Extubation Failure In Preterm Infants Research Articles

Diaphragm atrophy during invasive mechanical ventilation is related to extubation failure in preterm infants: An ultrasound study.

Diaphragm dysfunction is associated with poor outcomes in critically ill patients. Ventilator-induced diaphragmatic dysfunction (VIDD), including diaphragm atrophy (DA), is poorly studied in newborns. We aimed to assess VIDD and its associations in newborns. Single-center prospective study. Diaphragm thickness was measured at end-inspiration (TDI) and end-expiration (TDE) on the right midaxillary line. DA was defined as decrease in TDE ≥ 10%. Daily measurements were recorded in preterm newborns on invasive mechanical ventilation (IMV) for ≥2 days. Clinical characteristics of patients and extubation failure were recorded. Univariate analysis, logistic regression, and mixed models were performed to describe VIDD and associated factors. We studied 17 patients (median gestational age 270/7 weeks) and 22 IMV cycles (median duration 9 days). Median TDE decreased from 0.118 cm (interquartile range [IQR]0.094-0.165) on the first IMV day to 0.104 cm (IQR 0.083-0.120) on the last IMV day (p = .092). DA occurred in 11 IMV cycles (50%) from 10 infants early during IMV (median: second IMV day). Mean airway pressure (MAP) and lung ultrasound score (LUS) on the first IMV day were significantly higher in patients who developed DA. DA was more frequent in patients with extubation failure than in those with extubation success within 7 days (83.3 vs. 33.3%, p = .038). DA, significantly associated with extubation failure, occurred in 58.8% of the study infants on IMV. Higher MAP and LUS at IMV start were associated with DA. Our results suggest a potential role of diaphragm ultrasound to assess DA and predict extubation failure in clinical practice.

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.

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

BackgroundPremature 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.MethodsWhen 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.ResultsForty-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.ConclusionsIn 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.ImpactComposite 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.

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

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. This prospective, single-center, randomized controlled trial enrolled preterm infants born at <30weeks 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 72hours of extubation. Electrical activity of the diaphragm (Edi) values were collected before extubation and at 1, 4, 12, and 24hours after extubation. 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 72hours 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 1hour after extubation, but values at 4, 12, and 24hours after extubation were lower in the NIV-NAVA group compared with the NCPAP group. In the present trial, NIV-NAVA was more effective than NCPAP in preventing extubation failure in preterm infants. ClinicalTrials.gov: NCT02590757.

Outcomes and factors associated with extubation failure in preterm infants

Background: Preterm infants usually have multiple complications, mainly due to their low birth weight. Multiple factors may lead to the need for intubating preterm infants. However, some infants may suffer from difficult extubation and failure to extubate from ventilation. This failure can result in increased morbidity or mortality. Objective: This study aims to evaluate the factors contributing to the failure of extubation and their outcomes in preterm infants. Materials and Methods: This is a retrospective descriptive cohort study that included records from neonatal intensive care unit for patients who had failed extubation from January 2014 to December 2020. The data included information about patients' demographics, pregnancy and delivery, description of ventilation course, and outcomes. SPSS version 26 was used for statistical analysis. Results: Seventy-seven infants were included. Males represented 61%, birth weight 37.7% had a <1 kg, 45.5% of the patients had a gestational age <28 weeks. The mean duration for mechanical ventilation was 19.21 ± 3.2 days, while the duration of intubation was 26.53 ± 2.3 days, and the average length of hospital stay was 86.2 ± 6.7 days. Male gender (P = 0.023), birth weight less than one kilogram (P = 0.004), gestational age <28 weeks (P = 0.033), sedation (P = 0.043), caffeine administration (P = 0.048), and a previous history of extubation failure (P = 0.036), lower hemoglobin levels (P = 0.039), lower APGAR score at 5 min (P = 0.013), and a previous history of extubation failure (P = 0.036) were significant factors associated with failure of extubation. Patent ductus arteriosus presence is not associated with failure of extubation. Mortality was 24.7% and prolonged length of hospital stay was significantly higher in babies with failure of extubation. Conclusion: Failure of extubation is more with babies received sedation, male gender, birth weight <1 kg, lower gestation age, and lower Apgar at 5 min. Patients with failing extubation have high in-hospital mortality and prolonged hospital stay.

Role of Spontaneous Breathing Trial as Predictors in Extubation Failure in Preterm Infants

Role of Spontaneous Breathing Trial as Predictors in Extubation Failure in Preterm Infants

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.

Respiratory setback associated with extubation failure in extremely preterm infants.

Extubation failure in preterm infants is associated with an increased risk of mortality and morbidity. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status. This was a retrospective study of infants with birth weight ≤ 1250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score (RSS), and ventilation index (VI) were used to assess the respiratory status of infants. Out of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77%, and 56% infants remained intubated at 24 h, 72 h, and 7 days, respectively. Respiratory status was worse at 24and 72 h after re-intubation when compared to pre-extubation levels. The median times for RSS and VI to reach pre-extubation levels were 4and 7 days, respectively. Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.

Randomised controlled trial of high-flow nasal cannula in preterm infants after extubation.

HFNC therapy is increasingly used as ‘non-invasive’ respiratory support for preterm infants. A 2016 Cochrane Review found that HFNC had similar efficacy to NCPAP for preterm infants following extubation,1 but that further studies were needed, particularly in extremely preterm infants born <28 weeks' gestation, who are at highest risk of extubation failure. The trial by Uchiyama et al is the largest randomised trial of HFNC as post-extubation support in preterm infants, and one of only a few to enrol extremely preterm infants (168 infants enrolled; 76 HFNC, 92 NCPAP/NIPPV). This multicentre non-inferiority trial found NCPAP/NIPPV was superior to HFNC (and HFNC did not satisfy non-inferiority criteria) for the primary outcome of treatment failure within 7 days. Reintubation rates were similar; more than 80% of infants who met HFNC treatment failure criteria avoided reintubation due to crossover to NCPAP/NIPPV. Like previous similar trials2-4 the intervention was not blinded, although objective treatment failure criteria were used. In the NCPAP/NIPPV group, 149 infants received NCPAP and 47 received NIPPV at extubation. In both groups, the escalation of respiratory support was at clinician discretion. As the control group could receive either NCPAP or NIPPV, the definition of ‘treatment failure’ is blurred: some infants received NIPPV before ‘treatment failure’ and others did not. It is not reported whether NIPPV inflations were synchronised with the infant's breathing or not, which may be important.5 A non-inferiority trial design is reasonable given the existing evidence, although the sample size calculation assumed a HFNC treatment failure rate 9% higher than that of NCPAP/NIPPV, and the chosen non-inferiority margin was rather large. There is an imbalance in the allocation of infants to HFNC (47%) and NCPAP/NIPPV (53%). A total of 378 infants were ultimately recruited to the study (38 more than required, even with inflation for anticipated dropouts); however this represents only 33% of eligible infants, which has implications for generalisability of the results. The use of respiratory stimulants prior to extubation is not reported. The trial was prospectively registered; however, there are inconsistencies between the registration and the published trial in the stated sample size, comparator and primary outcome. The starting HFNC gas flow was >2 L/min, lower than some previous studies,3, 4 and it is unclear whether infants received the maximal permitted gas flow of 8 L/min prior to treatment failure being determined. As increasing gas flow is associated with increased delivered pressure,6 this may have contributed to decreased efficacy in the HFNC group. Extubation failure in preterm infants is an important concern for neonatal clinicians, and the optimal mode of post-extubation respiratory support remains uncertain. The results of the trial by Uchiyama et al may tip the balance in favour of NCPAP/NIPPV as initial post-extubation support; however, consistent with previous evidence, reintubation rates are similar when HFNC is used with the ‘backup’ of NCPAP/NIPPV. For the most immature infants at highest risk of extubation failure, it seems prudent to avoid using HFNC as initial post-extubation support. The authors have no conflicts of interest to declare. https://ebneo.org/HFNC-after-extubation

Heated Humidified High-Flow Nasal Cannula vs. Nasal Continuous Positive Airway Pressure for Post-extubation Respiratory Support in Preterm Infants: A Randomized Controlled Trial.

The objective of this study was to compare the efficacy and safety of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (nCPAP) for prevention of extubation failure in preterm infants. Preterm infants (gestation ≥28 weeks) were randomized to HHHFNC or nCPAP after extubation. Primary outcome was extubation failure within 72 h of extubation. A total of 128 preterm infants were randomized to receive either HHHFNC (n = 63) or nCPAP (n = 65) after extubation. The primary outcome of extubation failure within 72 h after extubation was not different between the two groups (HHHFNC, 22.2% vs. nCPAP, 18.5%, risk difference of 3.7% and 95% CI -10.3 to 17.6, p = 0.604). The incidence of nasal trauma was significantly lower in the HHHFNC group than in the nCPAP group 6.3% vs. 21.5%, p = 0.020. In our study, HHHFNC was as effective as nCPAP for prevention of extubation failure in preterm infants. Also, HHHFNC was associated with significantly less nasal trauma compared with nCPAP.

Randomized Controlled Trial of Nonsynchronized Nasal Intermittent Positive Pressure Ventilation versus Nasal CPAP after Extubation of VLBW Infants

Background and Objectives: Nasal continuous positive airway pressure (NCPAP) is a useful method of respiratory support after extubation. However, some infants fail despite CPAP use and require reintubation. Some evidence suggests that synchronized nasal intermittent positive pressure ventilation (NIPPV) may decrease extubation failure in preterm infants. Nonsynchronized NIPPV (NS-NIPPV) is being widely used in preterm infants without conclusive evidence of its benefits and side effects. Our aim was to evaluate whether NS-NIPPV decreases extubation failure compared with NCPAP in ventilated very low birth weight infants (VLBWI) with respiratory distress syndrome (RDS). Methods: Randomized controlled trial of ventilated VLBWI being extubated for the first time. Before extubation, infants were randomized to receive NCPAP or NS-NIPPV. Primary outcome was the need for reintubation within 72 h. Results: 220 infants were included. The mean ± SD birth weight was 1,027 ± 256 g and gestational age 27.8 ± 1.9 weeks. Demographic and clinical characteristics were similar in both groups. Extubation failure was 32.4% for NCPAP versus 32.1% for NS-NIPPV, p = 0.98. The frequency of deaths, bronchopulmonary dysplasia, intraventricular hemorrhage, air leaks, necrotizing enterocolitis and duration of respiratory support did not differ between groups. Conclusions: In this population of VLBWI, NS-NIPPV did not decrease extubation failure after RDS compared with NCPAP.

Is noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) an alternative to NCPAP in preventing extubation failure in preterm infants?

Background Prolonged use of mechanical ventilation is associated with some complications as high mortality and high morbidities as bronchopulmonary dysplasia, ventilator-associated pneumonia, and pneumothorax. However, extubation failure in preterm infants is still high (40–60%) in very low birth weight infants (VLBW). Noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) is triggered by the diaphragmatic electrical activity through a nasogastric tube that synchronizes patient/ventilator respiration, cycle by cycle effectively shortening the assisted cycle trigger and the degree of ventilatory assistance, optimizing the effects of intermittent inspiratory pressure on nasal continuous positive airway pressure (NCPAP). This study aims to compare reintubation rates until 72 h after extubation in preterm infants of high risk for reintubation using NIV-NAVA or NCPAP. Methods A retrospective study of chart review data collection was performed in a private tertiary hospital. The study was approved by the local institutional Ethics Committee. We included infants considered at high risk of reintubation (BW < 1000 grams; use of invasive mechanical ventilation (IMV) for at least 7 days; or previous extubation failure episode) and compared the two groups according to the type of respiratory support after extubation: (1) NCPAP (n = 32); or (2) NIV-NAVA (n = 17). Demographics data were collected, the primary outcome was reintubation rate until 72 h after extubation. Secondary outcome was time to reintubation, BPD rate, IVH grade ≥ III, pneumothorax and death. Results There was no difference between both groups in demographic data. The reintubation rate decreased significantly in the NIV-NAVA group compared to NCPAP (50.0–11.7, p < .02) despite the significantly higher length of invasive mechanical ventilation (IMV) before extubation attempt in NIV-NAVA group (12.4 versus 5.5 days, p < .04). There was no difference between both groups in secondary outcomes. Conclusions In this small retrospective cohort study, the use of NIV-NAVA as postextubation strategy was effective in reducing extubation failure within 72 h in preterm infants when compared to traditional NCPAP.

Neural breathing pattern in newborn infants pre‐ and postextubation

To describe the neural breathing pattern before and after extubation in newborn infants. Prospective, observational study. In infants deemed ready for extubation, the diaphragm electrical activity (EAdi) was continuously recorded from 30 minute before to two hours after extubation. Total of 25 neonates underwent 29 extubations; 10 extubations resulted in re-intubation within 72 hours. Postextubation, there was an increase in peak EAdi (EAdi-max) and EAdi-delta (peak minus minimum EAdi) in both groups. The pre- to postextubation change in EAdi-max (8.9-11.1 μv) and EAdi-delta (6-8 μv) was less in the failure group in comparison with the change in EAdi-max (10.2-13.4 μv) and EAdi-delta (6.3-10.6 μv) in the success group, (p = 0.02 and 0.01, respectively). In our neonatal cohort, extubation failure was associated with a smaller increase in peak and delta EAdi after extubation. If confirmed, these findings indicate an important cause of extubation failure in preterm infants.

Preventing extubation failure in preterm infants: nasal CPAP remains the standard of care

Commentary on: Manley BJ, Owen LS, Doyle LW, Andersen CC, Cartwright DW, Pritchard MA, Donath SM, Davis PG. High-Flow Nasal Cannulae in Very Preterm Infants after Extubation. N Engl J Med 2013; 369:1425-33. PMID 24106935. Improving rates of extubation failure in very preterm infants remains an important and elusive goal. Postextubation CPAP prevents extubation failure and is the standard of care for preterm infants 1, 2. Alternative methods of delivering positive distending pressure to preterm infants, including high-flow nasal cannula (HFNC), are widely used and increasingly popular. The stated advantages of HFNC are ease of use, increased comfort and less nasal trauma. Unfortunately, retrospective analysis suggests potential harm from HFNC use in VLBW infants, highlighting the urgent need for prospective randomised controlled trials to guide clinical practice 3. Manley and colleagues determined whether HFNC performed similarly to nasal CPAP for preventing extubation failure in very preterm infants (<32 weeks) 4. The trial revealed that HFNC was noninferior to CPAP in preventing extubation failure. Importantly, noninferiority was defined as 20 percentage points above the extubation failure rate for CPAP. Treatment failure occurred in 34.2% of the HFNC group and 25.8% in the CPAP group (risk difference, 8.4 percentage points, 95% confidence interval, −1.9 to 18.7). While this difference did not reach statistical significance, the upper limit of the 95% confidence interval bordered on the margin of noninferiority. A potential criticism of this otherwise well done trial has been using up to a 20% difference to define ‘noninferior’ 5. Additionally, the difference in failure rate was exaggerated in infants <26 weeks gestational age. Specifically, 61.3% of infants <26 weeks failed CPAP, while 81.3% of infants failed HFNC. Although the study was not powered to detect differences in this small subgroup of patients (63 infants), the authors urge caution when considering the use of HFNC in these patients. Furthermore, approximately half of the patients failing HFNC were salvaged with CPAP, thus resulting in a lower (17.8%) re-intubation rate in patients randomised to HFNC compared to those randomised to CPAP (25.2%). Lastly, nasal trauma was infrequent and rates did not differ by group. Where do these data leave us? Does HFNC perform similarly to CPAP for preventing extubation failure in very preterm infants (<32 weeks GA)? Statistically, yes. However, the authors acknowledge that they ‘chose a generous noninferiority margin’ 6. Ultimately, does HFNC perform well enough compared to CPAP to justify its use to prevent extubation failure? As the authors pointed out, these data clearly argue against the routine use of HFNC following extubation for infants <26 weeks. Furthermore, these data provide no compelling argument that HFNC should be considered as equivalent to nasal CPAP as the current standard of care for preventing extubation failure. However, these data would suggest that HFNC is safe and well tolerated and warrants further study in the NICU. https://ebneo.org/2015/04/delivering-non-invasive-positive-pressure-to-prevent-extubation-failure-in-preterm-infants-nasal-cpap-remains-the-standard-of-care/ None. CW: R01HL132941. LS: T32007186-32.

Risk factors associated with extubation failure in preterm infants with very low birth weight

Repeated endotracheal intubation is associated with complications and additional risks for a preterm infant. The aim of this study was to determine the risk factors related to extubation failure (EF) in preterm newborns. Materials and methodsNinety two very preterm infants with respiratory distress syndrome (RDS), birth weight of <1500g, mechanically ventilated, and extubated before the 7th day of life were enrolled into prospective study. Following extubation, noninvasive respiratory support was provided. Infants who required reintubation within 72h after primary extubation constituted the main group (n=27) while those, whose primary extubation was successful, were included into the comparison group (n=65). ResultsInfants from the main group differed by lower antenatal steroid administration rate, higher incidence of intraventricular hemorrhage, severe RDS, arterial hypotension, metabolic acidosis, and pulmonary bleeding, as well as by the need in higher initial mechanical ventilation settings. According to logistic regression analysis the risk of EF was significantly associated with severe RDS (OR – 3.82; 95% CI: 1.21–12.02), arterial hypotension (OR – 24.05; 95% CI: 1.99–290.48) or metabolic acidosis (OR – 4.62; 95% CI: 1.41–15.16) in the first 3 days of life. Antenatal steroid prophylaxis considerably decreased the probability of EF (OR – 0.2; 95% CI: 0.063–0.68). ConclusionsThe risk of reintubation after primary extubation is determined by severe RDS, arterial hypotension or metabolic acidosis during the first 3 days of life. Antenatal steroid prophylaxis substantially decreases this risk. The method of non-invasive respiratory support following primary extubation does not influence the reintubation risk.

PS-381 Nasal High Frequency Ventilation Is Not More Effective Than Noninvasive Ventilation To Prevent Extubation Failure In Very Preterm Infants

Background In animal models nasal high frequency oscillatory ventilation appears to provide better lung development and less injury that means it could be protective against repeated need of conventional ventilation. In a randomised study we compared the clinical efficacy of nasal high frequency oscillatory ventilation (nHFOV) and nasal intermittent positive pressure ventilation (NIPPV) in prevention of repeated intubation in preterm infants with very low birth weight. Methods 24 preterm infants with birth weight Results Extubation failure rate after primary extubation was the same in the both groups – 41.67%. There was no difference in total duration of respiratory support between the groups. BPD developed in 2 infants (16.67%) in the nHFOV group and in 1 infant (8.33%) in the control group (p > 0.05). Conclusions In this study nHFOV was not found to be more effective than NIPPV in prevention of primary extubation failure in preterm infants with very low birth weight.

A Randomized Controlled Trial of Two Nasal Continuous Positive Airway Pressure Levels after Extubation in Preterm Infants

To compare extubation failure rate with two ranges of nasal continuous positive airway pressure (NCPAP) in oxygen dependent preterm infants. Preterm infants of birth weight 500-1000 g and gestational age 23-30 weeks, extubated for the first time during the first 6 weeks while requiring fraction of inspired oxygen ≥ 0.25, were randomly assigned to a NCPAP range of 4-6 (low NCPAP) or 7-9 (high NCPAP) cmH2O. Infants were randomized to low (n = 47) or high NCPAP (n = 46) at day 16.3 ± 14.7 and 15.5 ± 12.4, respectively. Rates of extubation failure per criteria (24% vs 43%, P = .04, OR and 95% CI: 0.39 [0.16-0.96]) and re-intubation (17% vs 38%, P = .023, 0.33 [0.016-0.85]) within 96 hours were significantly lower in the high- compared with the low NCPAP group. This was mainly due to a strikingly lower failure rate in the 500-750 g birth weight strata. Duration of ventilation, bronchopulmonary dysplasia, or severe bronchopulmonary dysplasia did not differ significantly. No infant developed pneumothorax during 96 hours post-extubation. Extubation failure in preterm infants with residual lung disease was lower with NCPAP range of 7-9 compared with 4-6 cmH2O. These findings suggest the need for higher distending pressure post-extubation in the more immature infants who are still oxygen dependent.

Heliox non-invasive ventilation for preventing extubation failure in preterm infants

Objectives: Our aim was to assess whether non-invasive ventilation with heliox may decrease the incidence of extubation failure in preterm infants with RDS.Methods: Infants <29 weeks of gestation were treated immediately after extubation with heliox combined with nasal continuous airway pressure (Hx-NCPAP) or bilevel NCPAP (Hx-BiPAP) for 24 h, while infants in the control groups were treated with conventional NCPAP or BiPAP. The primary endpoint was the comparison of the extubation failure rate in the two groups, where failure was defined as the need for MV during the 24 h following extubation.Results: Eighteen infants were assigned to the heliox group and 18 to the control group. The extubation failure rate was similar (p = 0.249) in the heliox (n = 6; 33%) and in the control group (n = 9; 50%), but required mean airway pressure (MAP: 4.0+1.0 vs. 4.8+1.2 cm H2O; p = 0.037) and PaCO2 (39+8 mmHg vs. 52+7 mmHg; p < 0.001) at 24 h of treatment were lower in the heliox group.Conclusions: Non-invasive ventilation with heliox was not effective in decreasing extubation failure in preterm infants with RDS, but did improve their respiratory function. Our findings might support the planning of large randomized controlled studies to evaluate the effectiveness of heliox non-invasive ventilation for decreasing extubation failure in premature infants.

The Mapleson D continuous positive airway pressure system: a novel indication for the Mapleson circuit?

The Mapleson D continuous positive airway pressure system: a novel indication for the Mapleson circuit?

Prediction of extubation failure in preterm infants

Objective: To identify whether the results of assessment of respiratory muscle strength or respiratory load were better predictors of extubation failure in preterm infants than readily available clinical data. Patients:...