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Weaning from mechanical ventilation: The rapid

shallow breathing index
Author: Scott K Epstein, MD
Section Editor: Polly E Parsons, MD
Deputy Editor: Geraldine Finlay, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2020. | This topic last updated: Aug 12, 2019.

INTRODUCTION

Determining readiness for weaning involves several parameters, among which the rapid
shallow breathing index (RSBI) is one. The definition, accuracy, effect on clinical outcomes,
and measurement of the RSBI are reviewed here. The role of the RSBI in readiness testing,
general aspects of readiness testing, methods of weaning, and extubation are described
separately. (See "Weaning from mechanical ventilation: Readiness testing" and "Initial
weaning strategy in mechanically ventilated adults" and "Extubation management in the
adult intensive care unit".)

DEFINITION

Discontinuing mechanical ventilation is a two-step process:

● Readiness testing – Readiness testing refers to the evaluation of objective clinical criteria
in order to decide whether a patient is ready to begin the process of discontinuing
mechanical ventilation. Some clinicians also use physiological tests, known as weaning
predictors, to predict whether a patient is ready because they are hesitant to begin
weaning on the basis of clinical criteria alone.

The rapid shallow breathing index (RSBI) is one of the best studied and most commonly
used weaning predictors. The RSBI is the ratio of respiratory frequency to tidal volume
(f/VT). As an example, a patient who has a respiratory rate of 25 breaths/min and a tidal
volume of 250 mL/breath has an RSBI of (25 breaths/min)/(.25 L) = 100 breaths/min/L.
Patients who cannot tolerate independent breathing tend to breathe rapidly (high

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frequency) and shallowly (low tidal volume). Thus, they generally have a high RSBI, while
patients who can tolerate independent breathing tend to breathe more slowly (lower
frequency) and deeply (higher tidal volume). Thus, they generally have a low RSBI.

● Weaning – Weaning is the process of decreasing ventilator support and allowing

patients to assume a greater proportion of their ventilation. It may involve either an
immediate shift from full ventilatory support to a period of breathing without assistance
from the ventilator (ie, a spontaneous breathing trial [SBT]) or a gradual reduction in the
amount of ventilator support [1,2]. Regardless of which approach is chosen, extubation
is considered once the patient demonstrates the ability to breathe without the
ventilator.

MEASUREMENT

We suggest that the respiratory frequency (f) and tidal volume (VT) be measured using a
hand-held spirometer attached to the endotracheal tube while a patient is breathing room
air for one minute without any ventilator assistance [3]. The frequency and tidal volume can
then be used to calculate the rapid shallow breathing index (RSBI).

There are many variables that may influence measurement of the RSBI:

● Ventilator support – If the RSBI is measured on ventilatory support, the values will be
lower than if measured during independent breathing [4,5]. This was demonstrated by a
study of 36 patients that measured the RSBI during pressure support ventilation,
continuous positive airway pressure (CPAP), and independent breathing through a T-
piece in each patient [4]. The RSBI was <105 breaths/min/L during pressure support
ventilation (PSV) and CPAP in all patients, but increased to >105 breaths/min/L during
independent breathing through the T-piece in 13 of the 36 patients (36 percent).
Another study of 80 patients found a significant 17 percent decrease in RSBI
(determined on CPAP and PSV set at 0 cm H2O), when comparing measurements made
with and without flow triggering [6]. To reduce this confounding influence, we set the
ventilator to a pressure support level of 0 cm H2O and a positive end-expiratory pressure
(PEEP) of 0 cm H2O, without flow trigger, if we plan to measure the RSBI while the
patient is connected to the ventilator [6,7].

● Method of measuring the respiratory frequency – If the RSBI is determined while the
patient is breathing through the ventilator, one must be cautious about using the
respiratory rate measured by the ventilator because it may be underestimated if the
patient makes inspiratory efforts that are not sensed by the ventilator (untriggered
breaths). Such unmeasured inspiratory efforts falsely lower the RSBI. This is most likely

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to occur in patients who have chronic obstructive lung disease with dynamic
hyperinflation [8].

● Other – A number of other factors have been shown to increase the RSBI, including a
narrow endotracheal tube, female gender, sepsis, fever, supine position, anxiety,
suctioning, and chronic restrictive lung disease. In one study, women and those with a
narrow endotracheal tube were more likely than others to have an RSBI >100
breaths/min/L, independent of the weaning outcome [9]. In another study, endotracheal
suctioning increased the RSBI for up to five minutes, often rising to >100 breaths/min/L
[10].

ACCURACY

Evidence suggests that a negative RSBI (RSBI ≥105 breaths/min/L) is better at identifying
patients who will fail weaning than a positive RSBI (RSBI <105 breaths/min/L) is at identifying
patients who can be successfully weaned.

The rapid shallow breathing index (RSBI) was originally described in a prospective cohort
study that evaluated a population of mechanically ventilated patients [3]. The study found
that an RSBI >105 breaths/min/L was associated with weaning failure, while an RSBI <105
breaths/min/L predicted weaning success with a sensitivity, specificity, positive predictive
value, and negative predictive value of 97, 64, 78, and 95 percent, respectively. The pretest
probability of weaning success in the study population was approximately 60 percent.

The sensitivity is the probability that a patient who successfully weans will have an RSBI <105
breaths/min/L and the specificity is the probability that a patient who fails weaning will have
an RSBI ≥105 breaths/min/L. The positive predictive value is the probability of successfully
weaning when the RSBI is <105 breaths/min/L and the negative predictive value is the
probability of failing weaning when the RSBI is >105 breaths/min/L.

Positive and negative predictive values are not optimal measures for assessing the quality of
a weaning predictor, since they vary according to the pretest probability (ie, prevalence) of
weaning success in the population studied. Likelihood ratios are better measures because
they are independent of the pretest probability. The likelihood ratio positive (LR+) and
likelihood ratio negative (LR-) are calculated as shown in the table ( table 1). The greater
the deviation of the LR+ from 1, the more powerful a positive test is as a predictor of a
positive outcome. The greater the deviation of the LR- from 1, the more powerful a negative
test is as a predictor of a negative outcome. (See "Evaluating diagnostic tests".)

When data from the original prospective cohort study were used to calculate likelihood
ratios, the LR+ was 2.7 and the LR- was 0.05. This indicated that there was only a small
increase in the probability of weaning success among patients with a positive RSBI (<105
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breaths/min/L). In contrast, there was a large increase in the probability of weaning failure
among patients with a negative RSBI (≥105 breaths/min/L).

These findings were supported by a systematic review of 20 RSBI studies [11]. Pooled results
of predictors of success in trials of unassisted breathing found an LR+ of 1.66 to 2.1 and an
LR- of 0.11, indicating that there is only a small increase in the probability of weaning
success among patients with a positive RSBI, but a moderate increase in the probability of
weaning failure among patients with a negative RSBI. A Bayesian analysis of the same
studies found similar LR+ and LR- values, supporting the conclusions from the systematic
review [12].

CLINICAL OUTCOMES

Use of the rapid shallow breathing index (RSBI) has not been shown to decrease duration of
weaning or mechanical ventilation. For example, in one trial 304 mechanically ventilated
patients [13] had their RSBI measured daily and all of the patients underwent daily
screening. Patients randomized to RSBI-dependent weaning underwent an SBT if they
passed all components of the screening and had an RSBI <105 breaths/min/L. In contrast,
patients randomized to RSBI-independent weaning underwent an SBT if they passed all
components of the screening, regardless of their RSBI. The group that underwent RSBI-
dependent weaning took one day longer to discontinue mechanical ventilation. There was
no difference in the total duration of mechanical ventilation, length of stay, or reintubation
rate.

A limitation of the trial was that it used a single RSBI threshold; many clinicians with
expertise in discontinuing mechanical ventilation believe the optimal threshold varies from
patient to patient. The trial was otherwise rigorously conducted. There did not appear to be
any selection bias, since the trial's RSBI-independent weaning group had a nearly identical
rate of weaning success (59 percent) compared to that seen in the original prospective
cohort study described above [3].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Weaning from
mechanical ventilation".)

SUMMARY AND RECOMMENDATIONS

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● Discontinuing mechanical ventilation is a two-step process that consists of readiness

testing and weaning. During readiness testing, some clinicians also use physiological
tests, known as weaning predictors. The rapid shallow breathing index (RSBI) is a
popular weaning predictor. It is the ratio of respiratory frequency to tidal volume (f/VT).
(See 'Introduction' above and 'Definition' above.)

● We suggest the RSBI be measured using a hand-held spirometer attached to the

endotracheal tube while a patient is breathing room air for one minute without any
ventilator assistance. There are many factors that may influence the measurement of
the RSBI. (See 'Measurement' above.)

● There is only a small increase in the probability of weaning success among patients with
an RSBI <105 breaths/min/L, but a moderate increase in the probability of weaning
failure among patients with an RSBI ≥105 breaths/min/L. In other words, an RSBI ≥105
breaths/min/L is better at identifying patients who will fail weaning than an RSBI <105
breaths/min/L is at identifying patients who can be successfully weaned. (See 'Accuracy'
above.)

● There is no evidence that RSBI-dependent weaning improves clinical outcomes, such as

duration of weaning, duration of mechanical ventilation, length of stay, or reintubation
rate. (See 'Clinical outcomes' above.)

● The role of the RSBI in readiness testing is discussed separately.

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REFERENCES
1. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients
from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med
1995; 332:345.

2. Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual

withdrawal from ventilatory support during weaning from mechanical ventilation. Am J
Respir Crit Care Med 1994; 150:896.

3. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of
weaning from mechanical ventilation. N Engl J Med 1991; 324:1445.

4. El-Khatib MF, Zeineldine SM, Jamaleddine GW. Effect of pressure support ventilation
and positive end expiratory pressure on the rapid shallow breathing index in intensive
care unit patients. Intensive Care Med 2008; 34:505.

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5. Patel KN, Ganatra KD, Bates JH, Young MP. Variation in the rapid shallow breathing
index associated with common measurement techniques and conditions. Respir Care
2009; 54:1462.

6. Kheir F, Myers L, Desai NR, Simeone F. The effect of flow trigger on rapid shallow
breathing index measured through the ventilator. J Intensive Care Med 2015; 30:103.

7. Desai NR, Myers L, Simeone F. Comparison of 3 different methods used to measure the
rapid shallow breathing index. J Crit Care 2012; 27:418.e1.

8. Purro A, Appendini L, De Gaetano A, et al. Physiologic determinants of ventilator

dependence in long-term mechanically ventilated patients. Am J Respir Crit Care Med
2000; 161:1115.

9. Epstein SK, Ciubotaru RL. Influence of gender and endotracheal tube size on
preextubation breathing pattern. Am J Respir Crit Care Med 1996; 154:1647.

10. Seymour CW, Cross BJ, Cooke CR, et al. Physiologic impact of closed-system
endotracheal suctioning in spontaneously breathing patients receiving mechanical
ventilation. Respir Care 2009; 54:367.

11. Meade M, Guyatt G, Cook D, et al. Predicting success in weaning from mechanical
ventilation. Chest 2001; 120:400S.

12. Tobin MJ, Jubran A. Variable performance of weaning-predictor tests: role of Bayes'
theorem and spectrum and test-referral bias. Intensive Care Med 2006; 32:2002.

13. Tanios MA, Nevins ML, Hendra KP, et al. A randomized, controlled trial of the role of
weaning predictors in clinical decision making. Crit Care Med 2006; 34:2530.

Topic 1614 Version 13.0

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GRAPHICS

Likelihood ratios

Likelihood ratio (LR) Calculation Change in probability of success or failure

LR positive Sensitivity/(1-specificity) LR = 1-2, none/minimal

LR = 2-5, small

LR = 5-10, moderate

LR >10 = large

LR negative (1-sensitivity)/specificity LR = 0.5-1, none/minimal

LR = 0.3-0.5, small

LR = 0.1-0.3, moderate

LR <0.1 = large

LR: likelihood ratio.

Graphic 72793 Version 1.0

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Contributor Disclosures
Scott K Epstein, MD Nothing to disclose Polly E Parsons, MD Nothing to disclose Geraldine Finlay,
MD Consultant/Advisory Boards: LAM Board of directors, LAM scientific grant review committee for
The LAM Foundation.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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