Deciphering extubation failure in extremely preterm infants: Time to embrace complexity and move forward

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 is associated with lung injury and contributes to bronchopulmonary dysplasia. Therefore, clinicians attempt to extubate infants as quickly and use non-invasive respiratory support such as nasal continuous positive airway pressure (CPAP) to facilitate the transition. However, approximately 60% of extremely preterm infants experience ‘extubation failure’ and require reintubation. While CPAP pressures of 5–8 cm H2O are commonly used, the optimal CPAP pressure is unknown, and higher pressures may be beneficial in avoiding extubation failure. Our trial is the Extubation CPAP Level Assessment Trial (ÉCLAT). The aim of this trial is to compare higher CPAP pressures 9–11 cm H2O with a current standard pressures of 6–8 cmH2O on extubation failure in extremely preterm infants.Methods and analysis200 extremely preterm infants will be recruited prior to their first extubation from mechanical ventilation to CPAP. This is a parallel group randomised controlled trial. Infants will be randomised to one of two set CPAP pressures: CPAP 10 cmH2O (intervention) or CPAP 7 cmH2O (control). The primary outcome will be extubation failure (reintubation) within 7 days. Statistical analysis will follow standard methods for randomised trials on an intention to treat basis. For the primary outcome, this will be by intention to treat, adjusted for the prerandomisation strata (GA and centre). We will use the appropriate parametric and non-parametric statistical tests.Ethics and disseminationEthics approval has been granted by the Monash Health Human Research Ethics Committees. Amendments to the trial protocol will be submitted for approval. The findings of this study will be written into a clinical trial report manuscript and disseminated via peer-reviewed journals (on-line or in press) and presented at national and international conferences.Trial registration numberACTRN12618001638224; pre-results.

Download Full-text

Respiratory Setback Associated with Extubation Failure in Extremely Preterm Infants

10.22541/au.160559284.41967580/v1 ◽

2020 ◽

Author(s):

Dhruv Gupta ◽

Rachel Greenberg ◽

Girija Natarajan ◽

Sanket Jani ◽

Amit Sharma ◽

...

Keyword(s):

Preterm Infants ◽

Severity Score ◽

Extubation Failure ◽

Limited Evidence ◽

Respiratory Status ◽

Risk Of Mortality ◽

Increased Risk ◽

Extremely Preterm ◽

Extremely Preterm Infants ◽

Blood Gas Parameters

Background and Objectives: Extubation failure in preterm infants is associated with increased risk of mortality and morbidities. 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. Methods: This was a retrospective study of infants with birth weight ≤1,250 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 and ventilation index were used to assess respiratory status of infants. Results: Of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77% and 56% infants remained intubated at 24 hours, 72 hours and 7 days, respectively. Respiratory status was worse at 24 hours and 72 hours after re-intubation when compared to pre-extubation levels. The median times for respiratory severity score and ventilation index to reach pre-extubation levels were 4 days and 7 days respectively. Conclusion: 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.

Download Full-text

Respiratory setback associated with extubation failure in extremely preterm infants

Pediatric Pulmonology ◽

10.1002/ppul.25387 ◽

2021 ◽

Author(s):

Dhruv Gupta ◽

Rachel G. Greenberg ◽

Girija Natarajan ◽

Sanket Jani ◽

Amit Sharma ◽

...

Keyword(s):

Preterm Infants ◽

Extubation Failure ◽

Extremely Preterm ◽

Extremely Preterm Infants

Download Full-text

Predictors and outcomes of extubation failure in extremely preterm infants

Journal of Paediatrics and Child Health ◽

10.1111/jpc.15356 ◽

2021 ◽

Author(s):

Anna Madeline Kidman ◽

Brett J Manley ◽

Rosemarie A Boland ◽

Peter G Davis ◽

Risha Bhatia

Keyword(s):

Preterm Infants ◽

Extubation Failure ◽

Extremely Preterm ◽

Extremely Preterm Infants

Download Full-text

Mortality in Extremely Preterm Infants Are Strongly Associated with NEC: Data from Czech Neonatal Network

10.1055/s-0039-1693258 ◽

2019 ◽

Author(s):

J. Smisek

Keyword(s):

Preterm Infants ◽

Extremely Preterm ◽

Extremely Preterm Infants

Download Full-text

Life expectancy of extremely preterm infants

Orvosi Hetilap ◽

10.1556/oh.2007.28098 ◽

2007 ◽

Vol 148 (48) ◽

pp. 2279-2284 ◽

Cited By ~ 1

Author(s):

Gabriella Vida ◽

Ilona Sárkány ◽

Simone Funke ◽

Judit Gyarmati ◽

Judit Storcz ◽

...

Keyword(s):

Life Expectancy ◽

Preterm Infants ◽

Extremely Preterm ◽

Extremely Preterm Infants

Optimális esetben a 24–28. gesztációs hét közötti, igen éretlen újszülöttek olyan szülészeti intézményben születnek, ahol neonatalis intenzív centrum működik, így mind az akut, mind a hosszú távú ellátásukat magas színvonalon biztosítják. A PTE OEKK ÁOK Szülészeti és Nőgyógyászati Klinikán 2000. január 1. és 2004. december 31. között 7499 újszülött született. A koraszülési frekvencia 20% (1499/7499), ezen belül az extrém alacsony gesztációs korúak aránya (≦28. gesztációs hét) 18% (272/1499), míg a 25. gesztációs hét alattiaké 3,2% (48/1499) volt. A túlélés a gesztációs hetek emelkedésével fokozatosan javul. Az életben maradt koraszülöttek későbbi életkilátásai és társadalmi beilleszkedése függ az olyan maradandó károsodásoktól, mint a látáscsökkenés, halláskárosodás, somatomentalis fejlődés zavarai, krónikus tüdőbetegség. A klinikán vizsgált alacsony gesztációs korú csoportban az összes fogyatékkal élő betegek aránya 15,3%. Döntő többségük a 25. gesztációs hétnél korábban született koraszülöttek közül kerül ki. A 26. gesztációs héttől a koraszülöttek több mint fele tartós károsodás nélkül éli túl az extrém éretlenség társuló problémáit. Megállapították, hogy a korai koponya-ultrahangvizsgálattal, szemészeti szűréssel, otoacusticus emissio mérésével jól prognosztizálhatók a maradandó károsodások, így lehetővé válik a korai kezelés.

Download Full-text