Risk Factors for Extubation Failure in Extremely Low Birth Weight Infants

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.

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.

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.

Accuracy of lung and diaphragm ultrasound in predicting successful extubation in extremely preterm infants: A prospective observational study

OBJECTIVE

Chest ultrasound has emerged as a promising tool in predicting extubation readiness in adults and children, yet its utility in preterm infants is lacking. Our aim was to assess the utility of lung ultrasound severity score (LUSS) and diaphragmatic function in predicting extubation readiness in extremely preterm infants.

STUDY DESIGN

In this prospective cohort study, preterm infants < 28 weeks gestational age (GA) who received invasive mechanical ventilation for ≥12 h were enrolled. Chest ultrasound was performed before extubation. The primary outcome was lung ultrasound accuracy for predicting successful extubation at 3 days. Descriptive statistics and logistic regression were done using SPSS version 22.

RESULTS

We enrolled 45 infants, of whom 36 (80%) were successfully extubated. GA and postmenstrual age (PMA) at extubation were significantly higher in the successful group. The LUSS was significantly lower in the successful group compared to failed group (11.9 ± 3.2 vs. 19.1 ± 3.1 p < 0.001). The two groups had no statistically significant difference in diaphragmatic excursion or diaphragmatic thickness fraction. Logistic regression analysis controlling for GA and PMA at extubation showed LUSS was an independent predictor for successful extubation (odd ratio 0.46, 95% confidence interval [0.23-0.9], p = 0.02). The area under the receiver operating characteristic curve was 0.95 (p ˂ 0.001) for LUSS, and a cut-off value of ≥15 had 95% sensitivity and 85% specificity in detecting extubation failure.

CONCLUSION

In extremely preterm infants, lung ultrasound has good accuracy for predicting successful extubation. However, diaphragmatic measurements were not reliable predictors.

Does Arterial Blood Gas (ABG) Provide a Safety Net for Extubation in Surgical Patients?

Background Extubation has always been a critical aspect of anaesthesia. Guidelines and recommendations are in place for achieving successful extubation, but the risk of failure always persists. Through this study, we assess whether arterial blood gas (ABG) values taken intraoperatively help predict extubation success in the operation theatre. Materials and methods This was a prospective observational study for one year of extubated patients whose blood gas values were not within the normal range. The patients of age 18 years and above undergoing high-risk elective and emergency surgeries where at least one intraoperative arterial blood sample was taken for blood gas analysis were included. Apart from parameters of ABG demographic data, urgency and duration of surgery, blood loss, urine output, use of intraoperative fluid(s), and blood product(s) were also observed.  Results Of 578 patients enrolled, 116 patients were extubated based on the predefined extubation criteria. Of these, 24 patients were reintubated within 24 hours. ABG parameters such as partial pressure of arterial oxygen (PaO₂) and serum HCO_3- levels were significantly lower in the reintubated patients compared to non-reintubated patients (p-values of 0.045 and 0.003, respectively). Conclusion This study showed that the PaO₂ <100 mm Hg or ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) of less than 200 and an HCO_3- value of less than 18 are plausible ABG parameters to decide extubation in post-surgery patients in OT. PaCO₂, base deficit, and lactate were less reliable parameters for planning extubation.

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.

Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial

Background

Post-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA.

Materials and methods

We enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups.

Results

The prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation.

Conclusion

The use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates.

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Post extubation atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates.

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This study compares two different extubation methods for the prevention of PEA in neonates.

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The prevalence of PEA in the extubation with positive pressure method was significantly lower than the negative pressure.

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Extubation by a positive pressure method is recommended in neonates.

Can Fraction of Inspired Oxygen Predict Extubation Failure in Preterm Infants?

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.

Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants

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.

Role of Flexible Bronchoscopy in Ventilator-Dependent Neonates

Objective

To assess the usefulness and safety of flexible bronchoscopy in ventilated neonates with extubation failure.

Method

This was a prospective observational study. Flexible bronchoscopy was done in eligible patients with failure of extubation form invasive ventilation. The main outcome measure was to find the presence of any anatomic or dynamic abnormalities of the airways of these patients and the organism profile of bronchoalveolar lavage (BAL) fluid.

Results

Forty-eight babies (68.8% preterm) were enrolled in the study. The most common finding on bronchoscopy was airway edema seen in 13 (27%) patients. BAL culture was positive in 29 (74%) patients. Overall treatment was modified in 35 (73%) patients based on bronchoscopy findings/BAL culture. Majority of infants (83.3%) tolerated the procedure very well.

Conclusion

Flexible bronchoscopy provides useful information in the management of newborn babies with extubation failure.

[Risk factors for the first ventilator weaning failure in preterm infants receiving invasive mechanical ventilation]

OBJECTIVE

To study the risk factors for the first ventilator weaning failure and the relationship between the weaning failure and prognosis in preterm infants receiving invasive mechanical ventilation.

METHODS

A retrospective analysis was performed for the preterm infants who were admitted to the Neonatal Intensive Care Unit of Peking University Third Hospital and received mechanical ventilation within 72 hours after birth. According to whether reintubation was required within 72 hours after the first weaning, the infants were divided into a successful weaning group and a failed weaning group.

RESULTS

A total of 282 preterm infants were enrolled, and there were 43 infants (15.2%) in the failed weaning group. Compared with the successful weaning group, the failed weaning group had significantly lower gestational age and birth weight (P < 0.05), a significantly higher rate of intubation in the delivery room (P < 0.05), and a significantly higher proportion of infants with patent ductus arteriosus (PDA; diameter ≥ 2.5 mm) (P < 0.05). Use of ≥ 2 vasoactive agents before ventilator weaning (OR=2.48, 95%CI:1.22-5.03, P < 0.05) and PDA (≥ 2.5 mm) (OR=4.54, 95%CI:2.02-10.24, P < 0.05) were risk factors for ventilator weaning failure. Compared with the successful weaning group, the failed weaning group had significantly higher incidence rates of ventilator-associated pneumonia, moderate-to-severe bronchopulmonary dysplasia, and sepsis (P < 0.05). The oxygen inhalation time and hospital stay in the failed weaning group were significantly longer than those in the successful weaning group (P < 0.05).

CONCLUSIONS

Use of ≥ 2 vasoactive agents before ventilator weaning and PDA (≥ 2.5 mm) are risk factors for ventilator weaning failure, and ventilator weaning failure may be associated with adverse outcomes in hospitalized preterm infants.

[Safety of two ventilator weaning strategies after high-frequency oscillatory ventilation in preterm infants with respiratory distress syndrome: a prospective randomized controlled trial]

OBJECTIVE

To study the safety of two ventilator weaning strategies after high-frequency oscillatory ventilation (HFOV) for the treatment of neonatal respiratory distress syndrome (NRDS) in preterm infants.

METHODS

A prospective randomized controlled trial was conducted for 101 preterm infants with NRDS, with a gestational age of ≤32⁺⁶ weeks or a birth weight of ≤1 500 g, who were admitted to the neonatal intensive care unit of Xiamen Maternal and Child Health Hospital from January 1, 2019 to June 30, 2020. The infants underwent HFOV as the preferred treatment. The infants were randomly divided into an observation group (50 infants with direct weaning from HFOV) and a control group (51 infants with weaning after HFOV was switched to conventional mechanical ventilation). The two groups were compared in terms of failure rate of ventilator weaning within 72 hours, changes in blood gas parameters at 2 hours before weaning and at 2 and 24 hours after weaning, respiratory support therapy, incidence rates of complications, and outcome at discharge.

RESULTS

There was no significant difference in the failure rate of ventilator weaning within 72 hours (8% vs 14%, P > 0.05). The observation group had a significantly shorter duration of mechanical ventilation than the control group [(64±39) hours vs (88±69) hours, P < 0.05]. There were no significant differences between the two groups in the duration of mechanical ventilation, total oxygen supply time, blood gas parameters before and after ventilator weaning, incidence rates of complications, and outcome at discharge (P > 0.05).

CONCLUSIONS

For preterm infants with NRDS, the strategy of weaning directly from HFOV is safe and reliable and can reduce the duration of invasive mechanical ventilation, and therefore, it holds promise for clinical application.

A Prediction Model of Extubation Failure Risk in Preterm Infants

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

Ventilator-delivered nasal intermittent positive pressure ventilation versus nasal biphasic positive airway pressure following extubation in infants ≤1250 g birth weight: a randomized trial

Background and objective: To determine the effectiveness of ventilator-delivered nasal intermittent positive pressure ventilation and nasal biphasic positive airway pressure (n-BiPAP) after first extubation attempt in infants ≤1250-g birthweight.Methods: This randomized controlled study included mechanically ventilated preterm infants of ≤1250-g birthweight who were randomly assigned to ventilator-delivered NIPPV or n-BiPAP at first extubation within 2 weeks of age. The primary outcome (extubation failure within 96 h following extubation) and secondary outcomes were compared.Results: Extubation failure occurred in 22 of 74 infants in n-BiPAP group and 34 of 75 infants in NIPPV group (OR 0.51, 95% CI: 0.26-1.002; p = .05). Duration of invasive and noninvasive ventilation were found to be similar between groups. Also, there were no significant differences among groups for intraventricular hemorrhage, medically/surgically treated patent ductus arteriosus, necrotizing enterocolitis, BPD or death.Conclusion: Sustained extubation in infants ≤1250-g birthweight and <2 weeks age did not differ between ventilator-delivered NIPPV and n-BiPAP.Trial registration: Clinical Trials.gov under identifier NCT02842190.