaneous breathing trial (SBT). In this issue of RESPIRATORY CARE, Menon et al2 add to our understanding of the incidence, patient characteristics, and consequences of tracheal reintubation among critically ill patients. In their retrospective cohort study, 11% of patients required reintubation within 48 hours of extubation. The patients requiring reintubation were older, more likely to be male, and had higher Simplified Acute Physiology Score II on admission. Reintubation was associated with 5-fold increase in mortality and 2-fold increase in median ICU stay, hospital stay, and institutional costs. Difficult intubation was also associated with increased mortality.