Markers of successful extubation in extremely preterm infants, and morbidity after failed extubation
Chawla, S., Natarajan, G., Shankaran, S., Carper, B., Brion, L. P., Keszler, M., Carlo, W. A., Ambalavanan, N., Gantz, M. G., Das, A., Finer, N., Goldberg, R. N., Cotten, C. M., Higgins, R. D., & Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (2017). Markers of successful extubation in extremely preterm infants, and morbidity after failed extubation. Journal of Pediatrics, 189, 113-121. Advance online publication. https://doi.org/10.1016/j.jpeds.2017.04.050
OBJECTIVES: To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.
STUDY DESIGN: This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 24(0/7) to 27(6/7) weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.
RESULTS: Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).
CONCLUSIONS: Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.
TRIAL REGISTRATION: ClinicalTrials.gov: NCT00233324.