When the Breathing Tube Has to Go Back In: What Families Should Know About Extubation in Premature Babies

Three recent studies from China, India and Saudi Arabia (Tan et al. 2025, George et al. 2026, Ali et al. 2026) on which babies may need the tube put back, how long a breathing test needs to be, and what a failed attempt means

Premature babies on a breathing machine sometimes need their breathing tube put back in within days of it being removed. Three new studies looked at which babies are most likely to need this, whether a 3-minute breathing test works as well as a 10-minute one, and what it means afterwards. Being born earlier was the most consistent warning sign, and needing the tube back is a sign that a baby may need more time and closer watching.

Why taking the tube out is such a big step

Many babies born very early need help to breathe. A soft plastic tube is passed through the mouth or nose into the windpipe and connected to a breathing machine, called a ventilator. Doctors and nurses want to remove the tube, a step called "extubation," as soon as the baby can manage, because a ventilator can injure delicate lungs [1]. After the tube comes out, most babies still get gentler help through small prongs or a mask at the nose. Sometimes, though, a baby tires, stops breathing for short spells, or cannot get enough oxygen, and the tube has to go back in. When that happens within three days, doctors call it "extubation failure." The word sounds harsh, but it describes something common and expected in very small babies, not a mistake. The three recent studies described in this article, from China [2], India [3] and Saudi Arabia [4], all used this three-day definition.

How doctors have tried to get the timing right

For many years, neonatal teams (the doctors and nurses who care for newborns in intensive care) have looked for a reliable way to know when a baby is ready. About twenty years ago, a group of researchers tested a simple idea: before removing the tube, turn off the machine's breaths for 3 minutes and let the baby breathe on their own through the tube while staff watch heart rate and oxygen levels. In 50 very small babies, this short test was good at picking out those who would manage without the tube [5]. Even so, hospitals did not all adopt it in the same way. When units in several countries were surveyed, only about 1 in 6 used such a test routinely, and those that did ran it for anything from 3 minutes to more than 10 minutes [6]. Researchers also could not agree on how long to wait before calling a removal "successful": studies used anything from half a day to a full week [7]. At the same time, a large study showed that babies who needed the tube put back tended to have a harder course. In one group of more than 900 babies born at 24 to 27 weeks of pregnancy, cared for in hospitals of a large United States research network, those whose tube had to be replaced were more likely to develop long-term lung disease or to die [8]. Families were often left wondering whether the failed attempt had caused these problems, or whether it was simply a sign of how fragile their baby already was.

The three new studies

The three studies in this article each looked at a different part of that story. All three looked back at hospital records rather than testing a new treatment, and in all three a removal counted as unsuccessful if the tube had to go back in within 72 hours.

In China, Tan and colleagues studied 265 babies weighing less than 1,500 g (about 3.3 pounds) who were treated for breathing problems caused by immature lungs [2]. They built a scoring chart from five pieces of information and then checked it on 71 babies at a second hospital, Huzhou Maternal & Child Health Care Hospital.

In India, George and colleagues at Kasturba Medical College in Manipal compared two versions of the breathing test [3]. In the first half of 2018 their unit used a 10-minute test; in the second half it used a 3-minute test. Each group had 44 babies.

In Saudi Arabia, Ali and colleagues at King Abdulaziz Medical City in Riyadh reviewed nine years of records for 877 babies born before 32 weeks of pregnancy who had at least one planned tube removal [4].

What the researchers found

Being born earlier was the one warning sign found in all three studies. In the Saudi study, about 1 in 10 babies overall (89 of 877) needed the tube back. But the chance depended strongly on how early the baby was born: 42 of 187 babies born before 26 weeks (a little more than 1 in 5) compared with 12 of 244 babies born at 30 to 31 weeks (about 1 in 20) [4].

The Chinese study found that a few other things also mattered [2]. Babies who needed the tube back more often had a larger patent ductus arteriosus, or PDA (a blood vessel near the heart that normally closes after birth but often stays open in premature babies). They also had a slightly lower level of red blood cells and more often had a bloodstream infection (sepsis). Combining these factors with how early and how small the baby was gave a chart that sorted babies well in both hospitals. However, the infection information included some infections found after the tube was removed, and the authors themselves say the chart needs testing in more hospitals before it is used widely. An earlier study of 360 very small babies had also linked a larger open PDA with needing the tube back, while noting that it was not yet known whether treating the PDA helps [9].

The Indian study found that the 3-minute breathing test worked about as well as the 10-minute one [3]. Similar numbers of babies passed each test (36 of 44 with the 10-minute test, 38 of 44 with the 3-minute test). Of the 74 babies who passed and had their tube removed, 17 needed it back within three days, and the difference between the two groups could have been due to chance. Most babies who struggled during the test did so in the first 3 minutes. How much breathing support a baby needed beforehand mattered more than the length of the test, which fits with an earlier study that found the same measure useful [10].

The Saudi study looked at what happened next [4]. Among babies who survived, about half of those who needed the tube back (50.6%) went on to develop moderate or severe bronchopulmonary dysplasia, or BPD, a long-term lung condition in which babies still need breathing support several weeks after birth, when they reach 36 weeks counted from the start of pregnancy. This compared with about 1 in 5 (18.7%) of babies whose first removal went well. Doctors grade BPD by how much breathing help a baby needs at that point [11]. Babies who needed the tube back also spent more days on the ventilator (a typical 31 days compared with 6) and stayed in hospital longer (a typical 97 days compared with 59). Reassuringly, the chance of dying before going home was similar in both groups, about 7 in 100.

What these findings mean for your baby

If your baby was born very early, it is normal for the team to try removing the tube and normal for some babies to need it back. These studies suggest that the most important factor is simply how early a baby was born, which no one can change. Other factors, such as an open PDA, infection or how much oxygen a baby needs, may help the team choose a good moment, and the team may wait for these to improve.

If the tube does need to go back in, it does not mean anyone did something wrong. The Saudi researchers were careful to say that needing the tube back marks babies who are at higher risk; their study cannot show that the failed attempt itself causes later lung problems [4]. It can, however, be a sign that your baby may need a longer stay and closer watching of the lungs. You might ask your team how they decide when your baby is ready, what support your baby will have after the tube comes out, and whether they will be watching for BPD.

After the tube is removed, babies are usually given gentle pressure through nasal prongs, which may help them stay off the ventilator [12]. In[Neo]Sight has also written about steroid medicines used to try to prevent BPD.

Honest limits of these studies

All three studies looked back at records from one or two hospitals each, so they show links rather than proof. The Indian study compared two time periods rather than assigning babies at random, and its groups were not perfectly matched. Some numbers in the papers did not add up exactly; we explain these in this cluster's Source Transparency Report. Teams around the world differed widely in how they decided on tube removal in a 2015 international survey, which is part of why studies like these matter [6].

What researchers are working on next

The researchers agree on what is needed: larger studies across many hospitals, following babies forward in time rather than looking back. These would test whether a scoring chart that uses only information available before the tube comes out can reliably guide doctors, and whether a 3-minute breathing test is truly as good as a longer one when babies are assigned to each at random. Researchers also want to understand why babies who need the tube back have more lung problems, so that care can focus on what truly helps.

For now, the message for families is steady and hopeful. Researchers are working on better ways to choose the right moment, a short breathing test may be enough, and if the tube has to go back in, it often means your baby's lungs need more time and closer watching.

References

  1. Sangsari R, Saeedi M, Maddah M, Mirnia K, Goldsmith JP. Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review. BMC Pulm Med. 2022;22(1):421. doi:10.1186/s12890-022-02223-4 ↩
  2. Tan C, Sui Y, Wang L. Nomogram-based prediction model for extubation failure in preterm infants with invasive mechanical ventilation. Ital J Pediatr. 2025;51(1):313. doi:10.1186/s13052-025-02157-7 ↩
  3. George J, Joseph MS, Samuel PC, Purkayastha J, Kini S. 3-minute vs 10-minute Spontaneous Breathing Evaluations (SBE) for predicting extubation success in preterm very low birth weight infants: Retrospective observational study. J Neonatal Perinatal Med. 2026;19(6):687-696. doi:10.1177/19345798261450453 ↩
  4. Ali K, Aljarbou T, Algarni S, et al. Extubation failure in very preterm infants: associations with respiratory outcomes in a nine-year cohort study. BMC Pediatr. 2026;26(1):1023. doi:10.1186/s12887-026-07399-w ↩
  5. Kamlin CO, Davis PG, Morley CJ. Predicting successful extubation of very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2006;91(3):F180-183. doi:10.1136/adc.2005.081083 ↩
  6. Al-Mandari H, Shalish W, Dempsey E, Keszler M, Davis PG, Sant'Anna G. International survey on periextubation practices in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed. 2015;100(5):F428-431. doi:10.1136/archdischild-2015-308549 ↩
  7. Giaccone A, Jensen E, Davis P, Schmidt B. Definitions of extubation success in very premature infants: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2014;99(2):F124-127. doi:10.1136/archdischild-2013-304896 ↩
  8. Chawla S, Natarajan G, Shankaran S, et al. Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation. J Pediatr. 2017;189:113-119.e2. doi:10.1016/j.jpeds.2017.04.050 ↩
  9. Gupta D, Greenberg RG, Natarajan G, et al. Association of patent ductus arteriosus with extubation failure among preterm infants. Pediatr Pulmonol. 2023;58(7):1977-1981. doi:10.1002/ppul.26420 ↩
  10. Mhanna MJ, Iyer NP, Piraino S, Jain M. Respiratory severity score and extubation readiness in very low birth weight infants. Pediatr Neonatol. 2017;58(6):523-528. doi:10.1016/j.pedneo.2016.12.006 ↩
  11. Jensen EA, Dysart K, Gantz MG, et al. The Diagnosis of Bronchopulmonary Dysplasia in Very Preterm Infants. An Evidence-based Approach. Am J Respir Crit Care Med. 2019;200(6):751-759. doi:10.1164/rccm.201812-2348OC ↩
  12. Ho JJ, Kidman AM, Chua B, Chang G, Fiander M, Davis PG. Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev. 2024;10(10):CD000143. doi:10.1002/14651858.CD000143.pub2 ↩