Extubating Extremely Preterm Infants: Predictors of Success and Outcomes following Failure

Factors associated with extubation failure in very low birth weight infants: a cohort study in the northeast Brazil

OBJECTIVES

Identifying and understanding the main risk factors associated with extubation failure of very low birthweight (VLBW) infants in different populations can subsequently help in establishing better criteria while taking decision of extubation. The aim of the study was to identify factors associated with extubation failure in VLBW infants.

METHODS

A cohort study of VLBW infants who underwent their first extubation between April 2018 and December 2019 in a Neonatal Intensive Care Unit, Alagoas, Brazil, were included in this study. Extubation failure was defined as reintubation within seven days of extubation. Relative risks of predictive variables different between the extubation success group (ES) and extubation failure group (EF) were estimated with a robust Poisson regression model.

RESULTS

Out of the 112 infants included, 26 (23%) cases exhibited extubation failure. Extremely low birth weight (RR 2.55, 95% CI 1.07, 6.06), mechanical ventilation duration for first extubation greater than seven days (RR 2.66, 95% CI 1.10, 6.45), vaginal delivery (RR 2.07, 95% CI 1.03, 4.18) and maternal chorioamnionitis (RR 4.89, 95% CI 1.26-18.98) remained independently associated with extubation failure. EF had a significant greater need for respiratory support, longer oxygen therapy duration, more bronchopulmonary dysplasia (BPD) and longer length of hospital stay, even when adjusted for confounding variables.

CONCLUSIONS

Extremely low birth weight infants needing mechanical ventilation, wherein the duration for first extubation was longer than seven days, with vaginal delivery and maternal chorioamnionitis failed more frequently at the first attempt of extubation. And this failure increased the risk of BPD and the length of hospital stay.

Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants

BACKGROUND

Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD.

OBJECTIVE

The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD.

METHODS

We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy.

RESULTS

Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review.

DISCUSSION

There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.

A Prediction Model of Extubation Failure Risk in Preterm Infants

Objectives: This study aimed to identify variables and develop a prediction model that could estimate extubation failure (EF) in preterm infants. Study Design: We enrolled 128 neonates as a training cohort and 58 neonates as a validation cohort. They were born between 2015 and 2020, had a gestational age between 25^0/7 and 29^6/7 weeks, and had been treated with mechanical ventilation through endotracheal intubation (MVEI) because of acute respiratory distress syndrome. In the training cohort, we performed univariate logistic regression analysis along with stepwise discriminant analysis to identify EF predictors. A monogram based on five predictors was built. The concordance index and calibration plot were used to assess the efficiency of the nomogram in the training and validation cohorts. Results: The results of this study identified a 5-min Apgar score, early-onset sepsis, hemoglobin before extubation, pH before extubation, and caffeine administration as independent risk factors that could be combined for accurate prediction of EF. The EF nomogram was created using these five predictors. The area under the receiver operator characteristic curve was 0.824 (95% confidence interval 0.748-0.900). The concordance index in the training and validation cohorts was 0.824 and 0.797, respectively. The calibration plots showed high coherence between the predicted probability of EF and actual observation. Conclusions: This EF nomogram was a useful model for the precise prediction of EF risk in preterm infants who were between 25^0/7 and 29^6/7 weeks' gestational age and treated with MVEI because of acute respiratory distress syndrome.

Association of time of day and extubation success in very low birthweight infants: a multicenter cohort study

OBJECTIVE

To determine the association of overnight extubation (OE) with extubation success.

STUDY DESIGN

Retrospective cohort study in three NICUs from 2016 to 2020. Infants without congenital anomalies, less than 1500 grams at birth, who were ventilated and received an extubation attempt were included. Primary exposure was OE (7:00 pm-6:59 am) and outcome was extubation success defined as no mechanical ventilation for at least 7 days after extubation.

RESULTS

A total of 76/379 (20%) infants received OE. Infants extubated during the daytime were older and had higher illness severity markers. Extubation success rates did not differ for overnight (57/76, 75%) versus daytime extubations (231/303, 76%) after adjusting for confounders (adjusted relative risk 0.95, 95% CI 0.82-1.11).

CONCLUSION

Though infants in our cohort undergoing daytime and OE were dissimilar, extubation success rates did not differ. Larger multicenter studies are needed to test our findings and identify markers of extubation readiness in preterm infants.

The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations

INTRODUCTION

There is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations.

OBJECTIVE

To determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings.

METHODS

A retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013-June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed.

RESULTS

Of the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB.

CONCLUSIONS

Infants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.

Predicting extubation outcomes using the Heart Rate Characteristics index in preterm infants: a cohort study

A strategy of early extubation to noninvasive respiratory support in preterm infants could be boosted by the availability of a decision support tool for clinicians. Using the Heart Rate Characteristics index (HRCi) with clinical parameters, we derived and validated predictive models for extubation readiness and success.Peri-extubation demographic, clinical and HRCi data for up to 96 h were collected from mechanically ventilated infants in the control arm of a randomised trial involving eight neonatal centres, where clinicians were blinded to the HRCi scores. The data were used to produce a multivariable regression model for the probability of subsequent re-intubation. Additionally, a survival model was produced to estimate the probability of re-intubation in the period after extubation.Of the 577 eligible infants, data from 397 infants (69%) were used to derive the pre-extubation model and 180 infants (31%) for validation. The model was also fitted and validated using all combinations of training (five centres) and test (three centres) centres. The estimated probability for the validation episodes showed discrimination with high statistical significance, with an area under the curve of 0.72 (95% CI 0.71-0.74; p<0.001). Data from all infants were used to derive models of the predictive instantaneous hazard of re-intubation adjusted for clinical parameters.Predictive models of extubation readiness and success in real-time can be derived using physiological and clinical variables. The models from our analyses can be accessed using an online tool available at www.heroscore.com/extubation, and have the potential to inform and supplement the confidence of the clinician considering extubation in preterm infants.

Etiology and Risk Factors for Extubation Failure in Low Birth Weight Infants Undergoing Congenital Heart Surgery

OBJECTIVE

The aim of the present study was to explore the etiology and risk factors of extubation failure (ExF) in low birth weight (LBW) infants undergoing congenital heart surgery.

DESIGN

Retrospective, comparative study.

SETTING

A Cantonese cardiac center in China.

PARTICIPANTS

The cases of all LBW infants undergoing congenital heart surgery admitted to the authors' neonatal intensive care unit from January 2010 to September 2018 were reviewed retrospectively. ExF was defined as reintubation within 72 hours after extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, preoperative, perioperative, and postoperative data were collected. The exclusion criteria were surgical ligation of patent ductus arteriosus and no extubation attempt. Risk factors for ExF were analyzed with univariate and multivariate logistic regression analysis. Ninety-nine infants met the inclusion criteria; the study comprised 66 males and 33 females, including 60 premature infants. ExF occurred in 16 of 99 infants for various kinds of reasons. Infants with ExF had longer postoperative intensive care unit length of stay (LOS) (p < 0.001) and total hospital LOS (p = 0.022). The multivariate logistic regression analysis identified preoperative mechanical ventilation (odds ratio 9.3; 95% confidence interval 1.11-79.52; p = 0.040) and prolonged mechanical ventilation before the first attempted extubation (odds ratio 6.48; 95% confidence interval 1.20-35.17; p = 0.030) as risk factors for ExF.

CONCLUSIONS

The prevalence of ExF is very high in LBW infants undergoing congenital cardiac surgery. ExF in LBW infants is associated with an increase in hospital LOS. Presumed reasons for failed extubation are diverse. Preoperative mechanical ventilation and prolonged mechanical ventilation before the first attempted extubation were independent risk factors for ExF.

Assessment of Extubation Readiness Using Spontaneous Breathing Trials in Extremely Preterm Neonates

IMPORTANCE

Spontaneous breathing trials (SBTs) are used to determine extubation readiness in extremely preterm neonates (gestational age ≤28 weeks), but these trials rely on empirical combinations of clinical events during endotracheal continuous positive airway pressure (ET-CPAP).

OBJECTIVES

To describe clinical events during ET-CPAP and to assess accuracy of comprehensive clinical event combinations in predicting successful extubation compared with clinical judgment alone.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter diagnostic study used data from 259 neonates seen at 5 neonatal intensive care units from the prospective Automated Prediction of Extubation Readiness (APEX) study from September 1, 2013, through August 31, 2018. Neonates with birth weight less than 1250 g who required mechanical ventilation were eligible. Neonates deemed to be ready for extubation and who underwent ET-CPAP before extubation were included.

INTERVENTIONS

In the APEX study, cardiorespiratory signals were recorded during 5-minute ET-CPAP, and signs of clinical instability were monitored.

MAIN OUTCOMES AND MEASURES

Four clinical events were documented during ET-CPAP: apnea requiring stimulation, presence and cumulative durations of bradycardia and desaturation, and increased supplemental oxygen. Clinical event occurrence was assessed and compared between extubation pass and fail (defined as reintubation within 7 days). An automated algorithm was developed to generate SBT definitions using all clinical event combinations and to compute diagnostic accuracies of an SBT in predicting extubation success.

RESULTS

Of 259 neonates (139 [54%] male) with a median gestational age of 26.1 weeks (interquartile range [IQR], 24.9-27.4 weeks) and median birth weight of 830 g (IQR, 690-1019 g), 147 (57%) had at least 1 clinical event during ET-CPAP. Apneas occurred in 10% (26 of 259) of neonates, bradycardias in 19% (48), desaturations in 53% (138), and increased oxygen needs in 41% (107). Neonates with successful extubation (71% [184 of 259]) had significantly fewer clinical events (51% [93 of 184] vs 72% [54 of 75], P = .002), shorter cumulative bradycardia duration (median, 0 seconds [IQR, 0 seconds] vs 0 seconds [IQR, 0-9 seconds], P < .001), shorter cumulative desaturation duration (median, 0 seconds [IQR, 0-59 seconds] vs 25 seconds [IQR, 0-90 seconds], P = .003), and less increase in oxygen (median, 0% [IQR, 0%-6%] vs 5% [0%-18%], P < .001) compared with neonates with failed extubation. In total, 41 602 SBT definitions were generated, demonstrating sensitivities of 51% to 100% (median, 96%) and specificities of 0% to 72% (median, 22%). Youden indices for all SBTs ranged from 0 to 0.32 (median, 0.17), suggesting low accuracy. The SBT with highest Youden index defined SBT pass as having no apnea (with desaturation requiring stimulation) or increase in oxygen requirements by 15% from baseline and predicted extubation success with a sensitivity of 93% and a specificity of 39%.

CONCLUSIONS AND RELEVANCE

The findings suggest that extremely preterm neonates commonly show signs of clinical instability during ET-CPAP and that the accuracy of multiple clinical event combinations to define SBTs is low. Thus, SBTs may provide little added value in the assessment of extubation readiness.

Cardiorespiratory behavior of preterm infants receiving continuous positive airway pressure and high flow nasal cannula post extubation: randomized crossover study

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) and high flow nasal cannula (HFNC) are modes of non-invasive respiratory support commonly used after extubation in extremely preterm infants. However, the cardiorespiratory physiology of these infants on each mode is unknown.

METHODS

Prospective, randomized crossover study in infants with birth weight ≤1250 g undergoing their first extubation attempt. NCPAP and HFNC were applied randomly for 45 min each, while ribcage and abdominal movements, electrocardiogram, oxygen saturation, and fraction of inspired oxygen (FiO₂) were recorded. Respiratory signals were analyzed using an automated method, and differences between NCPAP and HFNC features and changes in FiO₂ were analyzed.

RESULTS

A total of 30 infants with median [interquartile range] gestational age of 27 weeks [25.7, 27.9] and birth weight of 930 g [780, 1090] were studied. Infants were extubated at 5 days [2, 13] of life with 973 g [880, 1170] and three failed (10%). No differences in cardiorespiratory behavior were noted, except for longer respiratory pauses (9.2 s [5.0, 11.5] vs. 7.3 s [4.6, 9.3]; p = 0.04) and higher FiO₂ levels (p = 0.02) during HFNC compared to NCPAP.

CONCLUSIONS

In extremely preterm infants studied shortly after extubation, the use of HFNC was associated with longer respiratory pauses and higher FiO₂ requirements.

Predictors and Outcomes of Early Intubation in Infants Born at 28-36 Weeks of Gestation Receiving Noninvasive Respiratory Support

OBJECTIVE

To identify predictors and outcomes of early intubation in preterm infants with respiratory distress, and predictors of need for brief respiratory support (≤1 day).

STUDY DESIGN

Secondary analysis of data from a randomized trial comparing nasal high-flow with continuous positive airway pressure as primary respiratory support in preterm infants born at 28-36 weeks of gestation. Intubation was assessed within 72 hours of randomization.

RESULTS

There were 564 included infants with a mean (SD) gestational age of 32.0 (2.2) weeks and birth weight 1744 (589) g; 76 infants (13.5%) received early intubation. On multivariable analysis, lower gestational age and higher pre-randomization fraction of inspired oxygen (FiO₂) predicted intubation. A test based on gestational age of <30 weeks and an FiO₂ of ≥0.30 produced a likelihood ratio of 9.1. Intubation was associated with prolonged duration of respiratory support and supplemental oxygen, with pneumothorax and nasal trauma, and in infants born at <32 weeks of gestational, with bronchopulmonary dysplasia and patent ductus arteriosus requiring treatment. Greater gestational age and lower FiO₂ predicted the need for ≤1 day of respiratory support. A test based on a gestational age of ≥34 weeks and an FiO₂ of 0.21 produced a likelihood ratio of 4.7.

CONCLUSIONS

In preterm infants 28-36 week of gestation receiving primary noninvasive respiratory support, lower gestational age, and higher FiO₂ predicted need for intubation within 72 hours. Intubation was associated with adverse respiratory outcomes. Greater gestational age and lower FiO₂ predicted need for ≤1 day of respiratory support. It may be reasonable to defer the use of respiratory support in more mature infants with low FiO₂ requirements. TRIAL REGISTRATION AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12613000303741.

Comparison of extubation success using noninvasive positive pressure ventilation (NIPPV) versus noninvasive neurally adjusted ventilatory assist (NI-NAVA)

OBJECTIVE

Compare rates of initial extubation success in preterm infants extubated to NIPPV or NI-NAVA.

STUDY DESIGN

In this pilot study, we randomized 30 mechanically ventilated preterm infants at the time of initial elective extubation to NI-NAVA or NIPPV in a 1:1 assignment. Primary study outcome was initial extubation success.

RESULTS

Rates of continuous extubation for 120 h were 92% in the NI-NAVA group and 69% in the NIPPV group (12/13 vs. 9/13, respectively, p = 0.14). Infants extubated to NI-NAVA remained extubated longer (median 18 vs. 4 days, p = 0.02) and experienced lower peak inspiratory pressures (PIP) than infants managed with NIPPV throughout the first 3 days after extubation. Survival analysis through 14 days post extubation showed a sustained difference in the primary study outcome until 12 days post extubation.

CONCLUSIONS

Our study is the first to suggest that a strategy of extubating preterm infants to NI-NAVA may be more successful.

Clinical Study of Different Modes of Non-invasive Ventilation Treatment in Preterm Infants With Respiratory Distress Syndrome After Extubation

Objective: This study aimed to investigate the clinical efficacy and safety of different non-invasive respiratory support methods in preterm infants with respiratory distress syndrome (RDS) after extubation. Methods: From Oct 2017 to 2018, 120 preterm infants were recruited from the NICUs of three hospitals. They were diagnosed with RDS and required mechanical ventilation. After extubation from mechanical ventilation, these infants were divided into NCPAP group, SNIPPV group and SNIPPV + NCPAP group. The time of non-invasive ventilation, reintubation rate within 72 h, success rate of non-invasive ventilation within 1 week, duration of oxygen therapy, hospital stay and incidence of complications were recorded and compared. Results: Compared with the NCPAP group, the SNIPPV group and the SNIPPV + NCPAP group had significantly higher rate of successful extubation and removal from non-invasive ventilation within 1 week (P < 0.05). There were no significant differences among three groups in the time of non-invasive ventilation, time of oxygen therapy, hospital stay or incidence of complications (P > 0.05). Conclusion: SNIPPV + NCPAP after mechanical ventilation is a relatively safe and effective ventilation strategy for preterm infants with severe RDS. The use of NCPAP facilitates the turnover of SNIPPV ventilators in developing countries.

Protocolized Versus Nonprotocolized Weaning to Reduce the Duration of Invasive Mechanical Weaning in Neonates: A Systematic Review of All Types of Studies

Mechanical ventilation is one of the most commonly used treatments in neonatology. Prolonged mechanical ventilation is associated with deleterious outcomes. To reduce the ventilation duration, weaning protocols have been developed to achieve extubation in adult and pediatric care in a safe and uniform manner. We performed a systematic review to obtain all available evidence on the effect of protocolized versus nonprotocolized weaning on the duration of invasive mechanical ventilation in critically ill neonates. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Web of Science, and the International Clinical Trial Registry Platform were searched until January 2018. Quantitative and qualitative studies involving neonates that investigated or described protocolized versus nonprotocolized weaning were included. Primary outcome was the difference in weaning duration. A total of 2099 potentially relevant articles were retrieved. Three studies met the inclusion criteria. Of 2 of these, the separate neonatal data could not be obtained. Only one retrospective study was included for this review. This reported a decrease in the mean weaning time from 18 to 5 and 6 days, respectively. There is no robust evidence in the literature to support or disprove the use of a weaning protocol in critically ill neonates.

A predictive model for extubation readiness in extremely preterm infants

OBJECTIVE

To develop an estimator for predicting successful extubation for an individual preterm infant.

STUDY DESIGN

This was a retrospective study that included infants with birth weights ≤1250 g, who were admitted to a tertiary NICU over a 7-year period, received mechanical ventilation and had an elective extubation attempt within 60 days of age. Perinatal and periextubation characteristics were compared in the successful and failed extubation groups.

RESULTS

Of 621 screened infants, 312 were included. Extubation succeeded in 73% and failed in 27%. Adjusted factors associated with successful extubation included greater gestational age, chronologic age, pre-extubation pH and lower pre-extubation FiO₂, along with lower "peak" respiratory severity score in the first 6 h of age.

CONCLUSIONS

We used readily available demographic and clinical data to create an extubation readiness estimator that provides the probability of extubation success for an individual preterm infant (http://elasticbeanstalk-us-east-2-676799334712.s3-website.us-east-2.amazonaws.com/).

[Research advances in the methods for weaning from high-frequency oscillatory ventilation in neonates]

Neonatal respiratory failure is a serious clinical illness commonly seen in the neonatal intensive care unit (NICU). Although clinicians want to maximize noninvasive respiratory support, some low-birth-weight preterm infants may require invasive respiratory support from the beginning. As an important respiratory management technique for the treatment of respiratory failure, high-frequency oscillatory ventilation (HFOV) allows gas exchange by rapid delivery at a tidal volume lower than or equal to anatomy death volume. Continuous distending pressure was applied to achieve uniform lung expansion, reduce repeated contraction of lung tissue, and exert a protective effect on lung tissue, and so it is preferred by clinicians and has been widely used in clinical practice. However, no consensus has been reached on the methods for weaning from HFOV. This article reviews the methods for weaning from HFOV, so as to provide help for clinical practice.

Undersampling and Bagging of Decision Trees in the Analysis of Cardiorespiratory Behavior for the Prediction of Extubation Readiness in Extremely Preterm Infants

Extremely preterm infants often require endotracheal intubation and mechanical ventilation during the first days of life. Due to the detrimental effects of prolonged invasive mechanical ventilation (IMV), clinicians aim to extubate infants as soon as they deem them ready.Unfortunately, existing strategies for prediction of extubation readiness vary across clinicians and institutions, and lead to high reintubation rates. We present an approach using Random Forest classifiers for the analysis of cardiorespiratory variability to predict extubation readiness. We address the issue of data imbalance by employing random undersampling of examples from the majority class before training each Decision Tree in a bag. By incorporating clinical domain knowledge, we further demonstrate that our classifier could have identified 71% of infants who failed extubation, while maintaining a success detection rate of 78%.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Early extubation is not associated with severe intraventricular hemorrhage in preterm infants born before 29 weeks of gestation. Results of an EPIPAGE-2 cohort study

Objective

To determine whether there is an association between severe intraventricular hemorrhage and early extubation in preterm infants born before 29 weeks of gestational age and intubated at birth.

Methods

This study included 1587 preterm infants from a nationwide French population cohort (EPIPAGE-2). Secondary data on intubated preterm infants were analyzed. After gestational age and propensity score matching (1:1) we built two comparable groups: an early extubation group and a delayed extubation group. Each neonate in one group was paired with a neonate in the other group having the same propensity score and gestational age. Early extubation was defined as extubation within 48 hours of life. Severe intraventricular hemorrhages were defined as grade III or IV hemorrhages according to the Papile classification.

Results

After matching, there were 398 neonates in each group. Using a generalized estimating equation model, we found that intraventricular hemorrhage was not associated with early extubation (adjusted OR 0.9, 95%CI 0.6–1.4). This result was supported by sensitivity analyses.

Conclusion

The practice of early extubation was not associated with an increased proportion of intraventricular hemorrhages. To complete these results, the long-term neurologic outcomes of these infants need to be assessed.

The Impact of Time Interval between Extubation and Reintubation on Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants

OBJECTIVE

To explore the relation between time to reintubation and death or bronchopulmonary dysplasia (BPD) in extremely preterm infants.

STUDY DESIGN

This was a subanalysis from an ongoing multicenter observational study. Infants with birth weight ≤1250 g, requiring mechanical ventilation, and undergoing their first elective extubation were prospectively followed throughout hospitalization. Time to reintubation was defined as the time interval between first elective extubation and reintubation. Univariate and multivariate logistic regression analyses were performed to evaluate associations between time to reintubation, using different observation windows after extubation (24-hour intervals), and death/BPD (primary outcome) or BPD among survivors (secondary outcome). aORs were computed with and without the confounding effects of cumulative mechanical ventilation duration.

RESULTS

Of 216 infants included for analysis, 103 (48%) were reintubated at least once after their first elective extubation. Reintubation was associated with lower gestational age/weight and greater morbidities compared with infants never reintubated. After adjusting for confounders, reintubation within observation windows ranging between 24 hours and 3 weeks postextubation was associated with increased odds of death/BPD (but not BPD among survivors), independent of the cumulative mechanical ventilation duration. Reintubation within 48 hours from extubation conferred higher risk-adjusted odds of death/BPD vs other observation windows.

CONCLUSIONS

Although reintubation after elective extubation was independently associated with increased likelihood of death/BPD in extremely preterm infants, the greatest risk was attributable to reintubation within the first 48 hours postextubation. Prediction models capable of identifying the highest-risk infants may further improve outcomes.

Patterns of reintubation in extremely preterm infants: a longitudinal cohort study

BackgroundThe optimal approach for reporting reintubation rates in extremely preterm infants is unknown. This study aims to longitudinally describe patterns of reintubation in this population over a broad range of observation windows following extubation.MethodsTiming and reasons for reintubation following a first planned extubation were collected from infants with birth weight ≤1,250 g. An algorithm was generated to discriminate between reintubations attributable to respiratory and non-respiratory causes. Frequency and cumulative distribution curves were constructed for each category using 24 h intervals. The ability of observation windows to capture respiratory-related reintubations while limiting non-respiratory reasons was assessed using a receiver operating characteristic curve.ResultsOut of 194 infants, 91 (47%) were reintubated during hospitalization; 68% for respiratory and 32% for non-respiratory reasons. Respiratory-related reintubation rates steadily increased from 0 to 14 days post-extubation before reaching a plateau. In contrast, non-respiratory reintubations were negligible in the first post-extubation week, but became predominant after 14 days. An observation window of 7 days captured 77% of respiratory-related reintubations while only including 14% of non-respiratory cases.ConclusionReintubation patterns are highly variable and affected by the reasons for reintubation and observation window used. Ideally, reintubation rates should be reported using a cumulative distribution curve over time.

Extubation from high-frequency oscillatory ventilation in extremely low birth weight infants: a prospective observational study

OBJECTIVE

To evaluate if weaning from high-frequency oscillatory ventilation (HFOV) directly to a non-invasive mode of respiratory support is feasible and results in successful extubation in extremely low birth weight (ELBW) infants.

DESIGN

Prospective observational study.

SETTING

Tertiary neonatal intensive care unit.

PATIENTS

One hundred and eight ELBW infants of 26.2±1.4 weeks of gestational age (GA) directly extubated from HFOV.

INTERVENTIONS

All infants were managed with elective HFOV and received surfactant after a recruitment HFOV manoeuvre. Extubation was attempted at mean airways pressure (MAP) ≤6 cm H₂O with FiO₂ ≤0.25. After extubation, all infants were supported by nasal continuous positive airway pressure (6-8 cm H₂O).

MAIN OUTCOME MEASURES

Extubation failure (clinical deterioration requiring reintubation) was defined as shorter than 7 days.

RESULTS

Ninety patients (83%) were successfully extubated and 18 (17%) required reintubation. No significant differences were found between the two groups in terms of birth weight, day of life and weight at the time of extubation. Multivariable analysis showed that GA (OR 1.71; 95% CI 1.04, 2.08) and higher MAP prior to surfactant (OR 1.51; 95% CI 1.06, 2.15) were associated with successful extubation.

CONCLUSIONS

In ELBW infants, direct extubation from HFOV at MAP ≤6 cm H₂O with FiO₂ ≤0.25 is feasible. Our extubation success rate (83%) is higher than conventional mechanical ventilation in this very vulnerable class of infants.

A semi-Markov chain approach to modeling respiratory patterns prior to extubation in preterm infants

After birth, extremely preterm infants often require specialized respiratory management in the form of invasive mechanical ventilation (IMV). Protracted IMV is associated with detrimental outcomes and morbidities. Premature extubation, on the other hand, would necessitate reintubation which is risky, technically challenging and could further lead to lung injury or disease. We present an approach to modeling respiratory patterns of infants who succeeded extubation and those who required reintubation which relies on Markov models. We compare the use of traditional Markov chains to semi-Markov models which emphasize cross-pattern transitions and timing information, and to multi-chain Markov models which can concisely represent non-stationarity in respiratory behavior over time. The models we developed expose specific, unique similarities as well as vital differences between the two populations.

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

OBJECTIVES

To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.

STUDY DESIGN

This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 24^0/7 to 27^6/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.

RESULTS

Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).

CONCLUSIONS

Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00233324.

Prediction of Extubation readiness in extremely preterm infants by the automated analysis of cardiorespiratory behavior: study protocol

Background

Extremely preterm infants (≤ 28 weeks gestation) commonly require endotracheal intubation and mechanical ventilation (MV) to maintain adequate oxygenation and gas exchange. Given that MV is independently associated with important adverse outcomes, efforts should be made to limit its duration. However, current methods for determining extubation readiness are inaccurate and a significant number of infants fail extubation and require reintubation, an intervention that may be associated with increased morbidities. A variety of objective measures have been proposed to better define the optimal time for extubation, but none have proven clinically useful. In a pilot study, investigators from this group have shown promising results from sophisticated, automated analyses of cardiorespiratory signals as a predictor of extubation readiness. The aim of this study is to develop an automated predictor of extubation readiness using a combination of clinical tools along with novel and automated measures of cardiorespiratory behavior, to assist clinicians in determining when extremely preterm infants are ready for extubation.

Methods

In this prospective, multicenter observational study, cardiorespiratory signals will be recorded from 250 eligible extremely preterm infants with birth weights ≤1250 g immediately prior to their first planned extubation. Automated signal analysis algorithms will compute a variety of metrics for each infant, and machine learning methods will then be used to find the optimal combination of these metrics together with clinical variables that provide the best overall prediction of extubation readiness. Using these results, investigators will develop an Automated system for Prediction of EXtubation (APEX) readiness that will integrate the software for data acquisition, signal analysis, and outcome prediction into a single application suitable for use by medical personnel in the neonatal intensive care unit. The performance of APEX will later be prospectively validated in 50 additional infants.

Discussion

The results of this research will provide the quantitative evidence needed to assist clinicians in determining when to extubate a preterm infant with the highest probability of success, and could produce significant improvements in extubation outcomes in this population.

Trial registration

Clinicaltrials.gov identifier: NCT01909947. Registered on July 17 2013.

Trial sponsor: Canadian Institutes of Health Research (CIHR).

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0911-z) contains supplementary material, which is available to authorized users.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.