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Jenkinson AC, Dassios T, Greenough A. Artificial intelligence in the NICU to predict extubation success in prematurely born infants. J Perinat Med 2024; 52:119-125. [PMID: 38059494 DOI: 10.1515/jpm-2023-0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/11/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Mechanical ventilation in prematurely born infants, particularly if prolonged, can cause long term complications including bronchopulmonary dysplasia. Timely extubation then is essential, yet predicting its success remains challenging. Artificial intelligence (AI) may provide a potential solution. CONTENT A narrative review was undertaken to explore AI's role in predicting extubation success in prematurely born infants. Across the 11 studies analysed, the range of reported area under the receiver operator characteristic curve (AUC) for the selected prediction models was between 0.7 and 0.87. Only two studies implemented an external validation procedure. Comparison to the results of clinical predictors was made in two studies. One group reported a logistic regression model that outperformed clinical predictors on decision tree analysis, while another group reported clinical predictors outperformed their artificial neural network model (AUCs: ANN 0.68 vs. clinical predictors 0.86). Amongst the studies there was an heterogenous selection of variables for inclusion in prediction models, as well as variations in definitions of extubation failure. SUMMARY Although there is potential for AI to enhance extubation success, no model's performance has yet surpassed that of clinical predictors. OUTLOOK Future studies should incorporate external validation to increase the applicability of the models to clinical settings.
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Affiliation(s)
- Allan C Jenkinson
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
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Nagaraj YK, Balushi SA, Robb C, Uppal N, Dutta S, Mukerji A. Peri-extubation settings in preterm neonates: a systematic review and meta-analysis. J Perinatol 2024; 44:257-265. [PMID: 38216677 DOI: 10.1038/s41372-024-01870-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVE To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates. STUDY DESIGN In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model. RESULTS Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP. CONCLUSIONS Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.
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Affiliation(s)
| | | | - Courtney Robb
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nikhil Uppal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Sourabh Dutta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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Scholten AWJ, van Leuteren RW, de Waal CG, Kraaijenga JV, de Jongh FH, van Kaam AH, Hutten GJ. Diaphragmatic electromyography in infants: an overview of possible clinical applications. Pediatr Res 2024; 95:52-58. [PMID: 37660179 DOI: 10.1038/s41390-023-02800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/04/2023]
Abstract
Preterm infants often experience breathing instability and a hampered lung function. Therefore, these infants receive cardiorespiratory monitoring and respiratory support. However, the current respiratory monitoring technique may be unreliable for especially obstructive apnea detection and classification and it does not provide insight in breathing effort. The latter makes the selection of the adequate mode and level of respiratory support difficult. Electromyography of the diaphragm (dEMG) has the potential of monitoring heart rate (HR) and respiratory rate (RR), and it provides additional information on breathing effort. This review summarizes the available evidence on the clinical potential of dEMG to provide cardiorespiratory monitoring, to synchronize patient-ventilator interaction, and to optimize the mode and level of respiratory support in the individual newborn infant. We also try to identify gaps in knowledge and future developments needed to ensure widespread implementation in clinical practice. IMPACT: Preterm infants require cardiorespiratory monitoring and respiratory support due to breathing instability and a hampered lung function. The current respiratory monitoring technique may provide unreliable measurements and does not provide insight in breathing effort, which makes the selection of the optimal respiratory support settings difficult. Measuring diaphragm activity could improve cardiorespiratory monitoring by providing insight in breathing effort and could potentially have an important role in individualizing respiratory support in newborn infants.
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Affiliation(s)
- Anouk W J Scholten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Juliette V Kraaijenga
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Faculty of Science and Technology, University of Twente, Drienerlolaan 5, Enschede, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands.
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Fu M, Hu Z, Yu G, Luo Y, Xiong X, Yang Q, Song W, Yu Y, Yang T. Predictors of extubation failure in newborns: a systematic review and meta-analysis. Ital J Pediatr 2023; 49:133. [PMID: 37784184 PMCID: PMC10546653 DOI: 10.1186/s13052-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023] Open
Abstract
Extubation failure (EF) is a significant concern in mechanically ventilated newborns, and predicting its occurrence is an ongoing area of research. To investigate the predictors of EF in newborns undergoing planned extubation, we conducted a systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for studies published in English from the inception of each database to March 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. Thirty-four studies were included, 10 of which were overall low risk of bias, 15 of moderate risk of bias, and 9 of high risk of bias. The studies reported 43 possible predictors in six broad categories (intrinsic factors; maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; characteristics before and after extubation; and clinical scores and composite indicators). Through a qualitative synthesis of 43 predictors and a quantitative meta-analysis of 19 factors, we identified five definite factors, eight possible factors, and 22 unclear factors related to EF. Definite factors included gestational age, sepsis, pre-extubation pH, pre-extubation FiO2, and respiratory severity score. Possible factors included age at extubation, anemia, inotropic use, mean airway pressure, pre-extubation PCO2, mechanical ventilation duration, Apgar score, and spontaneous breathing trial. With only a few high-quality studies currently available, well-designed and more extensive prospective studies investigating the predictors affecting EF are still needed. In the future, it will be important to explore the possibility of combining multiple predictors or assessment tools to enhance the accuracy of predicting extubation outcomes in clinical practice.
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Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhenjing Hu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China.
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ting Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Shalish W, Sant'Anna GM. Optimal timing of extubation in preterm infants. Semin Fetal Neonatal Med 2023; 28:101489. [PMID: 37996367 DOI: 10.1016/j.siny.2023.101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants.
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Affiliation(s)
- Wissam Shalish
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, 1001 Boul. Décarie, Room B05.2714, Montreal, Quebec, H4A 3J1, Canada.
| | - Guilherme M Sant'Anna
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, 1001 Boul. Décarie, Room B05.2714, Montreal, Quebec, H4A 3J1, Canada.
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Chen F, Chen Y, Wu Y, Zhu X, Shi Y. A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks. Neonatology 2023; 120:424-433. [PMID: 37257426 DOI: 10.1159/000530759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION How to avoid reintubations in prematurity remains a hard nut. This study aimed to develop and validate a nomogram for predicting extubation failure in preterm infants who received different modes of noninvasive ventilation as post-extubation support. METHODS This was a secondary analysis of pre-existing data from a large multicenter RCT combined with a multicenter retrospective investigation in three tertiary referral NICUs in China. The training cohort consisted of extubated infants from the RCT and the validation cohort included neonates admitted to the three NICUs in the last 5 years. The nomogram was developed through univariate and multivariate logistic regression analyses of peri-extubation clinical variables. RESULTS A total of 432 and 183 preterm infants (25 weeks ≤ gestational age [GA] <29 weeks) were, respectively, included in the training cohort and the validation cohort. Lower birth weight, lower Apgar 5-min score, lower postmenstrual age at extubation, lower PO2 and higher PCO2 before extubation, and continuous positive airway pressure rather than nasal intermittent positive pressure ventilation or noninvasive high-frequency oscillatory ventilation after extubation were associated with higher risks of extubation failure (p < 0.05), on which the nomogram was established. In both the training cohort and the validation cohort, the nomogram demonstrated good predictive accuracy (area under the receiver operating characteristic curve = 0.744 and 0.826); the Hosmer-Lemeshow test (p = 0.192 and 0.401) and the calibration curve (R2 = 0.195 and 0.307) proved a good fitness and conformity; and the decision curve analysis showed significant net benefit at the best threshold (p = 0.201). CONCLUSION This nomogram could serve as a good decision-support tool when predicting extubation failure in preterm infants with GA less than 29 weeks.
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Affiliation(s)
- Feifan Chen
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yanru Chen
- Department of Neonatology, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Yumin Wu
- Department of Neonatology, Qujing Maternity and Child Health-Care Hospital, Qujing, China
| | - Xingwang Zhu
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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Ferguson KN, Tingay DG. Predicting extubation success: still a conundrum? Pediatr Res 2022; 92:923-924. [PMID: 35986146 PMCID: PMC9586867 DOI: 10.1038/s41390-022-02220-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Kristin N. Ferguson
- grid.1058.c0000 0000 9442 535XNeonatal Research, Murdoch Children’s Research Institute, Parkville, VIC Australia ,grid.416107.50000 0004 0614 0346Department of Neonatology, The Royal Children’s Hospital, Parkville, VIC Australia
| | - David G. Tingay
- grid.1058.c0000 0000 9442 535XNeonatal Research, Murdoch Children’s Research Institute, Parkville, VIC Australia ,grid.416107.50000 0004 0614 0346Department of Neonatology, The Royal Children’s Hospital, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, The University of Melbourne, Parkville, VIC Australia
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