Comparative Diagnostic Accuracy of Predictors of Successful Weaning in Mechanically Ventilated Adults: A Systematic Review and Network Meta-Analysis.
TL;DR
Current evidence does not support a single universally optimal predictor and weaning decisions should rely on comprehensive clinical assessment rather than any single index alone, suggesting that no single index should be used in isolation to guide weaning decisions.
Abstract
Aims
AND
Objective
To compare the diagnostic accuracy of diagnostic predictors of successful weaning in mechanically ventilated adults using network meta-analysis.
Background
Timely liberation from mechanical ventilation is linked to patient outcomes, but the comparative performance of available predictors remains unclear.
Design
A systematic review and network meta-analysis.
Methods
We searched PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science from inception to April 8, 2026. Eligible diagnostic accuracy studies evaluated predictors of successful weaning in mechanically ventilated adults. The reference standard was successful liberation or extubation without reintubation or reinstitution of invasive ventilatory support within the study-defined window, most commonly 48 h. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, and certainty was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Results
Twenty-seven studies involving 2938 participants were included in the network meta-analysis and evaluated eight predictors. Four additional eligible studies were not synthesised quantitatively because each evaluated a predictor reported in only one study. The extubation predictive score (ExPreS) was excluded from the connected network because it was evaluated in two single-method studies without head-to-head comparisons, leaving seven predictors. Diaphragmatic excursion, diaphragm thickening fraction, and rapid shallow breathing index formed the core evidence network, and no significant threshold effect was detected. The network meta-analysis showed no clear statistical superiority of any single predictor. Surface under the cumulative ranking curve (SUCRA) rankings suggested that mechanical ventilation duration and diaphragmatic excursion tended to rank higher for overall discrimination and specificity, whereas rapid shallow breathing index and negative inspiratory force ranked higher for sensitivity.
Conclusion
Current evidence does not support a single universally optimal predictor. Diaphragmatic excursion showed a relatively balanced diagnostic profile, but this should be interpreted as a comparative signal rather than definitive superiority because certainty was generally low or very low. Weaning decisions should rely on comprehensive clinical assessment rather than any single index alone. IMPACT What problem did the study address? Clinicians caring for mechanically ventilated adults have multiple candidate predictors of weaning success, but their comparative diagnostic accuracy has remained uncertain, making bedside weaning decisions variable and potentially inconsistent. What were the main findings? Across 27 studies involving 2938 participants included in the network meta-analysis, no single predictor showed clear statistical superiority across all comparisons. Diaphragmatic excursion showed a relatively balanced diagnostic profile, whereas rapid shallow breathing index and negative inspiratory force ranked higher for sensitivity and mechanical ventilation duration ranked higher for overall discrimination and specificity; however, the certainty of evidence was generally low or very low. Where and on whom will the research have an impact? The findings are most relevant to critical care nurses, intensivists, respiratory therapists and multidisciplinary intensive care unit (ICU) teams caring for mechanically ventilated adults. They support a multidimensional weaning assessment strategy and may improve the safety and consistency of liberation decisions in adult critical care settings. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings suggest that no single index should be used in isolation to guide weaning decisions. Diaphragmatic excursion may be a useful adjunct because of its relatively balanced diagnostic profile, but bedside decisions should continue to integrate ultrasound-based measures, conventional respiratory indices, spontaneous breathing trial performance and overall clinical assessment to support safer, more individualised patient care. REPORTING
Method
This manuscript adhered to relevant Enhancing the QUAlity and Transparency Of health Research (EQUATOR) reporting guidance, specifically the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses incorporating Network Meta-analyses. NO PATIENT OR PUBLIC CONTRIBUTION Patients, service users, caregivers or members of the public were not involved in the design, conduct, analysis, interpretation or manuscript preparation for this systematic review and network meta-analysis. TRIAL REGISTRATION The protocol for this systematic review was prospectively registered in PROSPERO (registration number CRD420261362977). Because this study was a systematic review and network meta-analysis rather than a clinical trial, trial registration was not applicable.