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

Dexamethasone Use to Reduce Mechanical Ventilation and Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit

Background

Ventilator-dependent neonates are at risk of bronchopulmonary dysplasia (BPD), a chronic lung disease. Dexamethasone may be used to facilitate extubation and reduce the incidence of BPD.

Objectives

To determine the efficacy of dexamethasone in reducing the incidence of established BPD at 36 weeks postmenstrual age (PMA); to establish the rate of extubation success; to determine the factors affecting extubation success; and to describe complications associated with dexamethasone therapy.

Methods

A chart review was conducted at Surrey Memorial Hospital, in Surrey, British Columbia, for neonates who received dexamethasone to reduce the development of BPD between July 1, 2016, and June 30, 2022.

Results

A total of 47 neonates met the inclusion criteria. Of the 45 neonates still alive at 36 weeks PMA, all (100%) had BPD. Use of dexamethasone led to extubation success for 21 (47%) of these 45 neonates. The mean PMA at dexamethasone initiation was 30.7 weeks for neonates with extubation success, compared with 28.6 weeks for those with extubation failure (p = 0.001). Complications occurred in 43 (91%) of the 47 neonates.

Conclusions

BPD occurred in all of the neonates, despite a 47% extubation success rate. The timing of dexamethasone initiation was associated with extubation success. Further research is required to determine the dose and timing of dexamethasone needed to reduce the incidence of BPD.

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.

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.

Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease

BACKGROUND

Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation.

METHODS

We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively.

RESULTS

We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation.

CONCLUSIONS

The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.

Associations between unit workloads and outcomes of first extubation attempts in extremely premature infants below a gestational age of 26 weeks

Objective

The objective was to explore whether high workloads in neonatal intensive care units were associated with short-term respiratory outcomes of extremely premature (EP) infants born <26 weeks of gestational age.

Methods

This was a population-based study using data from the Norwegian Neonatal Network supplemented by data extracted from the medical records of EP infants <26 weeks GA born from 2013 to 2018. To describe the unit workloads, measurements of daily patient volume and unit acuity at each NICU were used. The effect of weekend and summer holiday was also explored.

Results

We analyzed 316 first planned extubation attempts. There were no associations between unit workloads and the duration of mechanical ventilation until each infant's first extubation or the outcomes of these attempts. Additionally, there were no weekend or summer holiday effects on the outcomes explored. Workloads did not affect the causes of reintubation for infants who failed their first extubation attempt.

Conclusion

Our finding that there was no association between the organizational factors explored and short-term respiratory outcomes can be interpreted as indicating resilience in Norwegian neonatal intensive care units.