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

Outcomes of infants with birthweights less than 501 g compared to infants weighing 501-750 g at a center utilizing first intention high frequency jet ventilation

Background

Data on clinical outcomes of infants with birthweights less than 501 g (ELBW<501) are limited.

Objective

To evaluate management strategies and clinical outcomes of ELBW<501infants compared to infants weighing 501-750 g (ELBW501-750).

Methods

A retrospective study of all ELBW<501 and ELBW501-750 infants born between 2012 and 2022 at a center utilizing first intention high frequency jet ventilation was performed. Patient characteristics, clinical and outcome data were compared between the two groups.

Results

A total of 358 infants (92 ELBW<501 infants and 266 ELBW501-750) were included. The survival rate for the ELBW<501 group was 60.9% compared to 86.5% for ELBW501-750. ELBW<501 infants required more frequent use of 2.0 mm endotracheal tubes, required higher FiO2 and longer duration of mechanical ventilation. Compared to ELBW501-750 group, the ELBW<501 group were more likely to be SGA (68.2% vs. 16.5%) and more premature (23.2 vs. 24.3 weeks) with lower survival, longer length of stay, higher incidence of ROP and lower weight at discharge but comparable rates of IVH, grade 3 BPD, discharged on supplemental oxygen, and tracheostomy.

Conclusion

ELBW<501 infants are at risk for significant morbidity and mortality. However, with specialized obstetric and neonatal care, survival rates of 60% are possible with respiratory outcomes comparable to ELBW501-750 infants. However, the increased risk of severe ROP for ELBW<501 requiring either surgical or medical intervention is concerning and warrants optimal surveillance.

Predicting Extubation Readiness in Preterm Infants Utilizing Machine Learning: A Diagnostic Utility Study

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.

Using machine-learning models to predict extubation failure in neonates with bronchopulmonary dysplasia

AIM

To develop a decision-support tool for predicting extubation failure (EF) in neonates with bronchopulmonary dysplasia (BPD) using a set of machine-learning algorithms.

METHODS

A dataset of 284 BPD neonates on mechanical ventilation was used to develop predictive models via machine-learning algorithms, including extreme gradient boosting (XGBoost), random forest, support vector machine, naïve Bayes, logistic regression, and k-nearest neighbor. The top three models were assessed by the area under the receiver operating characteristic curve (AUC), and their performance was tested by decision curve analysis (DCA). Confusion matrix was used to show the high performance of the best model. The importance matrix plot and SHapley Additive exPlanations values were calculated to evaluate the feature importance and visualize the results. The nomogram and clinical impact curves were used to validate the final model.

RESULTS

According to the AUC values and DCA results, the XGboost model performed best (AUC = 0.873, sensitivity = 0.896, specificity = 0.838). The nomogram and clinical impact curve verified that the XGBoost model possessed a significant predictive value. The following were predictive factors for EF: pO2, hemoglobin, mechanical ventilation (MV) rate, pH, Apgar score at 5 min, FiO2, C-reactive protein, Apgar score at 1 min, red blood cell count, PIP, gestational age, highest FiO2 at the first 24 h, heart rate, birth weight, pCO2. Further, pO2, hemoglobin, and MV rate were the three most important factors for predicting EF.

CONCLUSIONS

The present study indicated that the XGBoost model was significant in predicting EF in BPD neonates with mechanical ventilation, which is helpful in determining the right extubation time among neonates with BPD to reduce the occurrence of complications.

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

OBJECTIVE

This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP; ≥9 cm H2O), in relation to preextubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates.

STUDY DESIGN

In this retrospective cohort study, preterm neonates <29 weeks' gestational age (GA) extubated from mean Paw ≥9 cm H2O and to high CPAP (≥9 cm H2O) were classified into "higher level CPAP" (2-3 cm H2O higher than preextubation Paw) and "equivalent CPAP" (-1 to +1 cm H2O in relation to preextubation Paw). Only the first eligible extubation per infant was analyzed. The primary outcome was failure within ≤7 days of extubation, defined as any one or more of (1) need for reintubation, (2) escalation to an alternate noninvasive respiratory support mode, or (3) use of CPAP >preextubation Paw + 3 cm H2O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes.

RESULTS

Over a 10-year period (Jan 2011-Dec 2020), 175 infants were extubated from mean Paw >9 cm H2O to high CPAP pressures. Twenty-seven patients (median GA = 24.7, [interquartile range (IQR)]: (24.0-26.4) weeks and chronological age = 31, IQR: [21-40] days) were classified into the "higher level CPAP" group while 148 infants (median GA = 25.4, IQR: [24.6-26.6] weeks and chronological age = 26, IQR: [10-39] days) comprised the "equivalent CPAP" group. There was no difference in the primary outcome (44 vs. 51%; p = 0.51), including postadjustment for confounders (adjusted OR [aOR] = 0.47 [95% confidence interval (CI): 0.17-1.29; p = 0.14]). However, reintubation risk within 7 days was lower with higher level CPAP (7 vs. 37%; p < 0.01), including postadjustment (aOR = 0.07; 95% CI: 0.02-0.35; p < 0.01).

CONCLUSION

In this cohort, use of initial distending CPAP pressures 2 to 3 cm H2O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

KEY POINTS

· Use of high CPAP pressures (≥9 cm H2O) is gradually increasing in the care of preterm neonates.. · This study compares higher level versus equivalent CPAP in relation to preextubation Paw.. · The findings demonstrate no difference in failure as defined with use of higher level CPAP pressures..

Characteristics and Outcomes in Preterm Infants with Extubation Failure in the First Week of Life

OBJECTIVE

This study aimed to evaluate characteristics and outcomes in preterm infants with extubation failures in their first week of life.

STUDY DESIGN

Retrospective chart review of infants born between 24 and 27 weeks' gestational age at the Sharp Mary Birch Hospital for Women and Newborns between January 2014 and December 2020 who had an extubation attempt within the first 7 days of life. Infants that were successfully extubated were compared with those who required reintubation in the first 7 days. Maternal and neonatal outcome measures were analyzed.

RESULTS

A total of 215 extremely preterm infants had an extubation attempt in the first 7 days of life. Forty-six infants (21.4%) failed extubation and were reintubated within the first 7 days. Infants who failed extubation had a lower pH (p < 0.01), increased base deficit (p < 0.01), and more surfactant doses prior to first extubation (p < 0.01). Birth weight, Apgar scores, antenatal steroid doses, and maternal risk factors such as preeclampsia, chorioamnionitis, and duration of ruptured membranes were not different between success and failure groups. Rates of moderate to large patent ductus arteriosus (p < 0.01), severe intraventricular hemorrhage (p < 0.01), posthemorrhagic hydrocephalus (p < 0.05), periventricular leukomalacia (p < 0.01), and retinopathy of prematurity stage 3 or greater (p < 0.05) were higher in the failure group.

CONCLUSION

In this cohort of extremely preterm infants that failed extubation in the first week of life, there were as increased risk of multiple morbidities. Base deficit, pH, and number of surfactant doses prior to first extubation may be useful tools in predicting which infants are likely to have early extubation success, but this needs prospective study.

KEY POINTS

· Predicting extubation readiness in preterm infants remains challenging.. · Extubation failure is associated with multiple neonatal morbidities.. · Infant clinical characteristics may help predict extubation failure..

Training in neonatal neurocritical care: A case-based interdisciplinary approach

Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.

The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation

BACKGROUND

Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation.

METHODS

This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer.

DISCUSSION

The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , trial identifier NCT05446272 , registered July 6, 2022.

Comparison of the effectiveness of different high-flow devices in neonatal care

OBJECTIVE

To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs).

METHOD

This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h.

RESULTS

A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM).

CONCLUSION

Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.

Care from Birth to Discharge of Infants Born at 22 to 23 Weeks' Gestation

The clinical care of infants born at 22 weeks' gestation must be well-designed and standardized if optimal results are to be expected. Although several approaches to care in this vulnerable population are possible, protocols should be neither random nor inconsistent. We describe the approach taken at the University of Iowa Stead Family Children's Hospital neonatal intensive care unit with respect to preterm infants born at 22 weeks' gestation. We have chosen to present our standardize care plan with respect to prenatal, neurologic, nutritional, gastrointestinal, and skin management. Respiratory and cardiopulmonary care will be briefly reviewed, as these strategies have been published previously.

A clinical informatics approach to bronchopulmonary dysplasia: current barriers and future possibilities

Bronchopulmonary dysplasia (BPD) is a complex, multifactorial lung disease affecting preterm neonates that can result in long-term pulmonary and non-pulmonary complications. Current therapies mainly focus on symptom management after the development of BPD, indicating a need for innovative approaches to predict and identify neonates who would benefit most from targeted or earlier interventions. Clinical informatics, a subfield of biomedical informatics, is transforming healthcare by integrating computational methods with patient data to improve patient outcomes. The application of clinical informatics to develop and enhance clinical therapies for BPD presents opportunities by leveraging electronic health record data, applying machine learning algorithms, and implementing clinical decision support systems. This review highlights the current barriers and the future potential of clinical informatics in identifying clinically relevant BPD phenotypes and developing clinical decision support tools to improve the management of extremely preterm neonates developing or with established BPD. However, the full potential of clinical informatics in advancing our understanding of BPD with the goal of improving patient outcomes cannot be achieved unless we address current challenges such as data collection, storage, privacy, and inherent data bias.

Peri-extubation settings in preterm neonates: a systematic review and meta-analysis

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.

Predictors of successful extubation from volume-targeted ventilation in extremely preterm neonates

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.

A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units

(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.

A quality improvement strategy to reduce unintended extubation in the very low birth weight infant: A case report

BACKGROUND

Unintended extubations remain a common complication across neonatal intensive care units, with very low birthweight infants being the most vulnerable of them all. Ongoing efforts across different institutions exist with the goal of reducing the rate of unintended extubations to keep a median rate of <2 events per 100 ventilator days as defined by the Vermont Oxford Network. Our objective was to reduce unintended extubations in the very low birthweight infant in a large delivery hospital to ≤2/100 ventilator days.

METHODS

A collaborative group was formed between two academic health institutions targeting training and implementation of the Children's National unintended extubation system, focusing on endotracheal tube securement methods and surveillance protocols.

RESULTS

The unintended extubation rate decreased from 3.23 to 0.64 per 100 ventilator days. Changes were implemented from 2018-2020 with a sustained reduction in the unintended extubation rate of 1.54 per 100 ventilator days. Most events occurred between 12 : 00 pm -4 : 00 pm and the commonest cause was spontaneous (25%) followed by dislodgment during repositioning (19%).

CONCLUSION

Very low birth weight infants present a challenge to endotracheal tube maintenance due to their developmental and anatomical changes during their neonatal intensive care unit stay. Successful reduction of unintended extubations in the very low birthweight infant can be achieved by adaptation of successful protocols for older infants.

Higher versus lower nasal continuous positive airway pressure for extubation of extremely preterm infants in Australia (ÉCLAT): a multicentre, randomised, superiority trial

BACKGROUND

Extremely preterm infants often require invasive mechanical ventilation, and clinicians aim to extubate these infants as soon as possible. However, extubation failure occurs in up to 60% of extremely preterm infants and is associated with increased mortality and morbidity. Nasal continuous positive airway pressure (nCPAP) is the most common post-extubation respiratory support, but there is no consensus on the optimal nCPAP level to safely avoid extubation failure in extremely preterm infants. We aimed to determine if higher nCPAP levels compared with standard nCPAP levels would decrease rates of extubation failure in extremely preterm infants within 7 days of their first extubation.

METHODS

In this multicentre, randomised, open-label controlled trial done at three tertiary perinatal centres in Australia, we assigned extremely preterm infants to extubation to either higher nCPAP (10 cmH2O) or standard nCPAP (7 cmH2O). Infants were eligible if they were born at less than 28 weeks' gestation, were receiving mechanical ventilation via an endotracheal tube, and were being extubated for the first time to nCPAP. Eligible infants must have received previous treatment with exogenous surfactant and caffeine. Infants were ineligible if they were planned to be extubated to a mode of respiratory support other than nCPAP, if they had a known major congenital anomaly that might affect breathing, or if ongoing intensive care was not being provided. Parents or guardians provided prospective, written, informed consent. Infants were maintained within an assigned nCPAP range for a minimum of 24 h after extubation (higher nCPAP group 9-11 cmH2O and standard nCPAP group 6-8 cmH2O). Randomisation was stratified by both gestation (22-25 completed weeks or 26-27 completed weeks) and recruiting centre. The primary outcome was extubation failure within 7 days and analysis was by intention to treat. This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12618001638224.

FINDINGS

Between March 3, 2019, and July 31, 2022, 483 infants were born at less than 28 weeks and admitted to the recruiting centres. 92 infants were not eligible, 172 were not approached, 65 families declined to participate, and 15 consented but were not randomly assigned. 139 infants were enrolled and randomly assigned, 70 to the higher nCPAP group and 69 to the standard nCPAP group. One infant in the higher nCPAP group was excluded from the analysis because consent was withdrawn after randomisation. 104 (75%) of 138 mothers were White. The mean gestation was 25·7 weeks (SD 1·3) and the mean birthweight was 777 grams (201). 70 (51%) of 138 infants were female. Extubation failure occurred in 24 (35%) of 69 infants in the higher nCPAP group and in 39 (57%) of 69 infants in the standard nCPAP group (risk difference -21·7%, 95% CI -38·5% to -3·7%). There were no significant differences in rates of adverse events between groups during the primary outcome period. Three patients died (two in the higher nCPAP group and one in the standard nCPAP group), pneumothorax occurred in one patient from each group, spontaneous intestinal perforation in three patients (two in the higher nCPAP group and one in the standard nCPAP group) and there were no events of pulmonary interstitial emphysema.

INTERPRETATION

Extubation of extremely preterm infants to higher nCPAP significantly reduced extubation failure compared with extubation to standard nCPAP, without increasing rates of adverse effects. Future larger trials are essential to confirm these findings in terms of both efficacy and safety.

FUNDING

National Health and Medical Research Council Centre for Research Excellence in Newborn Medicine, number 1153176.

Variables related to bronchopulmonary dysplasia severity: a Six-Year retrospective study

OBJECTIVES

This was a retrospective observational study conducted in a tertiary neonatal intensive care unit, in order to investigate factors which influenced the severity of bronchopulmonary dysplasia under NICHD new classification.

METHODS

Six years of clinical data with different grades of bronchopulmonary dysplasia patients were collected and analyzed, bivariate ordinal logistic regression model and multivariable ordinal logistic regression model were used with sensitivity analyses.

RESULTS

We identified seven variables were associated with the severity of BPD via a bivariate ordinal logistic regression model, including the level of referral hospital (OR 0.273；95% CI 0.117, 0.636), method of caffeine administration (OR 00.418；95% CI 0.177, 0.991), more than two occurrences of reintubation (OR 4.925；95% CI 1.878, 12.915), CPAP reapplication (OR 2.255；95% CI 1.059, 4.802), presence of positive sputum cultures (OR 2.574；95% CI 1.200, 5.519), the cumulative duration of invasive ventilation (OR 1.047；95% CI 1.017, 1.078), and postmenstrual age at the discontinuation of oxygen supplementation (OR 1.190；95% CI 1.027, 1.38). These seven variables were further analyzed via all multivariable ordinal logistic regression models, and we found that tertiary hospital birth and early administration of caffeine could reduce the severity of BPD by approximately 70% (OR 0.263；95% CI 0.090, 0.770) and 60% (OR 0.371；95% CI 0.138, 0.995), respectively. In contrast, multiple reintubations were related to higher BPD severity with an OR of 3.358 (95% CI 1.002, 11.252).

CONCLUSION

Improving perinatal care in level II hospitals, standardized caffeine administration, and optimized extubation strategy could potentially decrease the severity of BPD.

Effect of different courses and durations of invasive mechanical ventilation on respiratory outcomes in very low birth weight infants

This multicenter retrospective study was conducted to explore the effects of different courses and durations of invasive mechanical ventilation (MV) on the respiratory outcomes of very low birth weight infants (VLBWI) in China. The population for this study consisted of infants with birth weight less than 1500 g needing at least 1 course of invasive MV and admitted to the neonatal intensive care units affiliated with the Chinese Neonatal Network within 6 h of life from January 1st, 2019 to December 31st, 2020. Univariate and multivariate logistic regression analyses were performed to evaluate associations between invasive MV and respiratory outcomes. Adjusted odds ratios (ORs) were computed with the effects of potential confounders. (1) Among the 3183 VLBWs with a history of at least one course of invasive MV, 3155 (99.1%) met inclusion criteria and were assessed for the primary outcome. Most infants received one course (76.8%) and a shorter duration of invasive MV (62.16% with ventilation for 7 days or less). (2) In terms of the incidence of all bronchopulmonary dysplasia (BPD) (mild, moderate, and severe BPD), there were no significant differences between different invasive MV courses [For 2 courses, adjusted OR = 1.11 (0.88, 1.39); For 3 courses or more, adjusted OR = 1.07 (0.72, 1.60)]. But, with the duration of invasive MV prolonging, the OR of BPD increased [8-21 days, adjusted OR = 1.98 (1.59, 2.45); 22-35 days, adjusted OR = 4.37 (3.17, 6.03); ≥ 36 days, adjusted OR = 18.44 (10.98, 30.99)]. Concerning severe BPD, the OR increased not only with the course of invasive MV but also with the duration of invasive MV [For 2 courses, adjusted OR = 2.17 (1.07, 4.40); For 3 courses or more, adjusted OR = 2.59 (1.02, 6.61). 8-21 days, adjusted OR = 8.42 (3.22, 22.01); 22-35 days, adjusted OR = 27.82 (9.08, 85.22); ≥ 36 days, adjusted OR = 616.45 (195.79, > 999.999)]. (3) When the interaction effect between invasive MV duration and invasive MV course was considered, it was found that there were no interactive effects in BPD and severe BPD. Greater than or equal to three courses would increase the chance of severe BPD, death, and the requirement of home oxygen therapy. Compared with distinct courses of invasive MV, a longer duration of invasive MV (> 7 days) has a greater effect on the risk of BPD, severe BPD, death, and the requirement of home oxygen therapy.

Predictors of extubation failure in newborns: a systematic review and meta-analysis

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.

Optimal timing of extubation in preterm infants

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.

Accuracy of lung ultrasound in predicting extubation failure in neonates: A systematic review and meta-analysis

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).

Development and validation of a prediction model for evaluating extubation readiness in preterm infants

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.

Predictive factors for extubation success in very low and extremely low birth weight preterm infants

Background

Although invasive mechanical ventilation (IMV) has contributed to the survival of preterm infants with extremely low birth weight (ELBW), it is also associated with unsatisfactory clinical outcomes when used for prolonged periods. This study aimed to identify factors that may be decisive for extubation success in very low birth weight (VLBW) and extremely low birth weight (ELBW) preterm infants.

Methods

The cohort study included preterm infants with gestational age (GA) <36 weeks, birth weight (BW) <1500 grams who underwent IMV, born between 2015 and 2018. The infants were allocated into two groups: extubation success (SG) or failure (FG). A stepwise logistic regression model was created to determine variables associated with successful extubation.

Results

Eighty-three preterm infants were included. GA and post-extubation arterial partial pressure of carbon dioxide (PaCO2) were predictive of extubation success. Infants from FG had lower GA and BW, while those from SG had higher weight at extubation and lower post-extubation PaCO2.

Discussion

Although we found post-extubation PaCO2 as an extubation success predictor, which is a variable representative of the moment after the primary outcome, this does not diminish its clinical relevance since extubation does not implicate in ET removal only; it also involves all the aspects that take place within a specified period (72 hours) after the planned event.

Conclusion

GA and post-extubation PaCO2 were predictors for extubation success in VLBW and ELBW preterm infants. Infants who experienced extubation failure had lower birth weight and higher FiO2 prior to extubation.

Accuracy of lung and diaphragm ultrasound in predicting infant weaning outcomes: a systematic review and meta-analysis

Background

Although lung and diaphragm ultrasound are valuable tools for predicting weaning results in adults with MV, their relevance in children is debatable. The goal of this meta-analysis was to determine the predictive value of lung and diaphragm ultrasound in newborn weaning outcomes.

Methods

For eligible studies, the databases MEDLINE, Web of Science, Cochrane Library, PubMed, and Embase were thoroughly searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method was used to evaluate the study's quality. Results were gathered for sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the curve of summary receiver operating characteristic curves (AUSROC). To investigate the causes of heterogeneity, subgroup analyses and meta-regression were conducted.

Results

A total of 11 studies were suitable for inclusion in the meta-analysis, which included 828 patients. The pooled sensitivity and specificity of lung ultrasound (LUS) were 0.88 (95%CI, 0.85-0.90) and 0.81 (95%CI, 0.75-0.87), respectively. The DOR for diaphragmatic excursion (DE) is 13.17 (95%CI, 5.65-30.71). The AUSROC for diaphragm thickening fraction (DTF) is 0.86 (95%CI, 0.82-0.89). The most sensitive and specific method is LUS. The DE and DTF were the key areas where study heterogeneity was evident.

Conclusions

Lung ultrasonography is an extremely accurate method for predicting weaning results in MV infants. DTF outperforms DE in terms of diaphragm ultrasound predictive power.

Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants

OBJECTIVE

This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH).

STUDY DESIGN

A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2.

RESULTS

A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048).

CONCLUSION

The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD.

KEY POINTS

· Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..

Feasibility of Endotracheal Extubation Evaluation Form in Predicting Successful Extubation in Neonatal Intensive Care Units: A Retrospective Study

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.

A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks

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.

Association of patent ductus arteriosus with extubation failure among preterm infants

BACKGROUND

Mechanical ventilation is associated with mortality/morbidities in preterm infants. Nearly a third of these infants fail extubation, and this may increase morbidities.

OBJECTIVE

To evaluate the association of moderate to large symptomatic patent ductus arteriosus (PDA) with failure of extubation among preterm infants.

METHODS

This was a retrospective study on preterm infants (birth weight <1250 g and gestational age ≥23 weeks) born between January 2009 and December 2016, who were mechanically ventilated and extubated within the first 60 days of age.

RESULTS

Three hundred and sixty infants were evaluated, of these, 26% failed, and 74% succeeded in the initial extubation attempt. On adjusted analysis, symptomatic PDA was associated with an increased risk of extubation failure.

CONCLUSION

The presence of symptomatic patent ductus arteriosus was associated with extubation failure. Further investigations are needed to establish whether there is a causal relationship between PDA and extubation failure and whether proactive screening for presence of PDA and treatment of the same, before extubation among these infants, improves chances of successful extubation and cardiorespiratory outcomes.

Autonomic markers of extubation readiness in premature infants

BACKGROUND

In premature infants, extubation failure is common and difficult to predict. Heart rate variability (HRV) is a marker of autonomic tone. Our aim is to test the hypothesis that autonomic impairment is associated with extubation readiness.

METHODS

Retrospective study of 89 infants <28 weeks. HRV metrics 24 h prior to extubation were compared for those with and without extubation success within 72 h. Receiver-operating curve analysis was conducted to determine the predictive ability of each metric, and a predictive model was created.

RESULTS

Seventy-three percent were successfully extubated. The success group had significantly lower oxygen requirement, higher sympathetic HRV metrics, and a lower parasympathetic HRV metric. α₁ (measure of autocorrelation, related to sympathetic tone) was the best predictor of success-area under the curve (AUC) of .73 (p = 0.001), and incorporated into a predictive model had an AUC of 0.81 (p < 0.0001)-sensitivity of 81% and specificity of 78%.

CONCLUSIONS

Extubation success is associated with HRV. We show an autonomic imbalance with low sympathetic and elevated parasympathetic tone in those who failed. α₁, a marker of sympathetic tone, was noted to be the best predictor of extubation success especially when incorporated into a clinical model.

IMPACT

This article depicts autonomic markers predictive of extubation success. We depict an autonomic imbalance in those who fail extubation with heightened parasympathetic and blunted sympathetic signal. We describe a predictive model for extubation success with a sensitivity of 81% and specificity of 78%.

Oxygen saturation histogram classification system to evaluate response to doxapram treatment in preterm infants

BACKGROUND

An oxygen saturation (SpO₂) histogram classification system has been shown to enable quantification of SpO₂ instability into five types, based on histogram distribution and time spent at SpO₂ ≤ 80%. We aimed to investigate this classification system as a tool to describe response to doxapram treatment in infants with severe apnea of prematurity.

METHODS

This retrospective study included 61 very-low-birth-weight infants who received doxapram. SpO₂ histograms were generated over the 24-h before and after doxapram start. Therapy response was defined as a decrease of ≥1 histogram types after therapy start.

RESULTS

The median (IQR) histogram type decreased from 4 (3-4) before to 3 (2-3) after therapy start (p < 0.001). The median (IQR) FiO₂ remained constant before (27% [24-35%]) and after (26% [22-35%]) therapy. Thirty-six infants (59%) responded to therapy within 24 h. In 34/36 (94%) of the responders, invasive mechanical ventilation (IMV) was not required during the first 72 h of therapy, compared to 15/25 (60%) of non-responders (p = 0.002). Positive and negative predictive values of the 24-h response for no IMV requirement within 72 h were 0.46 and 0.94, respectively.

CONCLUSIONS

Classification of SpO₂ histograms provides an objective bedside measure to assess response to doxapram therapy and can serve as a tool to detect changes in oxygenation status around respiratory interventions.

IMPACT

The SpO₂ histogram classification system provides a tool for quantifying response to doxapram therapy. The classification system allowed estimation of the probability of invasive mechanical ventilation requirement, already within a few hours of treatment. The SpO₂ histogram classification system allows an objective bedside assessment of the oxygenation status of the preterm infant, making it possible to assess the changes in oxygenation status in response to respiratory interventions.

Automated prediction of extubation success in extremely preterm infants: the APEX multicenter study

BACKGROUND

Extremely preterm infants are frequently subjected to mechanical ventilation. Current prediction tools of extubation success lacks accuracy.

METHODS

Multicenter study including infants with birth weight ≤1250 g undergoing their first extubation attempt. Clinical data and cardiorespiratory signals were acquired before extubation. Primary outcome was prediction of extubation success. Automated analysis of cardiorespiratory signals, development of clinical and cardiorespiratory features, and a 2-stage Clinical Decision-Balanced Random Forest classifier were used. A leave-one-out cross-validation was done. Performance was analyzed by ROC curves and determined by balanced accuracy. An exploratory analysis was performed for extubations before 7 days of age.

RESULTS

A total of 241 infants were included and 44 failed (18%) extubation. The classifier had a balanced accuracy of 73% (sensitivity 70% [95% CI: 63%, 76%], specificity 75% [95% CI: 62%, 88%]). As an additional clinical-decision tool, the classifier would have led to an increase in extubation success from 82% to 93% but misclassified 60 infants who would have been successfully extubated. In infants extubated before 7 days of age, the classifier identified 16/18 failures (specificity 89%) and 73/105 infants with success (sensitivity 70%).

CONCLUSIONS

Machine learning algorithms may improve a balanced prediction of extubation outcomes, but further refinement and validation is required.

IMPACT

A machine learning-derived predictive model combining clinical data with automated analyses of individual cardiorespiratory signals may improve the prediction of successful extubation and identify infants at higher risk of failure with a good balanced accuracy. Such multidisciplinary approach including medicine, biomedical engineering and computer science is a step forward as current tools investigated to predict extubation outcomes lack sufficient balanced accuracy to justify their use in future trials or clinical practice. Thus, this individualized assessment can optimize patient selection for future trials of extubation readiness by decreasing exposure of low-risk infants to interventions and maximize the benefits of those at high risk.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update

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).

Prediction of extubation failure among low birthweight neonates using machine learning

OBJECTIVE

To develop machine learning models predicting extubation failure in low birthweight neonates using large amounts of clinical data.

STUDY DESIGN

Retrospective cohort study using MIMIC-III, a large single-center, open-source clinical dataset. Logistic regression and boosted-tree (XGBoost) models using demographics, medications, and vital sign and ventilatory data were developed to predict extubation failure, defined as reintubation within 7 days.

RESULTS

1348 low birthweight (≤2500 g) neonates who received mechanical ventilation within the first 7 days were included, of which 350 (26%) failed a trial of extubation. The best-performing model was a boosted-tree model incorporating demographics, vital signs, ventilator parameters, and medications (AUROC 0.82). The most important features were birthweight, last FiO2, average mean airway pressure, caffeine use, and gestational age.

CONCLUSIONS

Machine learning models identified low birthweight ventilated neonates at risk for extubation failure. These models will need to be validated across multiple centers to determine generalizability of this tool.

Risk factors and clinical outcomes of extubation failure in very early preterm infants: a single-center cohort study

BACKGROUND

Early extubation success (ES) in preterm infants may reduce various mechanical ventilation-associated complications; however, extubation failure (EF) can cause adverse short- and long-term outcomes. Therefore, the present study aimed to identify differences in risk factors and clinical outcomes between ES and EF in very early preterm infants.

METHODS

This retrospective study was conducted between January 2017 and December 2021. Premature infants born at 32 weeks' gestational age in whom extubation had failed at least once were assigned to the EF group. Successfully extubated patients with a similar gestational age and birth weight as those in the EF group were assigned to the ES group. EF was defined as the need for re-intubation within 120 h of extubation. Various variables were compared between groups.

RESULTS

The EF rate in this study was 18.6% (24/129), and approximately 80% of patients with EF required re-intubation within 90.17 h. In the ES group, there was less use of inotropes within 7 days of life (12 [63.2%] vs. 22 [91.7%], p = 0.022), a lower respiratory severity score (RSS) at 1 and 4 weeks (1.72 vs. 2.5, p = 0.026; 1.73 vs. 2.92, p = 0.010), and a faster time to reach full feeding (18.7 vs. 29.7, p = 0.020). There was a higher severity of bronchopulmonary dysplasia BPD (3 [15.8%] vs. 14 [58.3%], p = 0.018), longer duration of oxygen supply (66.5 vs. 92.9, p = 0.042), and higher corrected age at discharge (39.6 vs. 42.5, p = 0.043) in the EF group. The cutoff value, sensitivity, and specificity of the respiratory severity score (RSS) at 1 week were 1.98, 0.71, and 0.42, respectively, and the cutoff value, sensitivity, and specificity of RSS at 4 weeks were 2.22, 0.67, and 0.47, respectively.

CONCLUSIONS

EF caused adverse short-term outcomes such as a higher BPD severity and longer hospital stay. Therefore, extubation in very early preterm infants should be carefully evaluated. Using inotropes, feeding, and RSS at 1 week of age can help predict extubation success.

Duration of mechanical ventilation and clinical outcomes in very low birth weight infants: A single center 10-years cohort study

BACKGROUND

Despite the important role of MV in reducing mortality in very preterm infants, its use is often associated with complications. The study was aimed to determine the duration of mechanical ventilation (MV), which significantly increased the risk of adverse outcomes in very low birth weight (VLBW) infants.

METHODS

Data obtained from a prospectively created computer database were used in a retrospective cohort study. The database included information about 1980 VLBW infants <32 weeks of gestation who were cared for at the tertiary care center between January 2010 and December 2020.

RESULTS

Out of 1980 VLBW infants, 1086 (55%) were ventilated sometime during the hospital stay. 678 (62.43%) of ventilated babies survived until discharge. With ROC analysis, it was identified that MV duration of 60.5 hours had 79.3% sensitivity and 64.6% specificity for the prediction of BPD with the AUC of 0.784 (95% CI 0.733-0.827; p < 0.0001). The duration of MV above 60.5 hours was a significant risk factor for bronchopulmonary dysplasia (aOR 6.005, 95% CI 3.626-9.946), death (aOR 3.610, 95% CI 2.470-5.276), bronchopulmonary dysplasia/death (aOR 4.561, 95% CI 3.328-6.252), sepsis (aOR 1.634, 95% CI 1.168-2.286), necrotizing enterocolitis (aOR 2.606, 95% CI 1.364-4.980), and periventricular leukomalacia (aOR 2.191, 95% CI 1.241-3.867).

CONCLUSIONS

Duration of MV longer than 60.5 hours is an independent risk factor for adverse outcomes in VLBW infants. It is essential to increase and optimize efforts to avoid MV or extubate very preterm infants as soon as possible, before reaching the established threshold duration of invasive respiratory support.

Age at First Extubation Attempt and Death or Respiratory Morbidities in Extremely Preterm Infants

OBJECTIVE

To describe the timing of first extubation in extremely preterm infants and explore the relationship between age at first extubation, extubation outcome, and death or respiratory morbidities.

STUDY DESIGN

In this subanalysis of a multicenter observational study, infants with birth weights of 1250 g or less and intubated within 24 hours of birth were included. After describing the timing of first extubation, age at extubation was divided into early (within 7 days from birth) vs late (days of life 8-35), and extubation outcome was divided into success vs failure (reintubation within 7 days after extubation), to create 4 extubation groups: early success, early failure, late success, and late failure. Logistic regression analyses were performed to evaluate associations between the 4 groups and death or bronchopulmonary dysplasia, bronchopulmonary dysplasia among survivors, and durations of respiratory support and oxygen therapy.

RESULTS

Of the 250 infants included, 129 (52%) were extubated within 7 days, 93 (37%) between 8 and 35 days, and 28 (11%) beyond 35 days of life. There were 93, 36, 59, and 34 infants with early success, early failure, late success, and late failure, respectively. Although early success was associated with the lowest rates of respiratory morbidities, early failure was not associated with significantly different respiratory outcomes compared with late success or late failure in unadjusted and adjusted analyses.

CONCLUSIONS

In a contemporary cohort of extremely preterm infants, early extubation occurred in 52% of infants, and only early and successful extubation was associated with decreased respiratory morbidities. Predictors capable of promptly identifying infants with a high likelihood of early extubation success or failure are needed.

Evaluation and validation of a prediction model for extubation success in very preterm infants

OBJECTIVE

To perform an external validation of a publicly available model predicting extubation success in very preterm infants.

STUDY DESIGN

Retrospective study of infants born <1250 g at a single center. Model performance evaluated using the area under the receiver operating characteristic curve (AUROC) and comparing observed and expected probabilities of extubation success, defined as survival ≥5 d without an endotracheal tube.

RESULTS

Of 177 infants, 120 (68%) were extubated successfully. The median (IQR) gestational age was 27 weeks (25-28) and weight at extubation was 915 g (755-1050). The model had acceptable discrimination (AUROC 0.72 [95% CI 0.65-0.80]) and adequate calibration (calibration slope 0.96, intercept -0.06, mean observed-to-expected difference in probability of extubation success -0.08 [95% CI -0.01, -0.15]).

CONCLUSIONS

The extubation success prediction model has acceptable performance in an external cohort. Additional prospective studies are needed to determine if the model can be improved or how it can be used for clinical benefit.

Care practices and short-term clinical outcomes of very low birth weight infants in Yangtze River Delta in China

BACKGROUND

Intensive care is of great significance for very low birth weight infants (VLBWI). The Yangtze River Delta is the most ecomonically developed area in China. However, there are few data on the care practices and survival of VLBWI in this region.

OBJECTIVES

To investigate the prevalence, care practices and motality of VLBWI in Yangtze River Delta in China.

METHODS

A multi-center retrospective investigation study was conducted at five tertiary hospitals within the Yangtze River Delta in China from January to December 2017. Clinical data included the general characteristics of the infants and the mothers, clinical prognosis, care practices in NICUs was collected by trained research members.

RESULTS

During the study period, 1059 VLBWIs were included. Infants with birth weight < 750 g, 750-1000 g, 1000-1250 g and 1250-1500 g accounted for 2.3, 14.9, 34.8 and 47.8%, respectively. Premature rupture of membranes (17.8%) was the main cause of premature delivery. The catheterization rates of umbilical vein catheterization (UVC) and peripherally inserted central catheter (PICC) were 25.0 and 64.4%, respectively. The duration of parenteral nutrition was 27.0 ± 19.5 d, the meantime of feeding tube indwelling was 36.2 ± 24.2 d. The corrected gestational age of the infants who reached full oral feeding was 35.8 ± 2.7 weeks. The breast feeding rate in the investigated infants was 61.9%. The mortality rate of preterm infants was 3.4%. The incidence of main complications BPD, PDA, ROP, NEC and sepsis were 24.9, 29.9, 21.7, 9.4 and 13.3% respectively.

CONCLUSIONS

Maternal and infant care practices need to be improved in the very preterm births. This study provides a baseline for the improvement in the further study.

An artificial intelligence system to predict the optimal timing for mechanical ventilation weaning for intensive care unit patients: A two-stage prediction approach

Background

For the intensivists, accurate assessment of the ideal timing for successful weaning from the mechanical ventilation (MV) in the intensive care unit (ICU) is very challenging.

Purpose

Using artificial intelligence (AI) approach to build two-stage predictive models, namely, the try-weaning stage and weaning MV stage to determine the optimal timing of weaning from MV for ICU intubated patients, and implement into practice for assisting clinical decision making.

Methods

AI and machine learning (ML) technologies were used to establish the predictive models in the stages. Each stage comprised 11 prediction time points with 11 prediction models. Twenty-five features were used for the first-stage models while 20 features were used for the second-stage models. The optimal models for each time point were selected for further practical implementation in a digital dashboard style. Seven machine learning algorithms including Logistic Regression (LR), Random Forest (RF), Support Vector Machines (SVM), K Nearest Neighbor (KNN), lightGBM, XGBoost, and Multilayer Perception (MLP) were used. The electronic medical records of the intubated ICU patients of Chi Mei Medical Center (CMMC) from 2016 to 2019 were included for modeling. Models with the highest area under the receiver operating characteristic curve (AUC) were regarded as optimal models and used to develop the prediction system accordingly.

Results

A total of 5,873 cases were included in machine learning modeling for Stage 1 with the AUCs of optimal models ranging from 0.843 to 0.953. Further, 4,172 cases were included for Stage 2 with the AUCs of optimal models ranging from 0.889 to 0.944. A prediction system (dashboard) with the optimal models of the two stages was developed and deployed in the ICU setting. Respiratory care members expressed high recognition of the AI dashboard assisting ventilator weaning decisions. Also, the impact analysis of with- and without-AI assistance revealed that our AI models could shorten the patients' intubation time by 21 hours, besides gaining the benefit of substantial consistency between these two decision-making strategies.

Conclusion

We noticed that the two-stage AI prediction models could effectively and precisely predict the optimal timing to wean intubated patients in the ICU from ventilator use. This could reduce patient discomfort, improve medical quality, and lower medical costs. This AI-assisted prediction system is beneficial for clinicians to cope with a high demand for ventilators during the COVID-19 pandemic.

Analysis of predictive parameters for extubation in very low birth weight preterm infants

BACKGROUND

Mechanical ventilation is the primary treatment for preterm infants with respiratory failure. Prolonged intubation may lead to complications; thus, early extubation is desirable. No standard criteria exist for determining the appropriateness of extubating very-low-birth-weight (VLBW) infants. This study explored the predictors of successful extubation in preterm VLBW infants.

METHODS

This retrospective cohort study included 60 preterm VLBW infants who underwent their first extubation in the neonatal intensive care unit in a regional hospital in Hsinchu, Taiwan, between January 2017 and November 2020. Successful extubation was defined as having no requirement of reintubation within 3 days of extubation. Potentially predictive variables, including demographics, prenatal characteristics, and ventilator parameters were compared between a successful extubation group and failed extubation group.

RESULTS

Of the 60 infants, 47 (78.33%) underwent successful extubation. The successful extubation group had higher Apgar scores at 1 (7 vs. 6, P = 0.02) and 5 min (9 vs. 7, P = 0.007) than those of the failed extubation group. Ventilator inspiratory pressure and mean airway pressure were significantly lower at 24, 16, 8, and 1 h before extubation and upon its completion in the successful extubation group. The areas under a number of the receiver operating characteristic curve curves in this study were moderate, specifically, 0.72, 0.74, and 0.69. Statistical analysis revealed an association between ventilator parameters before 1 h extubation (IP > 17.5cmH₂O, MAP >7.5 cmH₂O, RSS >1.82) and extubation failure (odds ratio 1.73, 2.27, 2.46 and 95% confidence interval:1.16-2.6, 1.26-4.08, 1.06-5.68, respectively).

CONCLUSION

Higher Apgar scores at birth, lower ventilator inspiratory pressure, and mean airway pressure 24, 16, 8, and 1 h and 1 h RSS prior to extubation are associated with successful extubation in VLBW preterm infants.

Outcome prediction in newborn infants: Past, present, and future

The perinatal and neonatal periods are the periods of considerable organ development and maturation. Perinatal and neonatal illnesses can result in mortality and morbidities that burden families and the healthcare system. Outcome prediction is essential for informing perinatal and intensive care management, prognosis, and post-discharge interventions. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) research databases include hospital and neurodevelopment follow-up outcomes of infants with various underlying diseases and conditions receiving intensive care, providing a unique opportunity to assess outcome risk prediction. The NRN has developed outcome risk prediction tools for use in infants with various diseases and conditions that allow data-driven, transparent discussions to inform family-focused communications and clinical management. This review presents the published neonatal outcome risk prediction research from the NRN, their present clinical utility, and possible future directions for advanced individualized risk prediction.

Predictors of extubation outcomes among extremely and very preterm infants: a retrospective cohort study

OBJECTIVE

To explore the clinical or sociodemographic predictors for both successful and failed extubation among Chinese extremely and very preterm infants METHODS: A retrospective cohort study was carried out among extremely and very preterm infants born at less than 32 weeks of gestational age (GA).

RESULTS

Compared with the infants who experienced extubation failure, the successful infants had higher birth weight (OR 0.997; CI 0.996-0.998), higher GA (OR 0.582; 95% CI 0.499-0.678), a caesarean section delivery (OR 0.598; 95% CI 0.380-0.939), a higher five-minute Apgar score (OR 0.501; 95% CI 0.257-0.977), and a higher pH prior to extubation (OR 0.008; 95% CI 0.001-0.058). Failed extubation was associated with older mothers (OR 1.055; 95% CI 1.013-1.099), infants intubated in the delivery room (OR 2.820; 95% CI 1.742-4.563), a higher fraction of inspired oxygen (FiO₂) prior to extubation (OR 5.246; 95% CI 2.540-10.835), higher partial pressure of carbon dioxide (PCO₂) prior to extubation (OR 7.820; 95% CI 3.725-16.420), and higher amounts of lactic acid (OR 1.478;95% CI 1.063-2.056).

CONCLUSIONS

Higher GA, higher pre-extubation pH, lower pre-extubation FiO₂ and PCO, and lower age at extubation are significant predictors of successful extubation among extremely and very preterm infants.

Accuracy of the spontaneous breathing trial using a combined CPAP + PSV model to predict extubation outcomes in very preterm infants

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.

Machine learning for prediction of bronchopulmonary dysplasia-free survival among very preterm infants

Background

Bronchopulmonary dysplasia (BPD) is one of the most common and serious sequelae of prematurity. Prompt diagnosis using prediction tools is crucial for early intervention and prevention of further adverse effects. This study aims to develop a BPD-free survival prediction tool based on the concept of the developmental origin of BPD with machine learning.

Methods

Datasets comprising perinatal factors and early postnatal respiratory support were used for initial model development, followed by combining the two models into a final ensemble model using logistic regression. Simulation of clinical scenarios was performed.

Results

Data from 689 infants were included in the study. We randomly selected data from 80% of infants for model development and used the remaining 20% for validation. The performance of the final model was assessed by receiver operating characteristics which showed 0.921 (95% CI: 0.899–0.943) and 0.899 (95% CI: 0.848–0.949) for the training and the validation datasets, respectively. Simulation data suggests that extubating to CPAP is superior to NIPPV in BPD-free survival. Additionally, successful extubation may be defined as no reintubation for 9 days following initial extubation.

Conclusions

Machine learning-based BPD prediction based on perinatal features and respiratory data may have clinical applicability to promote early targeted intervention in high-risk infants.

Noninvasive Neurally Adjusted Ventilation in Postextubation Stabilization of Preterm Infants: A Randomized Controlled Study

OBJECTIVE

To compare the effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) to nasal continuous positive airway pressure (NCPAP) in achieving successful extubation in preterm infants.

STUDY DESIGN

This prospective, single-center, randomized controlled trial enrolled preterm infants born at <30 weeks of gestation who received invasive ventilation. Participants were assigned at random to either NIV-NAVA or NCPAP after their first extubation from invasive ventilation. The primary outcome of the study was extubation failure within 72 hours of extubation. Electrical activity of the diaphragm (Edi) values were collected before extubation and at 1, 4, 12, and 24 hours after extubation.

RESULTS

A total of 78 infants were enrolled, including 35 infants in the NIV-NAVA group and 35 infants in the NCPAP group. Extubation failure within 72 hours of extubation was higher in the NCPAP group than in the NIV-NAVA group (28.6% vs 8.6%; P = .031). The duration of respiratory support and incidence of severe bronchopulmonary dysplasia were similar in the 2 groups. Peak and swing Edi values were comparable before and at 1 hour after extubation, but values at 4, 12, and 24 hours after extubation were lower in the NIV-NAVA group compared with the NCPAP group.

CONCLUSIONS

In the present trial, NIV-NAVA was more effective than NCPAP in preventing extubation failure in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02590757.

Predictors of extubation success: a population-based study of neonates below a gestational age of 26 weeks

OBJECTIVE

The aim of the study was to investigate first extubation attempts among extremely premature (EP) infants and to explore factors that may increase the quality of clinical judgement of extubation readiness.

DESIGN AND METHOD

A population-based study was conducted to explore first extubation attempts for EP infants born before a gestational age (GA) of 26 weeks in Norway between 1 January 2013 and 31 December 2018. Eligible infants were identified via the Norwegian Neonatal Network database. The primary outcome was successful extubation, defined as no reintubation within 72 hours after extubation.

RESULTS

Among 482 eligible infants, 316 first extubation attempts were identified. Overall, 173 (55%) infants were successfully extubated, whereas the first attempt failed in 143 (45%) infants. A total of 261 (83%) infants were extubated from conventional ventilation (CV), and 55 (17%) infants were extubated from high-frequency oscillatory ventilation (HFOV). In extubation from CV, pre-extubation fraction of inspired oxygen (FiO₂) ≤0.35, higher Apgar score, higher GA, female sex and higher postnatal age were important predictors of successful extubation. In extubation from HFOV, a pre-extubation FiO₂ level ≤0.35 was a relevant predictor of successful extubation.

CONCLUSIONS

The correct timing of extubation in EP infants is important. In this national cohort, 55% of the first extubation attempts were successful. Our results suggest that additional emphasis on oxygen requirement, sex and general condition at birth may further increase extubation success when clinicians are about to extubate EP infants for the first time.

Initial respiratory support modality and outcome in preterm infants with less than 32 weeks of gestation in China: A multicentre retrospective cohort study

BACKGROUND

For initial respiratory management, continuous positive airway pressure (CPAP) is increasingly used for preterm infants, especially for gestational age less than 32 weeks. However, neonatologists are concerned about the potential risks of CPAP support failure.

OBJECTIVES

To examine the association between different initial respiratory support modalities and the outcomes of preterm infants at <32 weeks of gestation across multiple neonatal intensive care units (NICU) in China.

METHODS

This study was carried out over a period of 12 months in 2018. Unadjusted relative risks (RR) for demographic and clinical characteristics were calculated for CPAP failure and CPAP success in the total cohort using log-linear model based on generalised estimating equations for clustered observations.

RESULTS

Among 1560 preterm infants delivered at <32 weeks, the incidence of CPAP failure was 10.3%. After adjustment for demographic and clinical factors, the relative risk of mortality (RR 7.54, 95% CI 5.56, 10.44), pneumothorax (RR 9.85, 95% CI 2.89, 61.53), pulmonary haemorrhage (RR 7.78, 95% CI 4.51, 14.64) and BPD (RR 3.65, 95% CI 3.65, 4.51) were considerably higher for infants in the CPAP failure group than those in the CPAP-S group. However, the risk of poor outcomes in CPAP failure infants was similar to that of those in the initial mechanical ventilation (MV) group.

CONCLUSIONS

Continuous positive airway pressure failure was associated with an increased risk of mortality and major morbidities, including BPD, pulmonary haemorrhage and pneumothorax, and was comparable to the risk associated with initial MV.

Risk Factors of Extubation Failure in Intubated Preterm Infants at a Tertiary Care Hospital in Oman

Objectives

This study aimed to determine extubation failure (EF) rate among intubated preterm infants (<37 weeks gestational age [GA]) admitted to a tertiary care neonatal intensive care unit (NICU) in Oman and identify the risk factors associated with EF.

Methods

This retrospective study included all intubated preterm infants (<37 weeks GA) admitted to the NICU at Sultan Qaboos University Hospital (SQUH) from January 2013 to December 2017. EF was defined as reintubation within seven days of planned extubation. Demographics, ventilation parameters, blood gas values and other possible risk factors of EF were collected. Statistical analysis included comparisons between EF and extubation success (ES) groups and a binary logistic regression analysis.

Results

A total of 190 preterm infants were intubated during the study period with 140 eligible for analysis. A total of 106 infants (75.7%) were successfully extubated while 34 (24.3%) failed extubation. GA <28 weeks (P = 0.029), lower 1-minute Apgar score (P = 0.023) and patent ductus arteriosus diagnosis (P = 0.018) were significantly associated with EF. After the multivariate analysis, only GA <28 weeks predicted EF with an adjusted odds ratio of 2.621 (95% confidence interval: 1.118 - 6.146).

Conclusion

EF rate in preterm infants admitted at the NICU of SQUH was within international rates. GA <28 weeks was the only predictor of the identified extubation failure. Neonatal practitioners need to seriously consider extreme prematurity in the extubation process and consider implementing strategies to decrease extubation failure in this group of fragile infants.

Respiratory management for extremely premature infants born at 22 to 23 weeks of gestation in proactive centers in Sweden, Japan, and USA

Survival of preterm newborn infants have increased steadily since the introduction of surfactant treatment and antenatal steroids. In the absence of randomized controlled trials on ventilatory strategies in extremely preterm infants, we present ventilatory strategies applied during the initial phase and the continued ventilatory care as applied in three centers with proactive prenatal and postnatal management and well documented good outcomes in terms of mortality and morbidity in this cohort of infants.

Cardiorespiratory management of infants born at 22 weeks' gestation: The Iowa approach

The approach to clinical care of infants born at 22 weeks' gestation must be consistent and well-designed if optimal results are to be expected. Publications from several international centers have demonstrated that, although there may be variance in aspects of care in this vulnerable population, treatment should be neither random nor inconsistent. In designing a standardized approach, careful attention should be paid to the unique anatomy, physiology, and biochemistry of this vulnerable patient population. Emerging evidence, suggesting a link between cardiopulmonary health and longer-term sequela, highlights the importance of understanding the relationship between cardiorespiratory illnesses of the 22-week infant, treatments provided, and subsequent cardiopulmonary development. In this review we will provide an overview to our approach to cardiopulmonary assessment and treatment, with a particular emphasis on the importance of early recognition of atypical phenotypes, timely interventions with evidence-based treatments, and longitudinal monitoring.

Association between pulmonary hemorrhage and CPAP failure in very preterm infants

BACKGROUND

Pulmonary hemorrhage (PH) in neonates is a life-threatening respiratory complication. We aimed to analyze the perinatal risk factors and morbidity with PH among very preterm infants in a large multicenter study.

METHODS

This was a multicenter case-control study based on a prospective cohort. Participants included 3,680 in-born infants with a gestational age at 24-32 weeks (birth weight <1,500 g) who were admitted between January 1, 2019, and October 31, 2021. All infants were divided into two groups, namely, the PH and no-PH groups, at a ratio of 1:2 according to the following factors: gestational age (GA), birth weight (BW), and the Score for Neonatal Acute Physiology with Perinatal extension II (SNAPPE II). Perinatal factors and outcomes were compared between the two groups by logistic regression analyses.

RESULTS

A total of 3,680 infants were included in the study, and the number of identified cases of PH was 262 (7.1%). The incidence was 16.9% (136/806) for neonates with extremely low BW (BW < 1,000 g) infants. The multivariate analysis showed that CPAP failure (OR 2.83, 95% CI 1.57, 5.08) was significantly associated with PH. PH was associated with a high likelihood of death (OR 3.81, 95% CI 2.67, 5.43) and bronchopulmonary dysplasia (BPD) (≥grade II) (OR 1.58, 95% CI 1.00, 2.48).

CONCLUSIONS

In this multicenter case-control study based on a prospective cohort, PH to be common among VLBW infants. PH is associated with significant morbidity and mortality, and perinatal management, especially CPAP failure. Respiratory management strategies to decrease the risk of PH should be optimized.