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To determine the degree to which neurologic function, cough peak flows and quantity of endotracheal secretions affected the extubation outcomes of patients who had passed a trial of spontaneous breathing (SBT).Prospective observational study.The medical intensive care unit of a 325-bed teaching hospital.Cough peak flow (CPF), endotracheal secretions and ability to complete four simple tasks were measured just before extubation in patients who had passed a SBT. Eighty-eight patients were studied; 14 failed their first trials of extubation. The CPF of patients who failed was lower than that of those who had a successful extubation (58.1±4.6 l/min vs 79.7±4.1 l/min, p=0.03) and those with CPF 60 l/min or less were nearly five times as likely to fail extubation compared to those with CPF higher than 60 l/min (risk ratio [RR]=4.8; 95% CI=1.4–16.2). Patients with secretions of more than 2.5 ml/h were three times as likely to fail (RR=3.0; 95% CI=1.0–8.8) as those with fewer secretions. Patients who were unable to complete four simple tasks (i.e. open eyes, follow with eyes, grasp hand, stick out tongue) were more than four times as likely to fail as those who completed the four commands (RR=4.3; 95% CI=1.8–10.4). There was synergistic interaction between these risk factors. The failure rate was 100% for patients with all three risk factors compared to 3% for those with no risk factors (RR=23.2; 95% CI=3.2–167.2). The presence of any two of the above risk factors had a sensitivity of 71 and specificity of 81% in predicting extubation failure. Patients who failed a trial of extubation were 3.8 times as likely to have any two risk factors compared to those who were successful.These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT.