ObjectiveTo determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure.DesignTwelve-month prospective, observational, clinical study.SettingSixteen diverse PICUs in the United States.PatientsPatients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial.InterventionsNone.Measurements and Main ResultsA descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3–7.1). Patient features associated with extubation failure (p< .05) included age ≤24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, sd ± 207.8 vs. success, 107.9 hrs, sd ± 171.3;p< .001), longer PICU length of stay (17.5 days, sd ± 15.6 vs. 7.6 days, sd ± 11.1;p< .001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%;p< .001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not.ConclusionA variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.