Extubation In Infants Research Articles

Variability for age at successful extubation in infants with congenital diaphragmatic hernia.

The objective of this study was to characterize clinical factors associated with successful extubation in infants with congenital diaphragmatic hernia. Using the Children's Hospitals Neonatal Database, we identified infants with congenital diaphragmatic hernia from 2017 to 2020 at 32 centers. The main outcome was age in days at the time of successful extubation, defined as the patient remaining extubated for 7 consecutive days. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards ratio equations were used to estimate associations between clinical factors and the main outcome. Observations occurred through 180days after birth. There were 840 eligible neonates with a median gestational age of 38weeks and birth weight of 3.0kg. Among survivors (n=693), the median age at successful extubation was 15days (interquartile range [IQR]: 8-29days, 95th percentile: 71days). For nonsurvivors (n=147), the median age at death was 21days (IQR: 11-39days, 95th percentile: 110days). Center (adjusted hazards ratio: 0.22-15, P<.01), low birth weight, intrathoracic liver position, congenital heart disease, lower 5-minute Apgar score, lower pH upon admission to Children's Hospitals Neonatal Database center, and use of extracorporeal support were independently associated with older age at successful extubation. Tracheostomy was associated with multiple failed extubations. Our findings suggest that infants who have not successfully extubated by about 3months of age may be candidates for tracheostomy with chronic mechanical ventilation or palliation. The variability of timing of successful extubation among our centers supports the development of practice guidelines after validating clinical criteria.

Effect of bilateral infraorbital nerve block on intraoperative anesthetic requirements, hemodynamics, glycemic levels, and extubation in infants undergoing cheiloplasty under general anesthesia.

BackgroundInappropriate use of intravenous and inhaled anesthetics may be dangerous in infants undergoing facial cleft surgeries. This study primarily aimed to compare the effect of infraorbital nerve block on sevoflurane requirement in infants undergoing cheiloplasty. Intraoperative opioid consumption, hemodynamics, blood glucose levels, extubation time, and delirium were also compared.MethodsThis prospective, randomized, double-blinded study was conducted in 34 infants undergoing cheiloplasty under general anesthesia. After induction, group A received bilateral infraorbital nerve block with 0.5 mL of 0.5% bupivacaine and group B 0.5 mL saline. An increase in heart rate or blood pressure > 20% was managed by increasing sevoflurane by 2–2.5%, followed by fentanyl 0.5 µg/kg bolus. The chi-square test and independent-sample t-test were used where applicable.ResultsDemographics, duration of surgery, and intravenous fluids used were comparable between the groups. Compared to group A, patients in group B had significantly higher consumption of fentanyl (14.2 ± 4.4 µg vs. 22.1 ± 6.2 µg) and sevoflurane (14.2 ± 4.8 mL vs. 26.8 ± 15.6 mL). Intraoperative hemodynamic parameters were significantly lower in group A, the number of times increases in hemodynamic parameters occurred, and fentanyl supplemental bolus was required remained significantly lower in group A than in group B. Intraoperative glycemic levels remained higher in group B, and the extubation time was significantly shorter in group A than in group B (4.40 ± 1.60 min vs. 9.2 ± 2.18 min). Group A had a lesser occurrence of postoperative delirium.ConclusionSupplemental infraorbital block in infants undergoing cheiloplasty under general anesthesia resulted in significantly decreased anesthetic requirements and optimal hemodynamic and glycemic levels with faster extubation and lesser delirium.

Can a predictive model for extubation readiness in preterm infants improve rates of successful extubation?

Extubation readiness is a complex, multifactorial topic with important clinical implications. In the premature neonatal population, there are no proven predictors of extubation readiness, success or failure; decisions surrounding extubation are left to clinician judgement resulting in practice variability and high rates of failure.1 Frequency of failed elective extubation in this patient population ranges from 23% to 42%.2-4 Extubation failure has been demonstrated to be associated with increased rates of death, bronchopulmonary dysplasia and retinopathy of prematurity as well as prolonged respiratory support requirement and hospitalisation.3, 4 In the current study, Gupta and colleagues created an extubation readiness estimator with available clinical and demographic data. The authors have made their calculator available to the public (http://elasticbeanstalk-us-east-2-676799334712.s3-website.us-east-2.amazonaws.com). After entering the gestational age, extubation day of life, pre-extubation per cent oxygen, highest RSS in first 6 hours, weight at extubation and pre-extubation pH, the clinician will receive the probability of successful extubation. Importantly, in this predictive model, the sensitivity and specificity of the prediction change with the results of the calculated probability of successful extubation. If the calculator predicts a 60% chance of success, the authors report 87% sensitivity and 53% specificity. This indicates that 87% of patients with similar values inserted into the calculator who succeed extubation will be predicted to succeed, and 53% of patients who fail extubation will be predicted to fail. If the calculator predicts an 80% chance of success, the sensitivity falls considerably to 54%; this implies that the ability to predict who will succeed is decreased at this level. Conversely, the sensitivity increases to 81%, suggesting that the ability to predict who will fail improves. Though difficult to conceptualise, this change in ‘test performance’ is intuitive and analogous to the way a clinician might make their own prediction. For example, a provider who feels an infant has a 95% chance of successful extubation likely has a high degree of certainty about the estimation. A clinical who feels an infant has only a 60% chance of extubation success may have uncertainty regarding the exact percentage. In this way, the predictive model performs similarly to clinical judgement, performing less well as uncertainty increases. A predictive model is most useful when it provides added certainty in the latter scenario; it is unlikely to be applied or improve outcomes if it only performs well when extubation success is either highly probable or very unlikely. It is unknown how the tool derived retrospectively will perform prospectively, and this uncertainty has potential to result in unanticipated harm. The authors comment that use of the estimator may help facilitate earlier extubation in infants estimated to have a high chance of success—if this hypothesis is true, rates of successful extubation should increase. Alternatively, a poor score could prevent an extubation attempt in some babies, with the unanticipated consequence of increasing ventilation days and lung injury. The balance of these potential harms and benefits should be prospectively assessed with broad implementation of this tool. None. URL TO THE FULL REVIEW ON THE EBNEO WEBSITE https://ebneo.org/2020/12/extubation-readiness/

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.

Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study.

The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. Five children's hospitals. A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). None. Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.

Assessment of Common Criteria for Awake Extubation in Infants and Young Children.

Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience

Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shiftsand require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects. We present nine years of caudal epidural anaesthesia in delayed bladder exstrophy repair and describe its facilitation of early extubation and early feeding (within 12h) without surgical complication. We retrospectively evaluated consecutive infants with classic bladder exstrophy undergoing delayed primary closure with anterior pelvic osteotomies between November 2007 and January 2016. Outcomes and complications were evaluated in terms of postoperative comfort (using the FLACC score-Face, Legs, Activity, Cry, Consolability), epidural failure rate, re-intubation rateand gastrointestinal complications. Forty-four infants had average age of 5.8 months (range 1.6-17.1 months) and weight of 7.0kg (range 3.5-11.8kg), and their duration of surgery was 9.5h (range 6.9-14.3h). Forty-two of 44 (95.5%) patients received caudal epidural catheters. At 24h, 15 of 42 (35.7%) caudal epidurals required supplementation with intravenous opioids. Fewer patients with optimally functioning epidurals required postoperative ventilation (1/27 [3.7%] compared with 3/15 [20.0%]). None of the patients with caudal epidural catheters required re-intubation. Pain scores were lower in infants with isolated caudal epidurals catheters than those with caudal epidurals supplemented by intravenous opioids(day 1 [18 vs 53; P=0.008]; day 2 [8 vs 15; P>0.05] and overall [32 vs 65; P=0.014]). Infants with intravenous opioids experienced higher complications: pruritus (25% [95% confidence interval {CI}: 5%-57%] vs 0% [95% CI: 0%-13%]; P=0.026)and nausea and vomiting (25% [95% CI: 5%-57%] vs 8% [95% CI: 1%-25%]; P=0.30) requiring treatment. Nineteen of 44 (43.1%) infants were fed early (within 12h of surgery). Infants who were fed early had lower pain scores than infants feeding late(day 1 [17.5 vs 31; P>0.05]; day 2 [5.5 vs 15; P=0.045]; overall [26 vs 55.5; P=0.015]) without increase in complications (nausea and vomiting [6.3% vs 20.0%; P=0.06]; ileus [0.0% vs 0.0%]; aspiration [0.0% vs 0.0%]and re-intubation aspiration [0.0% vs 0.0%]). Caudal epidural analgesia facilitates postoperative extubation in infants undergoing delayed exstrophy repair. Early feeding (within the first 12h) in delayed bladder exstrophy repair is likely to improve patient comfort and consolability without increasing the incidence of gastrointestinal complications. Intravenous opioid may be associated with increased postoperative complications that may influence peri-operative outcomes.

Predictive Factors for Efficacy and Safety of Prophylactic Theophylline for Extubation in Infants with Apnea of Prematurity.

PurposeThis study aimed to evaluate predictive factors involved in efficacy and safety in Japanese infants who received theophylline therapy to prevent apnea of prematurity (AOP) after weaning from mechanical ventilation.MethodsWe retrospectively reviewed the medical records of infants who were administered intravenous aminophylline (theophylline ethylenediamine) for AOP at the neonatal intensive care unit, Kagoshima University Hospital, Japan, between January 2009 and June 2013.ResultsA total of 100 infants were evaluated as two separate groups in terms of efficacy and safety of theophylline. Sixty-seven (67.0%) infants had effective theophylline therapy. Multivariate logistic regression analysis showed that gestational age at birth was significant, with an odds ratio of 0.59 (p < 0.001). Receiver operating characteristic analysis showed that the cut-off value was 31.1 weeks old for predicting the efficacy of theophylline (specificity, 66.7%; sensitivity, 86.6%; p < 0.001; area under the curve, 0.750; 95% confidence interval, 0.45–0.74). Adverse reactions were identified in 21 (21.0%) infants. Multivariate logistic regression analysis showed that the number of days of theophylline administration from birth was associated with an increased risk of adverse reactions after theophylline administration (p = 0.01).ConclusionsPhysicians need to be aware of the possibility that theophylline fails to produce therapeutic effects for extubation in infants aged less than 31.1 weeks old, and adverse reactions can easily develop when theophylline is administered soon after birth.

Efficacy and Safety of Postoperative Dexmedetomidine Administration in Infants and Children Undergoing Cardiac Surgery: A Retrospective Cohort Study.

In this retrospective cohort study, we describe efficacy and safety of dexmedetomidine administration in the cardiac intensive care unit, in children undergoing cardiac surgery. This study consisted of pediatric patients 3 days to 17.5 years of age, undergoing cardiac surgery from April 2010 to April 2011. In addition to a scheduled opioid, usually fentanyl, 107 patients received dexmedetomidine postoperatively, including 19 (18%) patients diagnosed with trisomy 21 and 9 (8%) neonates/newborns. Median dexmedetomidine starting dose was 0.45 µg/kg/h and overall median dose higher than previously published, ranging from 0.8 µg/kg/h to 2.17 µg/kg/h. We compared infants (younger than 1 year) with older children (1-17 years of age). Median duration of administration was 1.6 days (0-23.9 days) and duration to extubation in infants was 46.5 hours, and in the older children it was 22.6 hours. Seven patients (6.5%) were discontinued dexmedetomidine due to adverse events, most commonly bradycardia. Neonates experienced more pronounced heart rate reduction (no bradycardia) and received lower maintenance doses than older infants (0.56 vs. 0.77 µg/kg/h). The face, leg, activity, cry, consolability pain scale and the state behavioral scale scores indicated adequate sedation and good analgesia. The most common adverse reaction postdiscontinuation was agitation, more frequent in the infant group (20 vs. 11.2%). Thirty patients (28.3%) received prolonged infusion (>72 hours). Patients with and without trisomy 21 did not differ with dose, safety, efficacy, or adverse events. Dexmedetomidine, as part of multimodal management, appears to be a safe, efficacious agent providing analgesia and sedation throughout all pediatric age groups following cardiac surgery. Overall, dexmedetomidine is well tolerated and safe with higher doses than previously noted, and is well tolerated by neonates, infants, and patients with trisomy 21. Withdrawal effects were noted in patients following prolonged infusion.

Reasons for accidental extubation on infants mechanical ventilation and optimization research of intervention countermeasures

Objective To analyze the reasons for accidental extubation in infants during mechanical ventilation and to explore effective intervention countermeasures. Methods A total of 148 infants with accidental extubation from May 2013 to February 2014 who given routine nursing care were selected as control group. Another 152 infants with accidental extubation in pediatric intensive care unit (PICU) who given optimization nursing care from March to December 2014 were selected as observation group. Retrospective analysis of accidental extubation, artificial airway way and intervention care were conducted. Results The total intratracheal tube time was 283 d in control group and 253 d in observation group. Nineteen cases (6.7%)suffered accidental exudation in control group and that of 8 cases(3.2%) in observation group, and there was significant difference between two groups,χ2=5.25,P<0.05.The primary reason of unplanned extubation was that infants with unconsciousness, the second cause was the improper catheter fixed. The third cause was the patient's comfort level and so on the improper nursing operation leading to accidental extubation too short or too shallow. Conclusion Infants given mechanical ventilation should pay more attention to the intervention of accidental extubation, appropriate calm, physical constraints and correct fixed pipeline. Key words: Ventilators, negative-pressure; Nursing care; Infant; Accidental extubation; Reason

Tonic diaphragmatic activity in critically ill children with and without ventilatory support.

Infants have to actively maintain their end expiratory lung volume (EELV). In mechanically ventilated infants, the diaphragm stays activated until the end of expiration (tonic activity), contributing to EELV maintenance. It is unclear whether tonic activity compensates for the lack of laryngeal braking due to intubation or if it is normally present. To determine if tonic diaphragm activity remains after extubation in infants, and if it can be observed in older children. Prospective observational study of pediatric patients ventilated for >24 hr. Diaphragm electrical activity (EAdi) was recorded using a specific nasogastric catheter during four periods: (i) the acute phase, (ii) pre-extubation, (iii) post-extubation, and (iv) at PICU discharge. Tonic EAdi was defined as the EAdi in the last quartile of expiration. Fifty-five patients, median age 10 months (Interquartile range: 1-48) were studied. In infants (<1 year, n = 28), tonic EAdi was always present, and represented 33% (22-43) of inspiratory EAdi at PICU discharge. No significant change was observed between pre- and post-extubation periods. In older patients (n = 27), tonic activity was negligible as a whole, but 10 patients exhibited significant tonic EAdi at one time-point during PICU stay. Bronchiolitis was the only independent factor associated with tonic EAdi. In infants, tonic EAdi remains involved in ventilatory control after extubation and restoration of laryngeal braking. Tonic EAdi may play a pathophysiological role in bronchiolitis and it can be reactivated in older patients. The interest of tonic EAdi as a tool to titrate mechanical ventilation warrants further evaluation.

PETCO2 measurement and feature extraction of capnogram signals for extubation outcomes from mechanical ventilation

Capnography is a continuous and noninvasive method for carbon dioxide (CO2) measurement, and it has become the standard of care for basic respiratory monitoring for intubated patients in the intensive care unit. In addition, it has been used to adjust ventilatory parameters during mechanical ventilation (MV). However, a substantial debate remains as to whether capnography is useful during the process of weaning and extubation from MV during the postoperative period. Thus, the main objective of this study was to present a new use for time-based capnography data by measuring the end-tidal CO2 pressure (), partial pressure of arterial CO2 () and feature extraction of capnogram signals before extubation from MV to evaluate the capnography as a predictor of outcome extubation in infants after cardiac surgery. Altogether, 82 measurements were analysed, 71.9% patients were successfully extubated, and 28.1% met the criteria for extubation failure within 48 h. The ROC-AUC analysis for quantitative measure of the capnogram showed significant differences (p < 0.001) for: expiratory time (0.873), slope of phase III (0.866), slope ratio (0.923) and ascending angle (0.897). In addition, the analysis of (0.895) and (0.924) obtained 30 min before extubation showed significant differences between groups. The mean value for success and failure extubation group was 39.04 mmHg and 46.27 mmHg, respectively. It was also observed that high CO2 values in patients who had returned MV was 82.8 ± 21 mmHg at the time of extubation failure. Thus, measurements and analysis of features extracted from a capnogram can differentiate extubation outcomes in infant patients under MV, thereby reducing the physiologic instability caused by failure in this process.

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Introduction: In contrast with adults, infants have to actively maintain their end expiratory lung volume because of the high compliance of their rib cage. In mechanically ventilated infants, we previously showed that the diaphragm stays activated until the end of expiration (tonic activity). We hypothesized that this tonic activity was present to compensate for the lack of laryngeal braking secondary to endotracheal intubation. We conducted a clinical study to determine if the tonic activity of the diaphragm remains after extubation in infants, and if it can be observed at all ages in children. Methods: This is a prospective longitudinal observational study. Patients 1 week to 18 year old admitted to the pediatric intensive care unit (PICU), mechanically ventilated for at least 24 hours and with parental consent were eligible. Diaphragm electrical activity was recorded using a specific nasogastric catheter at four different times during PICU stay: in acute phase, before and after extubation and at PICU discharge. Diaphragmatic activity was analyzed in a semi-automatic manner to determine inspiratory and expiratory times. Tonic diaphragmatic activity was defined as the activity during the last quartile of expiration. Results: 55 patients with a median age of 10 months (Interquartile range: 1–48) were studied. In infants (< 1 year-old, n=28), tonic activity expressed as a percentage of inspiratory activity was 48% (30–56) in acute phase, 38% (25–44) pre-extubation, 28% (17–42) post-extubation and 33% (22–43) at PICU discharge (p<0.05, ANOVA, with significant difference between recording 1 and recordings 3 and 4). No significant change in tonic activity was observed between before and after extubation. As expected from physiology, the tonic diaphragmatic activity in older patients (> 1 year-old) was negligible during normal breathing (Median: 0.6mcv). However, significant tonic activity (> 1mcv and >10% of inspiratory activity) was observed at one point during the stay of 10 patients (aged 13 months to 118 months) out of 27 patients > 1 year-old. Conclusions: In infants, tonic diaphragmatic activity remains important after extubation despite restoration of laryngeal braking. Older patients breathing normally don’t show significant tonic activity but it can be re-activated in pathological conditions. Tonic activity seems to be an indicator of patient’s efforts to maintain their end expiratory lung volume. Further studies should evaluate if this monitoring could facilitate the detection of situations of inappropriate ventilatory support.

Is extubation associated with changes in ductal and pulmonary blood flow in extremely preterm neonates?

Early extubation is desirable in preterm neonates to minimise the risk of complications associated with prolonged intubation. The association of significant pulmonary haemorrhage (PH) with extubation in a cluster of very preterm infants instigated an assessment of ductal and pulmonary haemodynamic effects of early extubation. This is a prospective observational study in 20 neonates (gestation <28 weeks) undergoing early extubation. Echocardiography was performed 5 min pre-extubation and 20 min post-extubation to continuous positive airway pressure. Normal cardiac anatomy was ascertained. Left pulmonary artery (LPA) and ductus arteriosus diameter and flows were recorded. Doppler spectral pattern of velocity was recorded over a minimum of four cycles. Median (range) gestation, birthweight and age at extubation were 26.5 (24.0-28.0) weeks, 932 (595-1260) g and 18 (6-51) h, respectively. There was no significant change in pulmonary flow post-extubation: ductal size: (pre--1.2 (0-3.3) mm, post--1.0 (0-3.5) mm); ductal flow: (pre--44 (0-515), post--49 (0-441) mL/kg/min); LPA diameter: (pre--2.4 (1.9-3.8) mm, post--2.6 (1.9-3.4) mm); LPA flow: (pre--112 (59-255), post--122 (58-188) mL/kg/min. There were 3 out of 20 infants who developed PH at the post-natal age of 2, 11 and 16 days after extubation. Ductal and LPA flow did not change significantly after extubation in infants with or without PH irrespective of the ductal status. Early extubation was not associated with a significant change from baseline in ductal and pulmonary flow in extremely preterm infants.

Noninvasive Strategies for Management of Respiratory Problems in Neonates

Multiple techniques have been developed to provide noninvasive strategies for respiratory support of the newborn that provide positive airway pressure continuously, with or without ventilation cycles, in nonintubated infants. The core physiologic variable is positive airway pressure used clinically as nasal continuous positive airway pressure (CPAP). CPAP can be augmented with intermittent positive pressure breaths that are, or are not, synchronized to the breathing of the infant. Pressures delivered by high-flow nasal cannula are less predictable than those delivered by a CPAP device. A renewed interest in testing and innovating to improve noninvasive respiratory support techniques has resulted from efforts to avoid intubation, mechanical ventilation, and ultimately bronchopulmonary dysplasia. These noninvasive techniques now are used to stabilize respiratory status after birth, to manage respiratory distress syndrome, and to facilitate extubation of infants. Large trials, in aggregate, demonstrate a modest benefit from the use of CPAP soon after birth, relative to intubation, surfactant treatment, and ventilation. Small trials yield conflicting results for the relative benefits of different noninvasive techniques for the clinical management of respiratory distress syndrome and for attempts at extubation. Success with noninvasive ventilation for the management of preterm infants depends greatly on the skills and commitment of the personnel caring for the infant.

Prädiktion von Extubationsversagen bei ELBW-Frühgeborenen

The accurately timed extubation of ventilated ELBW preterm infants is still a problem. With different data systems the attempt has been made to more accurately predict the successful extubation of these infants. However, there do not yet exist any satisfying solutions. We retrospectively analysed 66 ELBW preterm infants who were endotracheal intubated and ventilated within 24 h postnatal. Basic data, clinical and ventilation data immediately before planned extubation and in several intervals during the following 24 h, as well as outcome variables at discharge were interpreted. 51 patients were successfully extubated (EE-group), 15 (22.7%) failed extubation (reintubation within 48 h after extubation, EV-group). Immediately before extubation in the EE-group there was found a significantly higher inspiratory oxygen concentration (FiO2) in comparison to the EV-group (0.25 vs. 0.3; p=0.01). After the extubation attempt the inspiratory oxygen concentration stayed lower in the EE-group, whereas in the EV-group it rose remarkably (2 h after ext.: 0.26 vs. 0.4; p<0.001). Neither of the basic data showed any significant difference. The outcome analysis indicated a longer intensive care in the EV-group and a trend towards increased BPD and ROP. The study shows that for ELBW preterm infants the inspiratory oxygen concentration is especially important to predict a successful extubation. According to our data, the inspiratory oxygen demand before and immediately after extubation establishes the essential difference between successfully extubated and reintubated infants.

Infant flow biphasic nasal continuous positive airway pressure (BP- NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants' ≤ 1,250 grams: a randomized controlled trial

BackgroundThe use of mechanical ventilation is associated with lung injury in preterm infants and therefore the goal is to avoid or minimize its use. To date there is very little consensus on what is considered the "best non-invasive ventilation mode" to be used post-extubation. The objective of this study was to compare the effectiveness of biphasic nasal continuous positive airway pressure (BP-NCPAP) vs. NCPAP in facilitating sustained extubation in infants ≤ 1,250 grams.MethodsWe performed a randomized controlled trial of BP-NCPAP vs. NCPAP in infants ≤ 1,250 grams extubated for the first time following mechanical ventilation since birth. Infants were extubated using preset criteria or at the discretion of the attending neonatologist. The primary outcome was the incidence of sustained extubation for 7 days. Secondary outcomes included incidence of adverse events and short-term neonatal outcomes.ResultsSixty-seven infants received BP-NCPAP and 69 NCPAP. Baseline characteristics were similar between groups. The trial was stopped early due to increased use of non-invasive ventilation from birth, falling short of our calculated sample size of 141 infants per group. The incidence of sustained extubation was not statistically different between the BP-NCPAP vs. NCPAP group (67% vs. 58%, P = 0.27). The incidence of adverse events and short-term neonatal outcomes were similar between the two groups (P > 0.05) except for retinopathy of prematurity which was noted to be higher (P = 0.02) in the BP-NCPAP group.ConclusionsBiphasic NCPAP may be used to assist in weaning from mechanical ventilation. The effectiveness and safety of BP-NCPAP compared to NCPAP needs to be confirmed in a large multi-center trial as our study conclusions are limited by inadequate sample size.Clinical Trials Registration #NCT00308789Source of supportGrant # 06-06, Physicians Services Incorporated Foundation, Toronto, Canada. Summit technologies Inc. provided additional NCPAP systems and an unrestricted educational grant. presented at The Society for Pediatric Research Meeting, Baltimore, USA, May 2nd-5th, 2009 and Canadian Paediatric Society Meeting, June 23rd-29th, Ottawa, 2009.

Prevalence of congenital heart defects in patients with Down’s syndrome

Correspondence:Keith J. BarringtonE-mail: keith.barrington@umontreal.ca8. O’Brien K, Campbell C, Havlin L, Wenger L. Shah V. Infant flow biphasic NCPAP versus infant flowCPAP for the facilitation of successful extubation in infants 1250 grams: A randomized controlled trial. Paediatrics and Child Health. 2009:14;11A (abstract).9. Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, et al. Caffeine therapy for apnea of prematurity. N Engl J Med. 2006;354:2112-21.10. Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, et al. Long-term effects of caffeine therapy for apnea of prematurity. N Engl J Med. 2007;357:1893-902.* MD. Pediatric Cardiology Division, Pediatrics Department, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.No conflicts of interest declared concerning the publication of this editorial.

Infant Flow Biphasic Ncpap Versus Infant Flow Ncpap for the Facilitation of Successful Extubation in Infants 1250 Grams: a Randomized Controlled Trial

Infant Flow Biphasic Ncpap Versus Infant Flow Ncpap for the Facilitation of Successful Extubation in Infants 1250 Grams: a Randomized Controlled Trial

Predictors of Successful Early Extubation Following Congenital Cardiac Surgery in Neonates and Infants

There is a paucity of literature discussing the predictive likelihood of successfully extubating neonates and infants in the operating room immediately following congenital cardiac surgery. Given the unknown consequences of anaesthetics on neurodevelopmental outcomes, minimising the exposure of this population to such agents may have long-term benefits. Retrospective chart review of 391 patients less than 1 year of age. The probability of successfully extubating these patients was based on quantifiable, objective criteria. The relevant variables include age, weight, bypass time, lactate level and specific congenital anomaly. The practice of immediate extubation of infants and neonates is achievable, safe and predicted based on specific patient variables. This practice will minimise the anaesthetic exposure of these especially young patients who may be at risk for long-term consequences related to anaesthetic exposure.