Table 2. Bedside Checklist for Direct Extubation to NIV in Neuromuscular Disease (NMD) Patients Admitted to the ICU for an Acute Trigger.
Underlying premise: This checklist assumes the defining condition of the NMD weaning scenario - the lung parenchyma is preserved, and intubation was driven by a transient worsening of chronic muscle weakness (e.g., from an acute infection) rather than by lung disease itself.

Domain Specific criterion Comment
1. Resolution of acute trigger Acute infection (pneumonia, sepsis) improving: declining CRP / procalcitonin trend; afebrile ≥ 24 h; hemodynamic stability without vasopressors; chest imaging stable or improving The acute event — not the underlying NMD — must be resolving; the underlying NMD itself is not expected to recover
2. Consciousness and cooperation Alert enough to cooperate with care: able to follow the care team's instructions and coordinate with NIV interface application and cough augmentation therapy (manually-assisted cough and/or MI-E); intermittent sedation acceptable if the patient is cooperative when awake NIV and cough augmentation success depends on the patient's ability to cooperate with the care team; a specific sedation score is less important than reliable cooperation when awake
3. Gas exchange targets Under the intended post-extubation support (full-setting NIV), gas exchange remains within target: SpO2 ≥ 95% on ambient air (a persistent supplemental O2 requirement indicates an unresolved acute insult); PaCO2 at or near the patient's chronic baseline (individualized; absolute normalization not required); pH ≥ 7.35 Because lung parenchyma is preserved in this scenario, maintenance of gas-exchange targets on NIV — not on the ventilator — confirms the acute insult has resolved and that ventilatory-muscle support alone now suffices; failure to hold targets on NIV signals an unresolved pulmonary problem. Chronic hypercapnia is the baseline in many NMD patients, so PaCO2 normalization is not required.
4. Airway protection Adequate cough: assisted peak cough flow (PCF) ≥ 160 L/min (ideally ≥ 270 L/min); manageable bulbar function (no severe oral pooling); able to handle oral secretions Insufficient cough is the most common cause of NIV failure; effective cough augmentation (manually-assisted cough and/or MI-E) should be established and confirmed effective before extubation, with the assisted PCF threshold serving as the practical benchmark
5. NIV readiness NIV interface fitted (oronasal or nasal mask, individualized); initial ventilator settings selected and then titrated to response (full-setting NIV: high-span inspiratory pressure with mandatory backup rate); cough augmentation therapy available; established home NIV users are often already adapted and need little additional preparation, whereas NIV-naive patients require a planned adaptation period and close monitoring for interface intolerance, asynchrony, and secretion-handling difficulty Settings are adjusted iteratively rather than fixed in advance. Patients already established on home NIV are typically adapted and require minimal additional readiness work. NIV-naive patients are the higher-risk group: a pre-extubation adaptation trial, interface and synchrony optimization, and a low threshold for early support escalation should be planned in advance. Caregiver training on the interface and cough augmentation proceeds in parallel where applicable.
6. Destination-ward readiness Arranged as part of the extubation plan: NIV device and cough augmentation therapy available; nursing / respiratory-therapy staff oriented to their use; a physiatrist or pulmonologist accessible for adjustment; escalation / transfer pathway agreed in advance Unlike the patient-side items, this is a system-level factor — and an underrecognized contributor to failed NMD extubation when overlooked. The point is not that extubation is permissible only in fully-equipped wards, but that ward readiness should be arranged in advance alongside patient readiness, through targeted staff orientation or involving the rehabilitation / pulmonary team in the transfer. Where the team is not confident that adequate NIV and cough-augmentation support can be provided, referral to a center experienced in neuromuscular respiratory care is the appropriate and safe option rather than proceeding and managing failure reactively.
7. Contingency plan Reintubation criteria pre-specified (refractory hypercapnia with worsening sensorium; hemodynamic instability; secretion management failure despite cough augmentation); escalation pathway documented, consistent with the transfer / referral plan in item 6 Predefined criteria reduce delayed reintubation and prevent inappropriate prolongation of NIV in failing patients
Items 1–5 address the patient; item 6 addresses destination-ward readiness; item 7 establishes the safety net. Cough augmentation therapy denotes manually-assisted cough and/or mechanical insufflation-exsufflation (MI-E); the specific modality is individualized rather than fixed to a single device.
CRP: C-reactive protein. MAC: manually-assisted cough, MI-E: mechanical insufflation-exsufflation, NIV: non-invasive ventilation, NMD: neuromuscular disease, PaCO2: partial pressure of carbon dioxide in arterial blood, PCF: peak cough flow, SpO2: peripheral oxygen saturation.