Elsevier

The Journal of Pediatrics

Volume 173, June 2016, Pages 45-49
The Journal of Pediatrics

Original Article
Extubating Extremely Preterm Infants: Predictors of Success and Outcomes following Failure

https://doi.org/10.1016/j.jpeds.2016.02.016Get rights and content

Objectives

To identify variables that predict extubation success in extremely preterm infants born <28 weeks gestational age (GA), and to compare outcomes between those who had successful or failed extubation.

Study design

A secondary analysis of data from a randomized trial of postextubation respiratory support that included 174 extremely preterm infants. “Extubation success” was defined as not requiring reintubation within 7 days, and “extubation failure” the converse. Predictive variables that were different between groups were included in a multivariable logistic regression model.

Results

Sixty-eight percent of infants were successfully extubated. Compared with those infants who had extubation failure, they had a higher GA and birth weight, were extubated earlier, were more often exposed to prolonged ruptured membranes, more often avoided intubation in the delivery room, had a higher pre-extubation pH, and had lower mean pre-extubation fraction of inspired oxygen and partial pressure of carbon dioxide (PCO2). Only GA and PCO2 remained significant in the multivariable analysis (area under a receiver operating characteristic curve = 0.81). Extubation failure was associated with death, bronchopulmonary dysplasia, severe retinopathy of prematurity, patent ductus arteriosus ligation, and longer durations of respiratory support, oxygen supplementation, and hospitalization. When adjusted for allocated treatment in the randomized trial, GA, and birth weight z-score, extubation failure remained associated with death before discharge and prolonged respiratory support and hospitalization.

Conclusions

In extremely preterm infants, higher GA and lower pre-extubation PCO2 predicted extubation success. Infants in whom extubation failed were more likely to die and have prolonged respiratory support and hospitalization.

Trial registration

Australian New Zealand Clinical Trials Network: ACTRN12610000166077.

Section snippets

Methods

Between 2010-2012, we performed a multicenter, randomized controlled trial comparing high-flow nasal cannula (HFNC) with starting gas flow 5-6 L per minute, depending on the prong size used, with nasal continuous positive airway pressure (CPAP) 7 cm of water (cm H2O) as postextubation support for very preterm infants.17 The trial was designed and conducted by the authors. The human research ethics committee at each center approved the trial. Infants were eligible if they were born <32 weeks GA,

Results

Of the 303 infants included in the randomized trial (recruited May 31, 2010, to July 3, 2012), 174 were extremely preterm and eligible for this analysis. Of these, 4 (2%) were born at 23 weeks GA, 31 (18%) at 24 weeks, 28 (16%) at 25 weeks, 54 (31%) at 26 weeks, and 57 (33%) at 27 weeks (Table I). Of the 174 extremely preterm infants, 118 (68%) infants were successfully extubated, and 56 (32%) had extubation failure. The reasons for extubation failure (more than 1 reason could be given) were

Discussion

In a cohort of extremely preterm infants who participated in a randomized trial, higher GA and lower pre-extubation PCO2 predicted extubation success. The area under a receiver operator characteristic curve for a model combining these 2 predictive variables was 0.81, indicating that on average those who failed extubation would have a more abnormal test result using this model than 81% of those who did not fail extubation. Infants in our cohort who had extubation failure were more likely to die

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Funded by the National Health and Medical Research Council (606789). The authors declare no conflicts of interest.

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