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

Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study

Objectives

This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes.

Methods

We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients' clinical status and extubation readiness criteria.

Results

In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38-36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2-48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001).

Conclusion

A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.

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 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.

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.

The possible role of artificial intelligence in deciding postnatal steroid management in extremely premature ventilated infants

Clinical decision support (CDS) has shown a positive effect on physicians. There is variability among physicians about using postnatal steroids (PNS) in preterm (PT) infants. It is, therefore, essential to develop tools supporting the decision to use PNS in PT infants. We propose a model using online tools such as CDS in deciding to use PNS in PT infants. We combined the online bronchopulmonary dysplasia (BPD) estimator and extubation success calculator tools to be used as a simple bedside tool assisting decisions about using PNS in ventilated PT infants.