Effect of the extubation predictive score (ExPreS) on reintubation in the ICU: a randomized controlled trial

Extubation failure occurs in 10–30% of critically ill patients who successfully complete a spontaneous breathing trial (SBT) and is associated with worse clinical outcomes. The Extubation Predictive Score (ExPreS) was developed to assist clinicians in identifying patients at risk for extubation failure; however, its effectiveness as a decision-support tool has not yet been evaluated in a randomized controlled trial. We aimed to determine whether the use of ExPreS reduces reintubation within 48 h in mechanically ventilated adults. We conducted a single-center, parallel-group, prospective, randomized, controlled superiority trial in two ICUs of a Brazilian university hospital (November 2021–December 2024). Adults ventilated ≥ 24 h who passed an SBT were randomized (1:1) to extubation guided by a standard protocol or by the ExPreS algorithm (score range 0–100; eight clinical variables). The primary outcome was extubation failure, defined as reintubation within 48 h. Secondary outcomes included duration of mechanical ventilation, ICU length of stay, and ICU mortality. A total of 540 patients were randomized (267 control, 273 ExPreS). In the intention-to-treat analysis, extubation failure within 48 h occurred in 13.0% of patients in the control group and 8.0% in the ExPreS group (absolute risk reduction 5.0%; relative reduction 38%; p = 0.070). In the per-protocol analysis, extubation failure occurred in 12.9% of controls and 7.3% of ExPreS patients (absolute risk reduction 5.6%; relative reduction 43%; p = 0.042). In a post-hoc analysis excluding airway obstruction, failure was further reduced with ExPreS (3.4% vs. 9.1%; p = 0.011). No differences were observed in duration of mechanical ventilation, ICU length of stay, or ICU mortality. In this randomized controlled trial, use of the Extubation Predictive Score (ExPreS) was associated with numerically lower rates of reintubation within 48 h compared with standard care, although the primary intention-to-treat analysis did not reach statistical significance. Secondary and exploratory analyses showed a consistent direction of effect. These findings should be interpreted cautiously and warrant confirmation in larger multicenter studies. registered in ClinicalTrials.gov on October 07, 2021(NCT05085457).