Age at First Extubation Attempt and Death or Respiratory Morbidities in Extremely Preterm Infants.

OBJECTIVE: To describe the timing of first extubation in extremely preterm infants and explore the relationship between age at first extubation, extubation outcome, and death or respiratory morbidities. STUDY DESIGN: In this subanalysis of a multicenter observational study, infants with birth weights of 1250 g or less and intubated within 24 hours of birth were included. After describing the timing of first extubation, age at extubation was divided into early (within 7 days from birth) vs late (days of life 8-35), and extubation outcome was divided into success vs failure (reintubation within 7 days after extubation), to create 4 extubation groups: early success, early failure, late success, and late failure. Logistic regression analyses were performed to evaluate associations between the 4 groups and death or bronchopulmonary dysplasia, bronchopulmonary dysplasia among survivors, and durations of respiratory support and oxygen therapy. RESULTS: Of the 250 infants included, 129 (52%) were extubated within 7 days, 93 (37%) between 8 and 35 days, and 28 (11%) beyond 35 days of life. There were 93, 36, 59, and 34 infants with early success, early failure, late success, and late failure, respectively. Although early success was associated with the lowest rates of respiratory morbidities, early failure was not associated with significantly different respiratory outcomes compared with late success or late failure in unadjusted and adjusted analyses. CONCLUSIONS: In a contemporary cohort of extremely preterm infants, early extubation occurred in 52% of infants, and only early and successful extubation was associated with decreased respiratory morbidities. Predictors capable of promptly identifying infants with a high likelihood of early extubation success or failure are needed.

Cardiorespiratory measures shortly after extubation and extubation outcomes in extremely preterm infants.

BACKGROUND: Nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation, and non-invasive neurally adjusted ventilatory assist are modes of non-invasive respiratory support. The objective was to investigate if cardiorespiratory measures performed shortly after extubation are associated with extubation outcomes and predictors of extubation success. METHODS: Randomized crossover trial of infants with birth weight (BW) ≤ 1250 g undergoing their first extubation. Shortly after extubation, electrocardiogram and electrical activity of the diaphragm (Edi) were recorded during 40 min on each mode. Measures of heart rate variability (HRV), diaphragmatic activity (Edi area, breath area and amplitude), and respiratory variability (RV) were computed on each mode and compared between infants with extubation success or failure (reintubation ≤ 7 days). RESULTS: Twenty-three extremely preterm infants with median [IQR] gestational age 25.9 weeks [25.2-26.4] and BW 760 g [595-900] were included: 14 success and 9 failures. There were significant differences for HRV (very low-frequency power and sample entropy) and RV parameters (breath areas, amplitudes and expiratory times) between groups, with moderate strength (0.75-0.80 areas under ROC curves) in predicting success. Diaphragmatic activity measures were similar between groups. CONCLUSIONS: In extremely preterm infants receiving non-invasive respiratory support shortly after extubation, several cardiorespiratory variability parameters were associated with successful extubation with moderate predictive accuracy. IMPACT: Measures of cardiorespiratory variability, performed in extremely preterm infants while receiving NCPAP, NIPPV, and NIV-NAVA shortly after extubation, were significantly different between patients that succeeded or failed extubation. Cardiorespiratory variability measures had a moderate predictive accuracy for extubation success and can be potentially used as biomarkers, in recently extubated infants. Future investigations in this population may also consider including cardiorespiratory variability measures when assessing types of post-extubation respiratory support and promote individualized care.

Automated prediction of extubation success in extremely preterm infants: the APEX multicenter study.

BACKGROUND: Extremely preterm infants are frequently subjected to mechanical ventilation. Current prediction tools of extubation success lacks accuracy. METHODS: Multicenter study including infants with birth weight ≤1250 g undergoing their first extubation attempt. Clinical data and cardiorespiratory signals were acquired before extubation. Primary outcome was prediction of extubation success. Automated analysis of cardiorespiratory signals, development of clinical and cardiorespiratory features, and a 2-stage Clinical Decision-Balanced Random Forest classifier were used. A leave-one-out cross-validation was done. Performance was analyzed by ROC curves and determined by balanced accuracy. An exploratory analysis was performed for extubations before 7 days of age. RESULTS: A total of 241 infants were included and 44 failed (18%) extubation. The classifier had a balanced accuracy of 73% (sensitivity 70% [95% CI: 63%, 76%], specificity 75% [95% CI: 62%, 88%]). As an additional clinical-decision tool, the classifier would have led to an increase in extubation success from 82% to 93% but misclassified 60 infants who would have been successfully extubated. In infants extubated before 7 days of age, the classifier identified 16/18 failures (specificity 89%) and 73/105 infants with success (sensitivity 70%). CONCLUSIONS: Machine learning algorithms may improve a balanced prediction of extubation outcomes, but further refinement and validation is required. IMPACT: A machine learning-derived predictive model combining clinical data with automated analyses of individual cardiorespiratory signals may improve the prediction of successful extubation and identify infants at higher risk of failure with a good balanced accuracy. Such multidisciplinary approach including medicine, biomedical engineering and computer science is a step forward as current tools investigated to predict extubation outcomes lack sufficient balanced accuracy to justify their use in future trials or clinical practice. Thus, this individualized assessment can optimize patient selection for future trials of extubation readiness by decreasing exposure of low-risk infants to interventions and maximize the benefits of those at high risk.

Wireless monitoring devices in hospitalized children: a scoping review.

The purpose of this study is to provide a structured overview of existing wireless monitoring technologies for hospitalized children. A systematic search of the literature published after 2010 was conducted in Medline, Embase, Scielo, Cochrane, and Web of Science. Two investigators independently reviewed articles to determine eligibility for inclusion. Information on study type, hospital setting, number of participants, use of a reference sensor, type and number of vital signs monitored, duration of monitoring, type of wireless information transfer, and outcomes of the wireless devices was extracted. A descriptive analysis was applied. Of the 1130 studies identified from our search, 42 met eligibility for subsequent analysis. Most included studies were observational studies with sample sizes of 50 or less published between 2019 and 2022. Common problems pertaining to study methodology and outcomes observed were short duration of monitoring, single focus on validity, and lack information on wireless transfer and data management.  Conclusion: Research on the use of wireless monitoring for children in hospitals has been increasing in recent years but often limited by methodological problems. More rigorous studies are necessary to establish the safety and accuracy of novel wireless monitoring devices in hospitalized children. What is Known: • Continuous monitoring of vital signs using wired sensors is the standard of care for hospitalized pediatric patients. However, the use of wires may pose significant challenges to optimal care. What is New: • Interest in wireless monitoring for hospitalized pediatric patients has been rapidly growing in recent years. • However, most devices are in early stages of clinical testing and are limited by inconsistent clinical and technological reporting.

Organizational Risk Factors and Clinical Impacts of Unplanned Extubation in the Neonatal Intensive Care Unit.

OBJECTIVES: To assess the association between organizational factors and unplanned extubation events in the neonatal intensive care unit (NICU) and to evaluate the association between unplanned extubation event and bronchopulmonary dysplasia (BPD) among infants born at <29 weeks of gestational age. STUDY DESIGN: This is a retrospective cohort study of infants admitted to a tertiary care NICU between 2016 and 2019. Nursing provision ratios, daily nursing overtime hours/total nursing hours ratio, and unit occupancy were compared between days with and days without unplanned extubation events. The association between unplanned extubation events (with and without reintubation) and the risk of BPD was evaluated in infants born at <29 weeks who required mechanical ventilation using a propensity score-matched cohort. Multivariable logistic regression analysis was used to assess the association between exposures and outcomes while adjusting for confounders. RESULTS: On 108 of 1370 days there was ≥1 unplanned extubation event for a total of 116 unplanned extubation event events. Higher median nursing overtime hours (20 hours vs 16 hours) and overtime ratios (3.3% vs 2.5%) were observed on days with an unplanned extubation event compared with days without an unplanned extubation event (P = .01). Overtime ratio was associated with higher adjusted odds of a unplanned extubation event (aOR, 1.09; 95% CI, 1.01-1.18). In the subgroup of infants born at <29 weeks, those with an unplanned extubation event who were reintubated had a longer postmatching duration of mechanical ventilation (aOR, 13.06; 95% CI, 4.88-37.69) and odds of BPD (aOR, 2.86; 95% CI, 1.01-8.58) compared with those without an unplanned extubation event. CONCLUSIONS: Nursing overtime ratio is associated with an increased number of unplanned extubation events in the NICU. In infants born at <29 weeks of gestational age, reintubation after an unplanned extubation event is associated with a longer duration of mechanical ventilation and increased risk of BPD.

Diaphragmatic activity and neural breathing variability during a 5-min endotracheal continuous positive airway pressure trial in extremely preterm infants.

BACKGROUND: Extremely preterm infants are often exposed to endotracheal tube continuous positive airway pressure (ETT-CPAP) trials to assess extubation readiness. The effects of ETT-CPAP trial on their diaphragmatic activity (Edi) and breathing variability is unknown. METHODS: Prospective observational study enrolling infants with birth weight ≤1250 g undergoing their first extubation attempt. Diaphragmatic activity, expressed as the absolute minimum (Edi min) and maximum values (Edi max), area under the Edi signal, and breath-by-breath analyses for breath areas, amplitudes, widths, and neural inspiratory and expiratory times, were analyzed during mechanical ventilation (MV) and ETT-CPAP. Neural breathing variability of each of these parameters was also calculated and compared between MV and ETT-CPAP. RESULTS: Thirteen infants with median (interquartile range) birth weight of 800 g [610-920] and gestational age of 25.4 weeks [24.4-26.3] were included. Diaphragmatic activity significantly increased during ETT-CPAP when compared to MV:Edi max (44.2 vs. 38.1 µV), breath area (449 vs. 312 µV·s), and amplitude (10.12 vs. 7.46 µV). Neural breathing variability during ETT-CPAP was characterized by increased variability for amplitude and area under the breath, and decreased for breath time and width. CONCLUSIONS: A 5-min ETT-CPAP in extremely preterm infants undergoing extubation imposed significant respiratory load with changes in respiratory variability. IMPACT: ETT-CPAP trials are often used to assess extubation readiness in extremely preterm infants, but its effects upon their respiratory system are not well known. Diaphragmatic activity analysis demonstrated that these infants are able to mount an important response to a short trial. A 5-min trial imposed a significant respiratory load evidenced by increased diaphragmatic activity and changes in breathing variability. Differences in breathing variability were observed between successful and failed extubations, which should be explored further in extubation readiness investigations. This type of trial cannot be recommended for preterm infants in clinical practice until clear standards and accuracy are established.

Cardiorespiratory behavior of preterm infants receiving continuous positive airway pressure and high flow nasal cannula post extubation: randomized crossover study.

BACKGROUND: Nasal continuous positive airway pressure (NCPAP) and high flow nasal cannula (HFNC) are modes of non-invasive respiratory support commonly used after extubation in extremely preterm infants. However, the cardiorespiratory physiology of these infants on each mode is unknown. METHODS: Prospective, randomized crossover study in infants with birth weight ≤1250 g undergoing their first extubation attempt. NCPAP and HFNC were applied randomly for 45 min each, while ribcage and abdominal movements, electrocardiogram, oxygen saturation, and fraction of inspired oxygen (FiO2) were recorded. Respiratory signals were analyzed using an automated method, and differences between NCPAP and HFNC features and changes in FiO2 were analyzed. RESULTS: A total of 30 infants with median [interquartile range] gestational age of 27 weeks [25.7, 27.9] and birth weight of 930 g [780, 1090] were studied. Infants were extubated at 5 days [2, 13] of life with 973 g [880, 1170] and three failed (10%). No differences in cardiorespiratory behavior were noted, except for longer respiratory pauses (9.2 s [5.0, 11.5] vs. 7.3 s [4.6, 9.3]; p = 0.04) and higher FiO2 levels (p = 0.02) during HFNC compared to NCPAP. CONCLUSIONS: In extremely preterm infants studied shortly after extubation, the use of HFNC was associated with longer respiratory pauses and higher FiO2 requirements.

COVID-19 and Neonatal Respiratory Care: Current Evidence and Practical Approach.

The novel coronavirus disease 2019 (COVID-19) pandemic has urged the development and implementation of guidelines and protocols on diagnosis, management, infection control strategies, and discharge planning. However, very little is currently known about neonatal COVID-19 and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infections. Thus, many questions arise with regard to respiratory care after birth, necessary protection to health care workers (HCW) in the delivery room and neonatal intensive care unit (NICU), and safety of bag and mask ventilation, noninvasive respiratory support, deep suctioning, endotracheal intubation, and mechanical ventilation. Indeed, these questions have created tremendous confusion amongst neonatal HCW. In this manuscript, we comprehensively reviewed the current evidence regarding COVID-19 perinatal transmission, respiratory outcomes of neonates born to mothers with COVID-19 and infants with documented SARS-CoV-2 infection, and the evidence for using different respiratory support modalities and aerosol-generating procedures in this specific population. The results demonstrated that to date, neonatal COVID-19 infection is uncommon, generally acquired postnatally, and associated with favorable respiratory outcomes. The reason why infants display a milder spectrum of disease remains unclear. Nonetheless, the risk of severe or critical illness in young patients exists. Currently, the recommended respiratory approach for infants with suspected or confirmed infection is not evidence based but should include all routinely used types of support, with the addition of viral filters, proper personal protective equipment, and placement of infants in isolation rooms, ideally with negative pressure. As information is changing rapidly, clinicians should frequently watch out for updates on the subject. KEY POINTS: · Novel coronavirus disease 2019 (COVID-19) pandemic urged development of guidelines.. · Neonatal COVID-19 disease is uncommon.. · Respiratory outcomes in neonates seems favorable.. · Current neonatal respiratory care should continue.. · Clinicians should watch frequently for updates..

Predictors of Severe Neurologic Injury on Ultrasound Scan of the Head and Risk Factor-based Screening for Infants Born Preterm.

OBJECTIVE: To identify risk factors for severe neurologic injury (intraventricular hemorrhage grade 3 or greater and/or periventricular leukomalacia) diagnosed by ultrasound scan of the head among infants born at 300-326 weeks of gestation and compare different screening strategies. STUDY DESIGN: This was a retrospective cohort study of infants born at 300-326 weeks or >326 weeks of gestation with a birth weight <1500 g admitted to neonatal intensive care units in the Canadian Neonatal Network from 2011 to 2016. Stepwise logistic regression analysis was used to identify significant risk factors and calculate aORs and 95% CIs. Risk factor-based screening strategies were compared. RESULTS: The rate of severe neurologic injury was 3.1% among infants screened (285/9221). Significant risk factors included singleton birth (aOR 1.96, 95% CI 1.35-2.85), 5-minute Apgar <7 (aOR 1.81, 95% CI 1.30-2.50), mechanical ventilation on day 1 (aOR 2.65, 95% CI 1.88-3.71), and treatment with vasopressors on day 1 (aOR 3.23, 95% CI 2.19-4.75). Risk categories were low (no risk factor, 1.2%, 25/2137), moderate (singleton with no other risk factor: 1.8%, 68/3678), and high (≥1 risk factor among 5-minute Apgar <7, receipt of vasopressors or mechanical ventilation on day 1: 5.6%, 192/3408). Screening moderate- to high-risk infants identified 91% (260/285) of infants with severe neurologic injury and would require screening fewer infants (1647 infants per year) than screening all infants <33 weeks of gestation (2064 infants screened per year, 93% [265/285] of cases identified). CONCLUSIONS: Risk factor-based ultrasound scan of the head screening among infants born at 30-32 weeks of gestation could help optimize resources better than gestational age based screening.

The Impact of Time Interval between Extubation and Reintubation on Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants.

OBJECTIVE: To explore the relation between time to reintubation and death or bronchopulmonary dysplasia (BPD) in extremely preterm infants. STUDY DESIGN: This was a subanalysis from an ongoing multicenter observational study. Infants with birth weight ≤1250 g, requiring mechanical ventilation, and undergoing their first elective extubation were prospectively followed throughout hospitalization. Time to reintubation was defined as the time interval between first elective extubation and reintubation. Univariate and multivariate logistic regression analyses were performed to evaluate associations between time to reintubation, using different observation windows after extubation (24-hour intervals), and death/BPD (primary outcome) or BPD among survivors (secondary outcome). aORs were computed with and without the confounding effects of cumulative mechanical ventilation duration. RESULTS: Of 216 infants included for analysis, 103 (48%) were reintubated at least once after their first elective extubation. Reintubation was associated with lower gestational age/weight and greater morbidities compared with infants never reintubated. After adjusting for confounders, reintubation within observation windows ranging between 24 hours and 3 weeks postextubation was associated with increased odds of death/BPD (but not BPD among survivors), independent of the cumulative mechanical ventilation duration. Reintubation within 48 hours from extubation conferred higher risk-adjusted odds of death/BPD vs other observation windows. CONCLUSIONS: Although reintubation after elective extubation was independently associated with increased likelihood of death/BPD in extremely preterm infants, the greatest risk was attributable to reintubation within the first 48 hours postextubation. Prediction models capable of identifying the highest-risk infants may further improve outcomes.

Patterns of reintubation in extremely preterm infants: a longitudinal cohort study.

BackgroundThe optimal approach for reporting reintubation rates in extremely preterm infants is unknown. This study aims to longitudinally describe patterns of reintubation in this population over a broad range of observation windows following extubation.MethodsTiming and reasons for reintubation following a first planned extubation were collected from infants with birth weight ≤1,250 g. An algorithm was generated to discriminate between reintubations attributable to respiratory and non-respiratory causes. Frequency and cumulative distribution curves were constructed for each category using 24 h intervals. The ability of observation windows to capture respiratory-related reintubations while limiting non-respiratory reasons was assessed using a receiver operating characteristic curve.ResultsOut of 194 infants, 91 (47%) were reintubated during hospitalization; 68% for respiratory and 32% for non-respiratory reasons. Respiratory-related reintubation rates steadily increased from 0 to 14 days post-extubation before reaching a plateau. In contrast, non-respiratory reintubations were negligible in the first post-extubation week, but became predominant after 14 days. An observation window of 7 days captured 77% of respiratory-related reintubations while only including 14% of non-respiratory cases.ConclusionReintubation patterns are highly variable and affected by the reasons for reintubation and observation window used. Ideally, reintubation rates should be reported using a cumulative distribution curve over time.

Prediction of Extubation readiness in extremely preterm infants by the automated analysis of cardiorespiratory behavior: study protocol.

BACKGROUND: Extremely preterm infants (≤ 28 weeks gestation) commonly require endotracheal intubation and mechanical ventilation (MV) to maintain adequate oxygenation and gas exchange. Given that MV is independently associated with important adverse outcomes, efforts should be made to limit its duration. However, current methods for determining extubation readiness are inaccurate and a significant number of infants fail extubation and require reintubation, an intervention that may be associated with increased morbidities. A variety of objective measures have been proposed to better define the optimal time for extubation, but none have proven clinically useful. In a pilot study, investigators from this group have shown promising results from sophisticated, automated analyses of cardiorespiratory signals as a predictor of extubation readiness. The aim of this study is to develop an automated predictor of extubation readiness using a combination of clinical tools along with novel and automated measures of cardiorespiratory behavior, to assist clinicians in determining when extremely preterm infants are ready for extubation. METHODS: In this prospective, multicenter observational study, cardiorespiratory signals will be recorded from 250 eligible extremely preterm infants with birth weights ≤1250 g immediately prior to their first planned extubation. Automated signal analysis algorithms will compute a variety of metrics for each infant, and machine learning methods will then be used to find the optimal combination of these metrics together with clinical variables that provide the best overall prediction of extubation readiness. Using these results, investigators will develop an Automated system for Prediction of EXtubation (APEX) readiness that will integrate the software for data acquisition, signal analysis, and outcome prediction into a single application suitable for use by medical personnel in the neonatal intensive care unit. The performance of APEX will later be prospectively validated in 50 additional infants. DISCUSSION: The results of this research will provide the quantitative evidence needed to assist clinicians in determining when to extubate a preterm infant with the highest probability of success, and could produce significant improvements in extubation outcomes in this population. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01909947 . Registered on July 17 2013. Trial sponsor: Canadian Institutes of Health Research (CIHR).

The use of mechanical ventilation protocols in Canadian neonatal intensive care units.

OBJECTIVES: To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols. METHODS: A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013. RESULTS: Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]). CONCLUSION: Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.

OBJECTIFS: Déterminer la proportion d'unités de soins intensifs néonatales canadiennes disposant de protocoles de ventilation mécanique ainsi que les caractéristiques et les pratiques de soins respiratoires des unités qui ont adopté ces protocoles. MÉTHODOLOGIE: Les chercheurs ont posté un sondage structuré comportant 36 questions sur les protocoles de ventilation mécanique et les pratiques de soins respiratoires aux directeurs médicaux de toutes les unités néonatales de soins tertiaires du Canada et les ont fait circuler entre décembre 2012 et mars 2013. RÉSULTATS: Vingt-quatre des 32 unités ont répondu au sondage (75 %). Parmi les répondants, 91 % étaient des directeurs médicaux et 71 % travaillaient dans un hôpital universitaire. Neuf unités (38 %) avaient au moins un type de protocole de ventilation mécanique, généralement pour la phase aiguë et le sevrage. Les unités disposant déjà de protocoles étaient surtout affiliées à une université et présentaient des ratios plus élevés de patients sous respirateur par médecin ou par inhalothérapeute, sans toutefois que cette observation soit statistiquement significative. La présence d'un protocole de ventilation mécanique était fortement corrélée avec la coexistence d'un protocole de ventilation non invasive (P<0,001, RC 4,5 [95 % IC 1,3 à 15,3]). Dans l'ensemble, les pratiques de ventilation étaient très variables entre les unités. Cependant, les unités disposant de protocoles de ventilation mécanique étaient significativement plus susceptibles d'extuber les nouveau-nés du mode de contrôle assisté (P=0,039, RC 8,25 [95 % IC 1,2 à 59]). CONCLUSION: Malgré l'absence de preuves convaincantes pour en soutenir l'utilisation chez les nouveau-nés, un nombre considérable d'unités des soins intensifs néonatales canadiennes a adopté des protocoles de ventilation mécanique. Il faudra d'autres recherches pour mieux en comprendre le rôle dans la réduction des variations de pratique inutiles et l'amélioration des résultats à court et à long terme.

Weaning from mechanical ventilation and assessment of extubation readiness.

Tremendous advancements in neonatal respiratory care have contributed to the improved survival of extremely preterm infants (gestational age ≤ 28 weeks). While mechanical ventilation is often considered one of the most important breakthroughs in neonatology, it is also associated with numerous short and long-term complications. For those reasons, clinical research has focused on strategies to avoid or reduce exposure to mechanical ventilation. Nonetheless, in the extreme preterm population, 70-100% of infants born 22-28 weeks of gestation are exposed to mechanical ventilation, with nearly 50% being ventilated for ≥ 3 weeks. As contemporary practices have shifted towards selectively reserving mechanical ventilation for those patients, mechanical ventilation weaning and extubation remain a priority yet offer a heightened challenge for clinicians. In this review, we will summarize the evidence for different strategies to expedite weaning and assess extubation readiness in preterm infants, with a particular focus on extremely preterm infants.

Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD.

BACKGROUND: A multidisciplinary comprehensive protocol to use bubble continuous positive airway pressure (bCPAP) as the primary respiratory support in the delivery room (DR) and the NICU was introduced. With this study, we aimed to assess the association of this change with respiratory outcomes over time. METHODS: Infants with gestational age <32 weeks and birth weight <1250 g admitted between January 2012 and June 2020 were included and categorized into 4 periods, including pre-implementation (P0: 2012-2014), and post-implementation (P1: 2014-2016, P2: 2016-2018, P3: 2018-2020). The primary outcome was the rates of death and severe bronchopulmonary dysplasia (BPD), and the secondary outcomes included the rates of DR and NICU intubation ≤7 days of age, need of surfactant, and pneumothorax. Multivariate logistic regression models accounting for relevant risk factors were used to calculate adjusted odds ratios (ORs). RESULTS: The study included 440 infants (P0 = 90, P1 = 91, P2 = 128, P3 = 131). Over time, more infants were free of BPD (P < .001), and the rates of death and severe BPD decreased significantly: P1 = OR 1.21 (95% confidence interval [CI] 0.56-2.67), P2 = OR 0.45 (95% CI 0.20-0.99), and P3 = OR 0.37 (95% CI 0.15-0.84). DR intubation decreased from 66% (P0) to 24% (P3) in the entire cohort (P < .001) and from 96% (P0) to 40% (P3) in infants <26 weeks of age (P < .001). The need for NICU intubation was similar (P = .98), with a decreased need for surfactant (P = .001) occurring at higher FiO2 (P0 = 0.35 vs P3 = 0.55, P < .001). Pneumothorax rates were unchanged. CONCLUSIONS: In very preterm infants, the implementation of a comprehensive bCPAP protocol led to a significant and consistent improvement in respiratory practices and the rates of death and severe BPD.

Optimal timing of extubation in preterm infants.

In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants.

Clinical usefulness of reintubation criteria in extremely preterm infants: a cohort study.

OBJECTIVE: To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions. DESIGN: Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018. SETTING: Multicentre (three neonatal intensive care units). PATIENTS: Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included. INTERVENTIONS: After extubation, hourly O2 requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first. MAIN OUTCOME MEASURES: Thresholds at reintubation were described and grouped into four categories: increased O2, respiratory acidosis, frequent cardiorespiratory events and severe cardiorespiratory events (requiring positive pressure ventilation). An automated algorithm was used to generate multiple combinations of criteria from the four categories and compute their accuracies in capturing reintubated infants (sensitivity) without including non-reintubated infants (specificity). RESULTS: 55 infants were reintubated (median gestational age 25.2 weeks (IQR 24.5-26.1 weeks), birth weight 750 g (IQR 640-880 g)), with highly variable thresholds at reintubation. After extubation, reintubated infants had significantly greater O2 needs, lower pH, higher pCO2 and more frequent and severe cardiorespiratory events compared with non-reintubated infants. After evaluating 123 374 combinations of reintubation criteria, Youden indices ranged from 0 to 0.46, suggesting low accuracy. This was primarily attributable to the poor agreement between clinicians on the number of cardiorespiratory events at which to reintubate. CONCLUSIONS: Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.