Preventing Extubation Failure Research Articles

Association of Diaphragmatic Thickness and Peripheral Muscle Thickness using Ultrasonography in Extubation Outcome

Introduction Patients in icu who are critically sick require basic life support in form of mechanical ventilator. Ventilator associated complication are common in them . Prediction of icu acquired weakness can prevent extubation failure, decrease in hospital mortality and increase icu free day. Thereby decreasing financial burden . Both central and peripheral muscle thickness play role in predicting extubation success. Aim/Objective :Aim is to measure muscle strength of diaphragm and quadriceps muscle using ultrasonography and to find if central and peripheral muscle strength can be used as a predictor for patients’ extubation outcome. Study design : Prospective crossectional single centred observational study . Place and duration of the study : The study was carried out in PCCM department of Kgmu from January 2023 to October 2023. Methodology: Diaphragm excursion , diaphragm thickness at inspiration and expiration was measured using ultrasonography on right side at 8 th and 9th intercostal space between anterior and mid axillary lines. Quadriceps thickness was also measured at mid point between the anterior superior Iliac spine to patella and was compared with the outcome of the intubated patient . Results : Out of 42 patients 52% were male(n=22) and 48% were female (n=20). The study showed that the diaphragmatic excursion ( p value <0.001 ) and diaphragmatic thickness at inspiration (p value 0.007 ) was significant in predicting outcome of the patient from mechanical ventilator but quadriceps thickness had no significance( pvalue 0.012). The excursion of the patient <7 , 7-11 and >11 has extubation success of .0%, 46.2 % and 53.8 % respectively. The diaphragmatic inspiration thickness of <1.65 , 1.65 - 3.7 >3.7 has successfull weaning of 0% , 100% and 0% respectively. Conclusion: Diaphragm excursion plays strong role in predicting the success of extubation and preventing icu acquired weakness. The study reflect the role of diaphragmatic thickness in better outcomes. Quadriceps muscle couldn't be related much with weaning and extubation.

Noninvasive respiratory support after extubation: a systematic review and network meta-analysis.

The effect of noninvasive respiratory support (NRS), including high-flow nasal oxygen, bi-level positive airway pressure and continuous positive airway pressure (noninvasive ventilation (NIV)), for preventing and treating post-extubation respiratory failure is still unclear. Our objective was to assess the effects of NRS on post-extubation respiratory failure, defined as re-intubation secondary to post-extubation respiratory failure (primary outcome). Secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), discomfort, intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), and time to re-intubation. Subgroup analyses considered "prophylactic" versus "therapeutic" NRS application and subpopulations (high-risk, low-risk, post-surgical and hypoxaemic patients). We undertook a systematic review and network meta-analysis (Research Registry: reviewregistry1435). PubMed, Embase, CENTRAL, Scopus and Web of Science were searched (from inception until 22 June 2022). Randomised controlled trials (RCTs) investigating the use of NRS after extubation in ICU adult patients were included. 32 RCTs entered the quantitative analysis (5063 patients). Compared with conventional oxygen therapy, NRS overall reduced re-intubations and VAP (moderate certainty). NIV decreased hospital mortality (moderate certainty), and hospital and ICU LOS (low and very low certainty, respectively), and increased discomfort (moderate certainty). Prophylactic NRS did not prevent extubation failure in low-risk or hypoxaemic patients. Prophylactic NRS may reduce the rate of post-extubation respiratory failure in ICU patients.

Neurally-adjusted ventilation superior to nasal CAP in preventing extubation failure

Neurally-adjusted ventilation superior to nasal CAP in preventing extubation failure

The Role of Prone Position Combined With Nasal CPAP in Preventing Extubation Failure in Infants After Cardiac Surgery

<h3>BACKGROUND:</h3> Previous studies suggest that prone position could improve oxygenation and prevent lung injury. Whether prone position can improve post-extubation clinical outcomes in infants undergoing cardiac surgery is unknown. The aim of our study was to investigate the effects of prone position in preventing extubation failure in noninvasively ventilated infants after cardiac surgery. <h3>METHODS:</h3> Ninety-six infants who were weaned to nasal CPAP after congenital cardiac surgery were randomly divided into 2 groups: the prone position group (<i>n</i> = 48) and the supine position group (<i>n</i> = 48). Primary outcomes measured were extubation failure rate within 48 h of extubation and arterial blood gas values within 6 h of a mandatory prone positioning session. Secondary outcomes included nasal trauma, pressure ulcers, pneumothorax, gastroesophageal reflux, abdominal distention, in-hospital mortality, postoperative nasal CPAP duration, and hospital length of stay. <h3>RESULTS:</h3> Compared with the supine position group, the prone position group had fewer extubation failure infants (2.0% vs 14.5%, <i>P</i> = .02). Arterial blood gas values after 6 h after a mandatory prone positioning session showed that the P_aO₂ and P_aO₂/F_IO₂ in the prone position group were significantly higher than those in the supine position group (P_aO₂ 93.3 ± 8.5 vs 82.5 ± 9.1 , <i>P</i> &lt; .05; P_aO₂/F_IO₂ 255.8 ± 23.6 vs 235.8 ± 20.7, <i>P</i> &lt; .05). Moreover, nasal CPAP duration and total hospital length of stay in the prone position group were significantly shorter than those in the supine position group (<i>P</i> &lt; .05). <h3>CONCLUSIONS:</h3> In infants supported with nasal CPAP following cardiac surgery, prone positioning improved postextubation oxygenation, helped reduced extubation failure, and reduced the duration of nasal CPAP ventilation and total hospital length of stay.

Noninvasive Respiratory Support Does Not Prevent Extubation Failure in High-Risk Norwood Patients.

OBJECTIVES:This study aims to determine whether bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) effectively mitigate the risk of extubation failure in children status post-Norwood procedure.DESIGN:Single-center, retrospective analysis. Extubation events were collected from January 2015 to July 2021. Extubation failure was defined as the need for reintubation within 48 hours of extubation. Demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations.SETTING:Pediatric cardiovascular ICU.PATIENTS:Neonates following Norwood procedure.INTERVENTIONS:Extubation following the Norwood procedure.MEASUREMENTS AND MAIN RESULTS:The analysis included 311 extubations. Extubation failure occurred in 31 (10%) extubation attempts within the first 48 hours. On univariate analysis, higher rate of extubation failure was observed when patients were extubated to CPAP/BiPAP relative to patients who were extubated to either high-flow nasal cannula (HFNC) or nasal cannula (NC) (16% vs 7.8%; p = 0.027). On multivariable analysis, the presence of vocal cord anomaly (odds ratio, 3.08; p = 0.005) and lower pre-extubation end-tidal co2 (odds ratio, 0.91; p = 0.006) were simultaneously associated with extubation failure while also controlling for the post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC).CONCLUSIONS:Clinicians should not rely on CPAP or BiPAP as the only supportive measure for a patient at increased risk of extubation failure. CPAP or BiPAP do not mitigate the risk of extubation failure in the Norwood patients. A multisite study is needed to generalize these conclusions.

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.

Identification and Prevention of Extubation Failure by Using an Automated Continuous Monitoring Alert Versus Standard Care.

Postextubation monitoring helps identify patients at risk of developing respiratory failure. This study aimed to evaluate the effect of our standard respiratory therapist (RT) assessment tool versus an automated continuous monitoring alert to initiate postextubation RT-driven care on the re-intubation rate. This was a single-center randomized clinical trial from March 2020 to September 2021 of adult subjects who received mechanical ventilation for > 24 h and underwent planned extubation in the ICU. The subjects were assigned to the standard RT assessment tool or an automated monitoring alert to identify the need for postextubation RT-driven care. The primary outcome was the need for re-intubation due to respiratory failure within 72 h. Secondary outcomes included re-intubation within 7 d, ICU and hospital lengths of stay, hospital mortality, ICU cost, and RT time associated with patient assessment and therapy provision. Of 234 randomized subjects, 32 were excluded from the primary analysis due to disruption in RT-driven care during the surge of patients with COVID-19, and 1 subject was excluded due to delay in the automated monitoring initiation. Analysis of the primary outcome included 85 subjects assigned to the standard RT assessment group and 116 assigned to the automated monitoring alert group to initiate RT-driven care. There was no significant difference between the study groups in re-intubation rate, median length of stay, mortality, or ICU costs. The RT time associated with patient assessment (P < .001) and therapy provided (P = .031) were significantly lower in the automated continuous monitoring alert group. In subjects who received mechanical ventilation for > 24 h, there were no significant outcome or cost differences between our standard RT assessment tool or an automated monitoring alert to initiate postextubation RT-driven care. Using an automated continuous monitoring alert to initiate RT-driven care saved RT time. (ClinicalTrials.gov registration NCT04231890).

A comparison of high-flow nasal cannula versus non-invasive positive pressure ventilation for respiratory support in infants following cardiac surgery.

Following cardiac surgery, infants often remain endotracheally intubated upon arrival to the cardiac ICU. High-flow nasal cannula and non-invasive positive pressure ventilation are used to support patients following extubation. There are limited data on the superiority of either mode to prevent extubation failure. We conducted a single-centre retrospective study for infants (<1 year) and/or <10 kg who underwent cardiac surgery between 3/2019-3/2020. Data included patient and clinical characteristics and operative variables. The study aimed to compare high-flow nasal cannula versus non-invasive positive pressure ventilation following extubation and their association with extubation failure. Secondarily, we examined risk factors associated with extubation failure. There were 424 patients who met inclusion criteria, 320 (75%) were extubated to high-flow nasal cannula, 104 (25%) to non-invasive positive pressure ventilation, and 64 patients (15%) failed extubation. The high-flow nasal cannula group had lower rates of extubation failure (11%, versus 29%, p = 0.001). Infants failing extubation were younger and had higher STAT score (p < 0.05). Compared to high-flow nasal cannula, non-invasive positive pressure ventilation patients were at 3.30 times higher odds of failing extubation after adjusting for patient factors (p < 0.0001). Extubation failure after cardiac surgery occurs in smaller, younger infants, and those with higher risk surgical procedures. Patients extubated to non-invasive positive pressure ventilation had 3.30 higher odds to fail extubation than patients extubated to high-flow nasal cannula. The optimal mode of respiratory support in this patient population is unknown.

Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery

This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). This was a single-center, randomized, unblinded clinical trial. The study was performed in a teaching hospital. Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.

Readiness Assessment for Extubation Planning in the Intensive Care Unit: A Quality Improvement Initiative.

Extubation failure is the reintubation of patients meeting criteria for weaning from mechanical ventilation. Extubation failure is correlated with mortality, prolonged mechanical ventilation, and longer hospital stays. Noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation is recommended to prevent extubation failure in high-risk patients. The extubation failure rate is unknown. Prophylactic measures (noninvasive ventilation or high-flow nasal cannula) after extubation are not commonly used and vary among clinicians. The objective was to assess extubation planning readiness by determining extubation failure rate, identifying high-risk patients, and determining prophylactic measure compliance. A quality improvement initiative included an evidence-based extubation failure risk assessment that identified high-risk patients and determined prophylactic measure compliance. A 2-year retrospective medical record review was used to determine baseline patient characteristics and extubation failure rate. Results Extubation failure rate within the retrospective cohort was 13 of 146 patients (8.9%). Extubation failure did not correlate with previously identified risk factors; however, 150 identified patients were excluded from analysis. During risk assessment integration, the extubation failure rate was 3 of 37 patients (8.1%) despite identifying 24 high-risk patients (65%). Few high-risk patients received prophylactic measures (noninvasive ventilation, 17%; high-flow nasal cannula, 12%). Extubation failure should be routinely measured because of its effects on patient outcomes. This project reveals the multifactorial nature of extubation failure. Further research is needed to assess patients' risk and account for acute conditions. This project used best practice guidelines for routine patient care and added transparency to a previously unmeasured event.

Protocol for a randomised controlled trial comparing two CPAP levels to prevent extubation failure in extremely preterm infants

IntroductionRespiratory distress syndrome is a complication of prematurity and extremely preterm infants born before 28 weeks’ gestation often require endotracheal intubation and mechanical ventilation. In this high-risk population, mechanical ventilation...

High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study.

We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Use of Dexamethasone to Prevent Extubation Failure in Pediatric Intensive Care Unit: A Randomized Controlled Clinical Trial.

Extubation failure is a common event in intensive care units. Corticosteroids are effective in preventing failure in adults, but no consensus has been reached on this matter in pediatrics. We assessed the efficacy of intravenous dexamethasone in mechanically ventilated children and adolescents for more than 48 hours, with at least one risk factor for failure. Extubations were scheduled 24 hours in advance when possible, and patients were randomly assigned into two groups: one group received a loading dose followed by up to four doses of dexamethasone, and the other group received no corticosteroids. Need for reintubation and length of stay in the pediatric intensive care unit were similar in both groups, and frequency of reintubation was 12.9%.

Heated humidified high flow nasal cannula versus nasal continuous positive airway pressure for respiratory support in extremely low birth weight preterm infants after extubation: a single centre randomized controlled trial

Background: The objective of the study was to assess the indications, frequency of usage, clinical efficacy, and safety of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (NCPAP) in extremely low birth weight preterm infants (ELBWI) after extubation.Methods: Hospital based prospective randomized control study involving ELBWI with respiratory distress admitted in NICU. In this study, all selected preterm infants were placed on one of the non-invasive respiratory supports (HHHFNC or NCPAP), after a period of positive pressure ventilation (post-extubation). Reintubation rate within 72 hours after initial extubation, duration of invasive ventilation, duration of non-invasive respiratory support, duration of supplemental oxygen, and time to reach full feeds were the primary outcome measures. Duration of total enteral feeding, average weight gain rate, duration of hospitalization, and complications including nasal injury, IVH, BPD, NEC, ROP, and PDA, were the secondary outcomes.Results: A sample size of 46 ELBWI were included. HHHFNC effectively reduced the incidence of nasal injury and NEC (p&lt;0.05) along with the decreased duration of supplementary oxygen. Additionally, HHHFNC achieved a significant advance in time to reach full enteral feeding; increased the average weight gain before discharge; reduced the duration of hospitalization (p&lt;0.05).Conclusions: HHHFNC was effective in preventing extubation failure in mechanically ventilated preterm ELBWI compared to NCPAP. HHHFNC shortens the duration of supplemental oxygen and significantly reduces the incidence of nasal injury and necrotizing enterocolitis; moreover, it can also reduce the duration of hospitalization and its cost.

Clinical variables associated to extubation failure in mexican pediatric patients

BackgroundFailure in extubation must be avoided in order to have a better outcome for patients. To understand when and how to extubate a patient, we need to take into account variables such as; blood gas analysis, nutritional state and more, is crucial so that we can lower the chances of reintubation and having a better outcome. MethodsAn observational, retrospective, monocentric study was performed, at the Pediatric Intensive Care Unit of the National Institute of Pediatrics in Mexico City. In the lapse between January to July 2018 we evaluated a total of 267 case files, from which 146 met the inclusion criteria. Results117 patients presented successful extubations, 29 presented extubation failure. The mean age was 7 years (85 months), with a range between 1.2 months and 126 months. In the multivariate analyses the presence of infectious, oncological, surgical diseases, being overweight and the use of post extubation dexamethasone presented significant differences. ConclusionWe did not find a physiologic indicator in particular for extubation failure, but the evaluation of the clinical state of the patient, in a close manner and daily was associated with a higher successful extubation. The use of blood gas parameters is not useful in preventing extubation failure.

Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: A systematic review and network meta-analysis.

Multiple noninvasive respiratory support (NRS) modalities are used for postextubation support in preterm neonates. Seven NRS modalities were compared-constant flow continuous positive airway pressure (CPAP) (CF-CPAP) (bubble CPAP; ventilator CPAP), variable flow CPAP (VF-CPAP), high flow nasal cannula (HFNC), synchronized noninvasive positive pressure ventilation (S-NIPPV), nonsynchronized NIPPV (NS-NIPPV), bilevel CPAP (BiPAP), noninvasive high-frequency oscillation ventilation (nHFOV). Systematic review and network meta-analysis (NMA) using the Bayesian random-effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched. Requirement of invasive mechanical ventilation within 7 days of extubation. A total of 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV, and VF-CPAP were more efficacious in preventing reintubation than CF-CPAP (risk ratio [RR] [95% credible intervals {CrI}]: 0.22 [0.12, 0.35]; 0.44 [0.27, 0.67]; 0.42 [0.18, 0.81]; 0.73 [0.52, 0.99]). Surface under the cumulative ranking curve (SUCRA) value ranked S-NIPPV to be the best postextubation intervention (SUCRA: 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP, and HFNC (RR [95% CrI]: 0.52 [0.24, 0.97]; 0.32 [0.14, 0.64]; 0.30 [0.16, 0.50]; 0.24 [0.12, 0.41]). NS-NIPPV resulted in lesser reintubation compared to VF-CPAP and HFNC (RR [95% CrI]: 0.61 [0.36, 0.97]; 0.49 [0.27, 0.80]). BiPAP, VF-CPAP, and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate. Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.

High-Flow Nasal Cannula versus Noninvasive Positive Pressure Ventilation in Patients with Heart Failure after Extubation: An Observational Cohort Study.

Noninvasive positive pressure ventilation (NPPV) has been widely applied in patients with high-risk extubation failure, including heart failure. High-flow nasal cannula (HFNC) has been demonstrated to benefit patients with heart failure by reducing cardiac preload. This study aimed to compare the effectiveness of HFNC to NPPV for preventing extubation failure in patients with heart failure. This 3-year retrospective and single-center cohort study included patients with heart failure with left ventricular ejection fraction <50% who received prophylactic HFNC or NPPV after scheduled extubation from January 2015 to January 2018 from a medical center with four adult intensive care units. Demographics, comorbidities, diagnosis, and weaning status were collected. The primary outcome was treatment failure within 72 hours after extubation, which was defined as escalation to NPPV or reintubation in the HFNC group and was defined as requiring reintubation in the NPPV group. Secondary outcomes were reintubation within 72 hours, reintubation, duration of stay, and mortality during the intensive care unit and hospital stay. Of the 104 patients analyzed, characteristics of 58 patients in the HFNC group and 46 patients in the NPPV group were compared. The treatment failure within 72 hours in the two groups was not significantly different (25.9% vs 13%, p=0.106). Hypoxemic respiratory failure related treatment failure was significantly higher in the HFNC group. Prophylactic HFNC as first-line therapy had a comparable rate of reintubation within 72 hours to the prophylactic NPPV alone (17.2% vs 13%, p=0.556). Other secondary outcomes were similar between the two groups. Among patients with heart failure, HFNC was not inferior to NPPV for preventing extubation failure and reintubation. However, in case of an impending respiratory failure, selective patients may benefit from rescue NPPV.

The Comparison of HHHFNC and NCPAP in Extremely Low-Birth-Weight Preterm Infants After Extubation: A Single-Center Randomized Controlled Trial.

Objectives: To compare the clinical efficacy of heated, humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (NCPAP) in extremely low-birth-weight preterm infants (ELBWI) after extubation.Methods: This trial included 94 extremely low-birth-weight infants (ELBWI), within 7 days after birth, and prepared for tracheal extubation and a change to non-invasive ventilation in the neonatal intensive care unit (NICU) admitted to our hospital from January 2015 to December 2018, with 48 infants in the HHHFNC group and 46 infants in the NCPAP group. Reintubation rate within 72 h after initial extubation, total ventilation time, non-invasive ventilation time, total oxygen inhalation time, and the time to reach full enteral feeding were the primary outcome measures. Total intestinal feeding time, average weight gain rate, days of hospitalization, costs of hospitalization, and complication rates, including nasal injury, IVH, BPD, NEC, ROP, and PDA, were used as secondary outcomes. Data were analyzed using Student's t-test or the Mann-Whitney U-test with a Chi-square test or Fisher's exact test, as appropriate, in SPSS (25.0).Results: HHHFNC not only shortened the oxygen exposure time but also effectively reduced the incidence of nasal injury (6.25 vs. 36.96%) and NEC (10.42 vs. 28.26%) (P < 0.05). Additionally, HHHFNC achieved a significant advance in the time to reach full enteral feeding (31.24 ± 11.35 vs. 34.21 ± 14.09 days); increased the average weight gain rate (16.07 ± 3.10 vs. 13.74 ± 4.21) and reduced the days of hospitalization (73.45 ± 18.84 vs. 79.24 ± 19.75), with a lower cost of hospitalization (16.04 ± 3.64 vs.18.79 ± 4.13) thousand dollars (all P < 0.05).Conclusions: Compared with NCPAP, HHHFNC was effective in preventing extubation failure in mechanically ventilated preterm ELBWI. HHHFNC shortens oxygen consumption time and significantly reduces the incidence of nasal injury and necrotizing enterocolitis; moreover, it can also reduce the length of stay and the hospitalization costs.

Reducing post-extubation failure rates in very preterm infants: is BiPAP better than CPAP?

Background and Aim Continuous positive airway pressure (CPAP) is currently used in neonates after mechanical ventilation though it may occasionally be associated with air leaks syndromes or it may fail to support the baby. The pressure difference offered by bilevel continuous positive distending pressure (BiPAP) respect to CPAP may be an advantage to the spontaneously breathing patient. In this study, we compared the efficacy of CPAP and BiPAP in the firstweek post-extubation in a series of very preterm infants. Methods Inborn neonates less than 30 weeks of gestational age who were intubated shortly after birth from January 2011 to December 2017 were enrolled in a retrospective study. The attending clinician assessed the patients for non-invasive respiratory support readiness and allocated them to CPAP (PEEP 4–6 cmH2O) or BiPAP (PEEP 4–5 cmH2O, rate 10–40; Thigh 0.7–1.2; upper-pressure level 8–10 cmH2O). Both techniques were compared for preventing extubation failure within 7 days from extubation as defined per local protocol (primary outcome). Secondary outcomes were: definitive failure of extubation, pneumothorax during non-invasive respiratory support, periventricular leukomalacia, bronchopulmonary dysplasia, sepsis, patent ductus arteriosus and retinopathy of prematurity at discharge. Results We enrolled 134 neonates; the CPAP group included 89 babies while 45 received BiPAP. Patients did not differ for their general characteristics (EG, antenatal steroids, incidence of SGA, maternal hypertension, surfactant replacement therapy). Short term extubation failure was significantly higher in the former group (23/89 in CPAP vs 5/45 in BiPAP; p = .005). No infant developed air leak syndrome. Secondary outcomes were comparable between groups. Multivariate analysis showed that on the whole population the extubation failure was correlated to the insurgence of late-onset sepsis. Conclusion BiPAP safely reduced early extubation failure compared to CPAP in our cohort of very preterm neonates within 7 days from extubation.

Early Identification and Prevention of Extubation Failure in Adults Using Integrated Pulmonary Index

Early Identification and Prevention of Extubation Failure in Adults Using Integrated Pulmonary Index