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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. TRIAL REGISTRATION: registered in ClinicalTrials.gov on October 07, 2021(NCT05085457).