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Brasher M, Virodov A, Raffay TM, Bada HS, Cunningham MD, Bumgardner C, Abu Jawdeh EG. Predicting Extubation Readiness in Preterm Infants Utilizing Machine Learning: A Diagnostic Utility Study. J Pediatr 2024; 271:114043. [PMID: 38561049 DOI: 10.1016/j.jpeds.2024.114043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 03/11/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The objective of this study was to predict extubation readiness in preterm infants using machine learning analysis of bedside pulse oximeter and ventilator data. STUDY DESIGN This is an observational study with prospective recordings of oxygen saturation (SpO2) and ventilator data from infants <30 weeks of gestation age. Research pulse oximeters collected SpO2 (1 Hz sampling rate) to quantify intermittent hypoxemia (IH). Continuous ventilator metrics were collected (4-5-minute sampling) from bedside ventilators. Data modeling was completed using unbiased machine learning algorithms. Three model sets were created using the following data source combinations: (1) IH and ventilator (IH + SIMV), (2) IH, and (3) ventilator (SIMV). Infants were also analyzed separated by postnatal age (infants <2 or ≥2 weeks of age). Models were compared by area under the receiver operating characteristic curve (AUC). RESULTS A total of 110 extubation events from 110 preterm infants were analyzed. Infants had a median gestation age and birth weight of 26 weeks and 825 g, respectively. Of the 3 models presented, the IH + SIMV model achieved the highest AUC of 0.77 for all infants. Separating infants by postnatal age increased accuracy further achieving AUC of 0.94 for <2 weeks of age group and AUC of 0.83 for ≥2 weeks group. CONCLUSIONS Machine learning analysis has the potential to enhance prediction accuracy of extubation readiness in preterm infants while utilizing readily available data streams from bedside pulse oximeters and ventilators.
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Affiliation(s)
- Mandy Brasher
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY
| | - Alexandr Virodov
- Institute of Biomedical Informatics, University of Kentucky, Lexington, KY
| | - Thomas M Raffay
- Department of Pediatrics/Neonatology, College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Henrietta S Bada
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY
| | - M Douglas Cunningham
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY
| | - Cody Bumgardner
- Institute of Biomedical Informatics, University of Kentucky, Lexington, KY
| | - Elie G Abu Jawdeh
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY.
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Sant'Anna G, Shalish W. Weaning from mechanical ventilation and assessment of extubation readiness. Semin Perinatol 2024; 48:151890. [PMID: 38553331 DOI: 10.1016/j.semperi.2024.151890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Tremendous advancements in neonatal respiratory care have contributed to the improved survival of extremely preterm infants (gestational age ≤ 28 weeks). While mechanical ventilation is often considered one of the most important breakthroughs in neonatology, it is also associated with numerous short and long-term complications. For those reasons, clinical research has focused on strategies to avoid or reduce exposure to mechanical ventilation. Nonetheless, in the extreme preterm population, 70-100% of infants born 22-28 weeks of gestation are exposed to mechanical ventilation, with nearly 50% being ventilated for ≥ 3 weeks. As contemporary practices have shifted towards selectively reserving mechanical ventilation for those patients, mechanical ventilation weaning and extubation remain a priority yet offer a heightened challenge for clinicians. In this review, we will summarize the evidence for different strategies to expedite weaning and assess extubation readiness in preterm infants, with a particular focus on extremely preterm infants.
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Affiliation(s)
- Guilherme Sant'Anna
- Professor of Pediatrics, Division of Neonatology, Montreal Children's Hospital Departments of Pediatrics and Experimental Medicine, Senior Scientist of the Research Institute of the McGill University Health Center, McGill University Health Center, 1001 Boulevard Decarie, Room B05.2711, Montreal, Quebec H4A3J1, Canada.
| | - Wissam Shalish
- Assistant Professor of Pediatrics, Division of Neonatology, Montreal Children's Hospital Departments of Pediatrics and Experimental Medicine, Junior Scientist of FRQS, McGill University Health Center, Montreal, Quebec, Canada
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Nagaraj YK, Balushi SA, Robb C, Uppal N, Dutta S, Mukerji A. Peri-extubation settings in preterm neonates: a systematic review and meta-analysis. J Perinatol 2024; 44:257-265. [PMID: 38216677 DOI: 10.1038/s41372-024-01870-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVE To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates. STUDY DESIGN In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model. RESULTS Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP. CONCLUSIONS Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.
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Affiliation(s)
| | | | - Courtney Robb
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nikhil Uppal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Sourabh Dutta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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Rallis D, Ben-David D, Woo K, Robinson J, Beadles D, Spyropoulos F, Christou H, Cataltepe S. Predictors of successful extubation from volume-targeted ventilation in extremely preterm neonates. J Perinatol 2024; 44:250-256. [PMID: 38123799 DOI: 10.1038/s41372-023-01849-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/22/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To identify variables associated with extubation success in extremely preterm neonates extubated from invasive volume-targeted ventilation. STUDY DESIGN We retrospectively evaluated 84 neonates ≤28 weeks' gestational age, on their first elective extubation. The primary outcome of successful extubation was defined as non-reintubation within seven days. We used multivariate logistic regression analysis. RESULTS We identified 58 (69%) neonates (mean gestational age of 26.5 ± 1.4 weeks, birthweight 921 ± 217 g) who met the primary outcome. Female sex (OR 1.15, 95% CI 1.01-9.10), higher pre-extubation weight (OR 1.29, 95% CI 1.05-1.59), and pH (OR 2.54, 95% CI 1.54-4.19), and lower pre-extubation mean airway pressure (MAP) (OR 0.49, 95% CI 0.33-0.73) were associated with successful extubation. CONCLUSIONS In preterm neonates, female sex, higher pre-extubation weight and pH, and lower pre-extubation MAP were predictors of successful extubation from volume-targeted ventilation. Evaluation of these variables will likely assist clinicians in selecting the optimal time for extubation in such vulnerable neonates.
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Affiliation(s)
- Dimitrios Rallis
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Neonatal Intensive Care Unit, University of Ioannina, Faculty of Medicine, Ioannina, Greece.
| | | | - Kendra Woo
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill Robinson
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Beadles
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Helen Christou
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sule Cataltepe
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Salotagi S, Kannan A, Jindal A. Lung Ultrasound Score: Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023; 27:855-856. [PMID: 37936808 PMCID: PMC10626243 DOI: 10.5005/jp-journals-10071-24516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
How to cite this article: Salotagi S, Kannan A, Jindal A. Lung Ultrasound Score: Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023;27(11):855-856.
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Affiliation(s)
- Siddannagoud Salotagi
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Abinaya Kannan
- Department of Pediatrics, All India Institute of Medical Sciences, Puducherry, India
| | - Atul Jindal
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Fu M, Hu Z, Yu G, Luo Y, Xiong X, Yang Q, Song W, Yu Y, Yang T. Predictors of extubation failure in newborns: a systematic review and meta-analysis. Ital J Pediatr 2023; 49:133. [PMID: 37784184 PMCID: PMC10546653 DOI: 10.1186/s13052-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023] Open
Abstract
Extubation failure (EF) is a significant concern in mechanically ventilated newborns, and predicting its occurrence is an ongoing area of research. To investigate the predictors of EF in newborns undergoing planned extubation, we conducted a systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for studies published in English from the inception of each database to March 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. Thirty-four studies were included, 10 of which were overall low risk of bias, 15 of moderate risk of bias, and 9 of high risk of bias. The studies reported 43 possible predictors in six broad categories (intrinsic factors; maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; characteristics before and after extubation; and clinical scores and composite indicators). Through a qualitative synthesis of 43 predictors and a quantitative meta-analysis of 19 factors, we identified five definite factors, eight possible factors, and 22 unclear factors related to EF. Definite factors included gestational age, sepsis, pre-extubation pH, pre-extubation FiO2, and respiratory severity score. Possible factors included age at extubation, anemia, inotropic use, mean airway pressure, pre-extubation PCO2, mechanical ventilation duration, Apgar score, and spontaneous breathing trial. With only a few high-quality studies currently available, well-designed and more extensive prospective studies investigating the predictors affecting EF are still needed. In the future, it will be important to explore the possibility of combining multiple predictors or assessment tools to enhance the accuracy of predicting extubation outcomes in clinical practice.
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Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhenjing Hu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China.
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ting Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Shalish W, Sant'Anna GM. Optimal timing of extubation in preterm infants. Semin Fetal Neonatal Med 2023; 28:101489. [PMID: 37996367 DOI: 10.1016/j.siny.2023.101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants.
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Affiliation(s)
- Wissam Shalish
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, 1001 Boul. Décarie, Room B05.2714, Montreal, Quebec, H4A 3J1, Canada.
| | - Guilherme M Sant'Anna
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, 1001 Boul. Décarie, Room B05.2714, Montreal, Quebec, H4A 3J1, Canada.
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Mohsen N, Solis-Garcia G, Jasani B, Nasef N, Mohamed A. Accuracy of lung ultrasound in predicting extubation failure in neonates: A systematic review and meta-analysis. Pediatr Pulmonol 2023; 58:2846-2856. [PMID: 37431954 DOI: 10.1002/ppul.26598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To systematically review and meta-analyze the diagnostic accuracy of lung ultrasound score (LUS) in predicting extubation failure in neonates. STUDY DESIGN MEDLINE, COCHRANE, EMBASE, CINAHL, and clinicaltrials.gov were searched up to 30 November 2022, for studies evaluating the diagnostic accuracy of LUS in predicting extubation outcome in mechanically ventilated neonates. METHODOLOGY Two investigators independently assessed study eligibility, extracted data, and assessed study quality using the Quality Assessment for Studies of Diagnostic Accuracy 2 tool. We conducted a meta-analysis of pooled diagnostic accuracy data using random-effect models. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated pooled sensitivity and specificity, pooled diagnostic odds ratios with 95% confidence intervals (CI), and area under the curve (AUC). RESULTS Eight observational studies involving 564 neonates were included, and the risk of bias was low in seven studies. The pooled sensitivity and specificity for LUS in predicting extubation failure in neonates were 0.82 (95% CI: 0.75-0.88) and 0.83 (95% CI: 0.78-0.86), respectively. The pooled diagnostic odds ratio was 21.24 (95% CI: 10.45-43.19), and the AUC for LUS predicting extubation failure was 0.87 (95% CI: 0.80-0.95). Heterogeneity among included studies was low, both graphically and by statistical criteria (I2 = 7.35%, p = 0.37). CONCLUSIONS The predictive value of LUS in neonatal extubation failure may hold promise. However, given the current level of evidence and the methodological heterogeneity observed, there is a clear need for large-scale, well-designed prospective studies that establish standardized protocols for lung ultrasound performance and scoring. REGISTRATION The protocol was registered in OSF (https://doi.org/10.17605/OSF.IO/ZXQUT).
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Affiliation(s)
- Nada Mohsen
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Gonzalo Solis-Garcia
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bonny Jasani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nehad Nasef
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Adel Mohamed
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital, Toronto, Ontario, Canada
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Song W, Hwa Jung Y, Cho J, Baek H, Won Choi C, Yoo S. Development and validation of a prediction model for evaluating extubation readiness in preterm infants. Int J Med Inform 2023; 178:105192. [PMID: 37619396 DOI: 10.1016/j.ijmedinf.2023.105192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
Successful early extubation has advantages not only in terms of short-term respiratory morbidities and survival but also in terms of long-term neurodevelopmental outcomes in preterm infants. However, no consensus exists regarding the optimal protocol or guidelines for extubation readiness in preterm infants. Therefore, the decision to extubate preterm infants was almost entirely at the attending physician's discretion. We identified robust and quantitative predictors of success or failure of the first planned extubation attempt before 36 weeks of post-menstrual age in preterm infants (<32 weeks gestational age) and developed a prediction model for evaluating extubation readiness using these predictors. Extubation success was defined as the absence of reintubation within 72 h after extubation. This observational cohort study used data from preterm infants admitted to the neonatal intensive care unit of Seoul National University Bundang Hospital in South Korea between July 2003 and June 2019 to identify predictors and develop and test a predictive model for extubation readiness. Data from preterm infants included in the Medical Informative Medicine for Intensive Care (MIMIC-III) database between 2001 and 2008 were used for external validation. From a machine learning model using predictors such as demographics, periodic vital signs, ventilator settings, and respiratory indices, the area under the receiver operating characteristic curve and average precision of our model were 0.805 (95% confidence interval [CI], 0.802-0.809) and 0.917, respectively in the internal validation and 0.715 (95% CI, 0.713-0.717) and 0.838, respectively in the external validation. Our prediction model (NExt-Predictor) demonstrated high performance in assessing extubation readiness in both internal and external validations.
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Affiliation(s)
- Wongeun Song
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Health Science and Technology, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jihoon Cho
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyunyoung Baek
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Sooyoung Yoo
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Liu YC, Yeh CY, Yang ST, Chung WC, Hsu TJ, Sheu CC, Chen HL. Feasibility of Endotracheal Extubation Evaluation Form in Predicting Successful Extubation in Neonatal Intensive Care Units: A Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1053. [PMID: 37371284 DOI: 10.3390/children10061053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
Abstract
Given the limited availability of evidence-based methods for assessing the timing of extubation in intubated preterm infants, we aimed to standardize the extubation protocol in this single-center, retrospective study. To accomplish this, we established an extubation evaluation form to assess the suitability of extubation in preterm infants. The form comprises six indicators: improved clinical condition, spontaneous breath rate ≥ 30 breaths per minute, peak inspiratory pressure (PIP) ≤ 15 cmH2O, fraction of inspired oxygen (FiO2) ≤ 30%, blood pH ≥ 7.2, and mixed venous carbon dioxide tension (PvCO2) < 70 mmHg. Each positive answer is given one point, indicating a maximum of six points. We enrolled 41 intubated preterm infants (gestational age < 32 weeks, birth weight < 1500 g) who were receiving mechanical ventilation support for over 24 h. Among them, 35 were successfully extubated, and 6 were not. After completing the extubation evaluation form and adjusting for birth weight and postextubation device, we observed that the total score of the form was significantly associated with successful extubation; the higher the score, the greater the chance of successful extubation. Thus, we infer that the extubation evaluation form may provide a more objective standard for extubation assessment in preterm infants.
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Affiliation(s)
- Yung-Cheng Liu
- Division of Respiratory Therapy, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Ching-Yi Yeh
- Division of Respiratory Therapy, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Shu-Ting Yang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wei-Chan Chung
- Division of Respiratory Therapy, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Tuan-Jung Hsu
- Division of Respiratory Therapy, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
- Department of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Hsiu-Lin Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Chen F, Chen Y, Wu Y, Zhu X, Shi Y. A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks. Neonatology 2023; 120:424-433. [PMID: 37257426 DOI: 10.1159/000530759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION How to avoid reintubations in prematurity remains a hard nut. This study aimed to develop and validate a nomogram for predicting extubation failure in preterm infants who received different modes of noninvasive ventilation as post-extubation support. METHODS This was a secondary analysis of pre-existing data from a large multicenter RCT combined with a multicenter retrospective investigation in three tertiary referral NICUs in China. The training cohort consisted of extubated infants from the RCT and the validation cohort included neonates admitted to the three NICUs in the last 5 years. The nomogram was developed through univariate and multivariate logistic regression analyses of peri-extubation clinical variables. RESULTS A total of 432 and 183 preterm infants (25 weeks ≤ gestational age [GA] <29 weeks) were, respectively, included in the training cohort and the validation cohort. Lower birth weight, lower Apgar 5-min score, lower postmenstrual age at extubation, lower PO2 and higher PCO2 before extubation, and continuous positive airway pressure rather than nasal intermittent positive pressure ventilation or noninvasive high-frequency oscillatory ventilation after extubation were associated with higher risks of extubation failure (p < 0.05), on which the nomogram was established. In both the training cohort and the validation cohort, the nomogram demonstrated good predictive accuracy (area under the receiver operating characteristic curve = 0.744 and 0.826); the Hosmer-Lemeshow test (p = 0.192 and 0.401) and the calibration curve (R2 = 0.195 and 0.307) proved a good fitness and conformity; and the decision curve analysis showed significant net benefit at the best threshold (p = 0.201). CONCLUSION This nomogram could serve as a good decision-support tool when predicting extubation failure in preterm infants with GA less than 29 weeks.
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Affiliation(s)
- Feifan Chen
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yanru Chen
- Department of Neonatology, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Yumin Wu
- Department of Neonatology, Qujing Maternity and Child Health-Care Hospital, Qujing, China
| | - Xingwang Zhu
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help 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 by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Sangsari R, Saeedi M, Maddah M, Mirnia K, Goldsmith JP. Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review. BMC Pulm Med 2022; 22:421. [DOI: 10.1186/s12890-022-02223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
AbstractMechanical ventilation is a lifesaving treatment used to treat critical neonatal patients. It facilitates gas exchange, oxygenation, and CO2 removal. Despite advances in non-invasive ventilatory support methods in neonates, invasive ventilation (i.e., ventilation via an endotracheal tube) is still a standard treatment in NICUs. This ventilation approach may cause injury despite its advantages, especially in preterm neonates. Therefore, it is recommended that neonatologists consider weaning neonates from invasive mechanical ventilation as soon as possible. This review examines the steps required for the neonate's appropriate weaning and safe extubation from mechanical ventilation.
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Li Z, Xue J, Guo XY, Wang F, Zhang X, Li Q, Tang JL, Ji J, Du GJ. Accuracy of the spontaneous breathing trial using a combined CPAP + PSV model to predict extubation outcomes in very preterm infants. BMC Pediatr 2022; 22:627. [PMID: 36324104 PMCID: PMC9632075 DOI: 10.1186/s12887-022-03642-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Very preterm infants often require mechanical ventilation. However, objective criteria to predict the outcomes of extubation in very premature neonates remain lacking. The aim of this study was to investigate the accuracy of the spontaneous breathing trial (SBT) using a combined model of continuous positive airway pressure (CPAP) and low-level pressure support ventilation (PSV) to predict the extubation outcomes of preterm infants with gestational age < 32 weeks. Methods Preterm infants with gestational age < 32 weeks, birth weight < 1500 g and requiring mechanical ventilation were selected for the study. All infants underwent a 10-minute SBT using CPAP combined with low-level PSV prior to the planned extubation. Then, the infants were extubated within 1 h after SBT. The outcomes of extubation were considered successful if the neonates did not require reintubation 72 h after extubation. Results A total of 119 eligible preterm infants were enrolled in the study, with a median gestational age of 28.9 (27.1–30.3) weeks and a median birth weight of 1100 (900–1350) g. In total, 101 of all infants had successful extubation, 18 of whom failed and eventually had to be reintubated. Of the 102 infants who achieved SBT, 99 were successfully extubated, and 15 of the 17 infants who did not pass SBT had failed extubation. Finally, the diagnostic value for SBT could be assessed with a sensitivity of 98%, a specificity of 83.3%, a positive predictive value of 97.1% and a negative predictive value of 88.2%. Conclusion SBT using a combined CPAP + low-level PSV model can predict the outcomes of extubation in very preterm infants with high sensitivity and specificity.
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Affiliation(s)
- Zhe Li
- grid.27255.370000 0004 1761 1174Department of Neonatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, 250033 Jinan, Shandong China
| | - Jiang Xue
- grid.27255.370000 0004 1761 1174Department of Neonatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, 250033 Jinan, Shandong China
| | - Xin-Yuan Guo
- grid.27255.370000 0004 1761 1174Department of Neonatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, 250033 Jinan, Shandong China
| | - Fang Wang
- grid.27255.370000 0004 1761 1174Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 250012 Jinan, Shandong China
| | - Xue Zhang
- grid.27255.370000 0004 1761 1174Department of Neonatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, 250033 Jinan, Shandong China
| | - Qi Li
- grid.27255.370000 0004 1761 1174Department of Neonatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, 250033 Jinan, Shandong China
| | - Jing-Liang Tang
- grid.413059.a0000 0000 9952 9510School of Ethnic Medicine, Key Laboratory of Chemistry in Ethnic Medicinal Resources, State Ethnic Affairs Commission & Ministry of Education, Yunnan Minzu University, 650500 Kunming, Yunnan, China
| | - Juan Ji
- Department of Neonatology, Feixian People’s Hospital, 273400 Feixian, Shandong China
| | - Guang-Jun Du
- grid.460018.b0000 0004 1769 9639Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021 Jinan, Shandong China
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Resch B. Duration of postoperative mechanical ventilation in neonates. Transl Pediatr 2022; 11:614-616. [PMID: 35685071 PMCID: PMC9173881 DOI: 10.21037/tp-22-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Bernhard Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, LKH-Uniklinikum and Medical University of Graz, Graz, Austria
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Variane GFT, Camargo JPV, Rodrigues DP, Magalhães M, Mimica MJ. Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care. Front Pediatr 2022; 9:755144. [PMID: 35402367 PMCID: PMC8984110 DOI: 10.3389/fped.2021.755144] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Division of Neonatology, Grupo Santa Joana, São Paulo, Brazil
| | - João Paulo Vasques Camargo
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Data Science Department, OPD Team, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Department of Pediatrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Department of Pathology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Can Fraction of Inspired Oxygen Predict Extubation Failure in Preterm Infants? CHILDREN 2022; 9:children9010030. [PMID: 35053655 PMCID: PMC8774464 DOI: 10.3390/children9010030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/30/2022]
Abstract
Background: Prolonged mechanical ventilation in preterm infants may cause complications. We aimed to analyze the variables affecting extubation outcomes in preterm infants at high risk of extubation failure. Methods: This was a single-center, observational, retrospective study. Extubation failure was defined as survival with the need for reintubation within 72 h. Successfully extubated neonates (group 1) were compared to those with failed extubation (group 2). Multivariate logistic regression analysis evaluated factors that predicted extubation outcomes. Results: Eighty infants with a birth weight under 1000 g and/or gestational age (GA) under 28 weeks were included. Extubation failure occurred in 29 (36.2%) and success in 51 (63.8%) neonates. Most failures (75.9%) occurred within 24 h. Pre-extubation inspired oxygen fraction (FiO2) of 27% had a sensitivity of 58.6% and specificity of 64.7% for extubation failure. Post-extubation FiO2 of 32% had a sensitivity of 65.5% and specificity of 62.8% for failure. Prolonged membrane rupture (PROM) and high GA were associated with extubation success in multivariate logistic regression analysis. Conclusions: High GA and PROM were associated with extubation success. Pre- and post-extubation FiO2 values were not significantly predictive of extubation failure. Further studies should evaluate if overall assessment, including ventilatory parameters and clinical factors, can predict extubation success in neonates.
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20
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Al-Matary A, AlOtaiby S, Alenizi S. Outcomes and factors associated with extubation failure in preterm infants. J Clin Neonatol 2022. [DOI: 10.4103/jcn.jcn_106_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Shalish W, Keszler M, Davis PG, Sant'Anna GM. Decision to extubate extremely preterm infants: art, science or gamble? Arch Dis Child Fetal Neonatal Ed 2022; 107:105-112. [PMID: 33627331 DOI: 10.1136/archdischild-2020-321282] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022]
Abstract
In the modern era of neonatology, mechanical ventilation has been restricted to a smaller and more immature population of extremely preterm infants. Given the adverse outcomes associated with mechanical ventilation, every effort is made to extubate these infants as early as possible. However, the scientific basis for determining extubation readiness remains imprecise and primarily guided by clinical judgement, which is highly variable and subjective. In the absence of accurate tools to assess extubation readiness, many infants fail their extubation attempt and require reintubation, which also increases complications. Recent advances in the field have led to unravelling some of the complexities surrounding extubation in this population. This review aims to synthesise the available knowledge and provide a more evidence-based approach towards the reporting of extubation outcomes and assessment of extubation readiness in extremely preterm infants.
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Affiliation(s)
- Wissam Shalish
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Martin Keszler
- Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
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22
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Li J, Zhang J, Hao Q, Shen Z, Du Y, Chen H, Cheng X. The Impact of Time Interval Between First Extubation and Reintubation on Bronchopulmonary Dysplasia or Death in Very Low Birth Weight Infants. Front Pediatr 2022; 10:867767. [PMID: 35547548 PMCID: PMC9085302 DOI: 10.3389/fped.2022.867767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To explore the association between time from first extubation to reintubation and moderate-to-severe bronchopulmonary dysplasia (BPD) or death in very low birth weight infants. STUDY DESIGN Infants weighing <1,500 g at birth, requiring mechanical ventilation, and undergoing their initial extubation were retrospectively included from January 2014 to December 2021. They were divided into the moderate-to-severe BPD/death group and the comparison group according to the incidence of moderate-to-severe BPD or death. We defined time to reintubation as the time interval between first extubation and reintubation. In a stepwise multivariate logistic regression analysis, we examined the association between time to reintubation and moderate-to-severe BPD/death using different observation windows after initial extubation (24-h intervals). RESULTS A total of 244 infants were recruited, including 57 cases in the moderate-severe BPD/death group and 187 cases in the comparison group, and 93 (38.1%) cases were reintubated at least one time after their first extubation. Univariate analysis showed that reintubation rates within different observation windows in the moderate-to-severe BPD/death group were statistically significantly (p < 0.05) higher than those in the comparison group. Multivariate regression analysis showed that reintubation within observation windows 48 h or 72 h post-extubation was an independent risk factor in moderate-to-severe BPD/death and death, but not moderate-to-severe BPD. When the time window was 48 h, the probability of moderate-to-severe BPD/death [odds ratio (OR): 3.778, 95% confidence interval (CI): 1.293-11.039] or death (OR: 4.734, 95% CI: 1.158-19.354) was highest. While after extending the observation window to include reintubations after 72 h from initial extubation, reintubation was not associated with increased risk of moderate-to-severe BPD and/or death. CONCLUSIONS Not all reintubations conferred increased risks of BPD/death. Only reintubation within 72 h from initial extubation was independently associated with increased likelihood of moderate-to-severe BPD/death and death in very low birth weight infants, and reintubation within the first 48 h post-extubation posed the greatest risk.
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Affiliation(s)
- Jing Li
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qingfei Hao
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziyun Shen
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanna Du
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haoming Chen
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants. Pediatr Res 2022; 92:1064-1069. [PMID: 35523885 PMCID: PMC9586868 DOI: 10.1038/s41390-022-02085-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/04/2022] [Accepted: 03/26/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants. METHODS When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure. RESULTS Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6-30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5-4.2) versus 3.5 (2.1-5.3) µV; p < 0.001]. In the whole cohort, postmenstrual age (PMA) was the strongest predictor for extubation failure (area under the curve (AUC) 0.77). In infants of gestational age <29 weeks, the percentage change of the EMG predicted extubation failure with an AUC of 0.74 while PMA was not associated with the outcome of extubation. CONCLUSIONS In all preterm infants, PMA was the strongest predictor of extubation failure; in those born <29 weeks of gestation, diaphragmatic electromyography during an SBT was the best predictor of extubation failure. IMPACT Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.
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Extubation Readiness in Preterm Infants: Evaluating the Role of Monitoring Intermittent Hypoxemia. CHILDREN-BASEL 2021; 8:children8030237. [PMID: 33803800 PMCID: PMC8003265 DOI: 10.3390/children8030237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
Preterm infants with respiratory distress may require mechanical ventilation which is associated with increased pulmonary morbidities. Prompt and successful extubation to noninvasive support is a pressing goal. In this communication, we show original data that increased recurring intermittent hypoxemia (IH, oxygen saturation <80%) may be associated with extubation failure at 72 h in a cohort of neonates <30 weeks gestational age. Current-generation bedside high-resolution pulse oximeters provide saturation profiles that may be of use in identifying extubation readiness and failure. A larger prospective study that utilizes intermittent hypoxemia as an adjunct predictor for extubation readiness is warranted.
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Nakato AM, Ribeiro DDF, Simão AC, Da Silva RP, Nohama P. Impact of Spontaneous Breathing Trials in Cardiorespiratory Stability of Preterm Infants. Respir Care 2021; 66:286-291. [PMID: 32994356 PMCID: PMC9994229 DOI: 10.4187/respcare.07955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A spontaneous breathing trial (SBT) is commonly used to determine extubation readiness in patients receiving mechanical ventilation. However, the physiological impact of such a trial in preterm infants has not been well described. This study aimed to investigate the effects of a 3-min SBT on the cardiorespiratory stability of these infants. METHODS A retrospective analysis of prospectively collected data was done for infants < 37 weeks gestational age who were extubated after a successful 3-min SBT. Heart rate, [Formula: see text], breathing frequency, exhaled tidal volume, and Silverman Andersen Respiratory Severity Score (SA-RSS) to assess work of breathing, before and at the end of the SBT, were recorded and compared using nonparametric paired Mann-Whitney tests. A secondary analysis was done between extubation success (ie, 72 h without the need for re-intubation) and failure groups. Differences were considered statistically significant if P < .05. RESULTS A total of 90 SBTs were performed in 70 premature infants; 65 had a successful SBT, and 5 failed the SBT. Of the 65 infants who had a successful SBT and were extubated, 6 failed extubation (9.2%). Subjects had a median (interquartile range [IQR]) gestational age of 30 (27-33) weeks at birth, a birthweight of 1,240 (860-1,790) g, and weight at extubation of 1,790 (1,440-2,500) g. Cardiorespiratory stability was noted by a significant decrease in median (IQR) exhaled tidal volume (6.4 [4.9-8.4] mL/kg vs 5.2 (3.8-6.6] mL/kg, P < .001), a significant increase in mean ± SD breathing frequency (45.1 ± 11.4 vs 52.6 ± 14.4 breaths/min, P < .001), and a significant median (IQR) increase in work of breathing (SA-RSS of 1 [1-2] vs 2 [1-3], P < .001) at the end of the SBT. Respiratory instability was more remarkable in the success group. CONCLUSIONS In preterm infants receiving prolonged mechanical ventilation, the performance of a 3-min SBT was associated with increased respiratory instability while still leading to a 10% extubation failure rate. Therefore, the routine use of SBTs to assess extubation readiness in this population is not recommended until there are clear standards and definitions, as well as good accuracy to identify failures.
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Affiliation(s)
- Adriane M Nakato
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil.
| | - Débora de Fc Ribeiro
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
- Neonatal Division, Waldemar Monastier Hospital, Campo Largo, Paraná, Brazil
| | - Ana Carolina Simão
- Neonatal Division, Waldemar Monastier Hospital, Campo Largo, Paraná, Brazil
| | - Regina Pgvc Da Silva
- Department of Pediatrics, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Percy Nohama
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Diaphragmatic activity and neural breathing variability during a 5-min endotracheal continuous positive airway pressure trial in extremely preterm infants. Pediatr Res 2021; 89:1810-1817. [PMID: 32942291 PMCID: PMC7533985 DOI: 10.1038/s41390-020-01159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Extremely preterm infants are often exposed to endotracheal tube continuous positive airway pressure (ETT-CPAP) trials to assess extubation readiness. The effects of ETT-CPAP trial on their diaphragmatic activity (Edi) and breathing variability is unknown. METHODS Prospective observational study enrolling infants with birth weight ≤1250 g undergoing their first extubation attempt. Diaphragmatic activity, expressed as the absolute minimum (Edi min) and maximum values (Edi max), area under the Edi signal, and breath-by-breath analyses for breath areas, amplitudes, widths, and neural inspiratory and expiratory times, were analyzed during mechanical ventilation (MV) and ETT-CPAP. Neural breathing variability of each of these parameters was also calculated and compared between MV and ETT-CPAP. RESULTS Thirteen infants with median (interquartile range) birth weight of 800 g [610-920] and gestational age of 25.4 weeks [24.4-26.3] were included. Diaphragmatic activity significantly increased during ETT-CPAP when compared to MV:Edi max (44.2 vs. 38.1 μV), breath area (449 vs. 312 μV·s), and amplitude (10.12 vs. 7.46 μV). Neural breathing variability during ETT-CPAP was characterized by increased variability for amplitude and area under the breath, and decreased for breath time and width. CONCLUSIONS A 5-min ETT-CPAP in extremely preterm infants undergoing extubation imposed significant respiratory load with changes in respiratory variability. IMPACT ETT-CPAP trials are often used to assess extubation readiness in extremely preterm infants, but its effects upon their respiratory system are not well known. Diaphragmatic activity analysis demonstrated that these infants are able to mount an important response to a short trial. A 5-min trial imposed a significant respiratory load evidenced by increased diaphragmatic activity and changes in breathing variability. Differences in breathing variability were observed between successful and failed extubations, which should be explored further in extubation readiness investigations. This type of trial cannot be recommended for preterm infants in clinical practice until clear standards and accuracy are established.
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Teixeira RF, Carvalho ACA, de Araujo RD, Veloso FCS, Kassar SB, Medeiros AMC. Spontaneous Breathing Trials in Preterm Infants: Systematic Review and Meta-Analysis. Respir Care 2021; 66:129-137. [PMID: 32843509 PMCID: PMC9993830 DOI: 10.4187/respcare.07928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Few data are available on the use of spontaneous breathing trials (SBTs) in the neonatal population, despite advocacy of the practice in many neonatal ICUs. In this meta-analysis, we systematically reviewed the literature regarding the accuracy of SBTs as a predictor for extubation failure in premature infants. METHODS Following the PRISMA recommendations, scientific articles were collected in December 2019 and January 2020 using PubMed, LILACS, Web of Science, Scopus, Google Scholar, OATD, and BDTD databases. The risk of bias in the studies included herein was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The pooled sensitivity and specificity of the studies were estimated using a mixed logistic regression model of 2 levels and a normal bivariate model. RESULTS Six studies were included for qualitative and quantitative evaluation in this study. All SBTs were performed with endotracheal CPAP, with a total observation time of 3-5 min. The parameters for passing/failing the test were similar in 5 of the 6 studies and included bradycardia or desaturation during the test. The SBT showed a high pooled sensitivity (0.97, 95% CI 0.85-0.99), indicating proper identification of neonates "ready" for successful extubation. However, a low pooled specificity (0.40, 95% CI 0.24-0.58), with many false-positive cases, indicated inaccurate prediction of extubation failure. Heterogeneity of included studies was considerable for sensitivity and substantial for specificity. CONCLUSIONS The SBT in premature infants can accurately predict extubation success but not extubation failure. Therefore, even though it is an attractive, practical, and easy-to-perform bedside assessment tool, there is a lack of evidence to support its use as an independent predictor of extubation failure in premature infants. Its routine use should be evaluated and monitored carefully.
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Affiliation(s)
- Raphaela Farias Teixeira
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Sergipe, Brazil.
- CESMAC University Centre, Maceió, Alagoas, Brazil
| | - Aline Carla Araújo Carvalho
- CESMAC University Centre, Maceió, Alagoas, Brazil
- State University of Health Sciences of Alagoas, Maceió, Alagoas, Brazil
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Cheng Z, Dong Z, Zhao Q, Zhang J, Han S, Gong J, Wang Y. A Prediction Model of Extubation Failure Risk in Preterm Infants. Front Pediatr 2021; 9:693320. [PMID: 34631610 PMCID: PMC8492984 DOI: 10.3389/fped.2021.693320] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/26/2021] [Indexed: 11/25/2022] Open
Abstract
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 250/7 and 296/7 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 250/7 and 296/7 weeks' gestational age and treated with MVEI because of acute respiratory distress syndrome.
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Affiliation(s)
- Zimei Cheng
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Ziwei Dong
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Qian Zhao
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Jingling Zhang
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Su Han
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Jingxian Gong
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Yang Wang
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Anhui, China
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Espahbodi M, Kallenbach SL, Thorgerson AA, Huang CC, Shay SG, McCormick ME, Chun RH. The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations. Int J Pediatr Otorhinolaryngol 2020; 138:110268. [PMID: 32805493 DOI: 10.1016/j.ijporl.2020.110268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/15/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Mana Espahbodi
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA
| | | | - Abigail A Thorgerson
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Chiang-Ching Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Sophie G Shay
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael E McCormick
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert H Chun
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA.
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