This document describes a new protocol for extubating patients with neuromuscular weakness who could not pass conventional spontaneous breathing trials. The protocol involved extubating 157 patients directly to noninvasive ventilation and aggressive mechanically assisted coughing. Extubation success was defined as not requiring re-intubation during hospitalization. Using this protocol, the first attempt extubation success rate was 95%. Factors associated with success included higher assisted cough peak flows, prior dependence on continuous noninvasive ventilation, and longer duration of prior noninvasive ventilation use. The protocol demonstrated that patients considered unweanable by conventional standards can often be safely extubated using noninvasive ventilation and cough assistance.