Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

Sanjay Chawla; Girija Natarajan; Seetha Shankaran; Benjamin Carper; Luc P Brion; Martin Keszler; Waldemar A Carlo; Namasivayam Ambalavanan; Marie G Gantz; Abhik Das; Neil Finer; Ronald N Goldberg; C Michael Cotten; Rosemary D Higgins; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network

doi:10.1016/j.jpeds.2017.04.050

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

J Pediatr. 2017 Oct:189:113-119.e2. doi: 10.1016/j.jpeds.2017.04.050. Epub 2017 Jun 7.

Authors

Sanjay Chawla¹, Girija Natarajan², Seetha Shankaran², Benjamin Carper³, Luc P Brion⁴, Martin Keszler⁵, Waldemar A Carlo⁶, Namasivayam Ambalavanan⁶, Marie G Gantz³, Abhik Das⁷, Neil Finer⁸, Ronald N Goldberg⁹, C Michael Cotten⁹, Rosemary D Higgins¹⁰; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network

Collaborators

Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network:
Alan H Jobe¹¹, Michael S Caplan¹², Richard A Polin¹³, Abbot R Laptook¹⁴, William Oh¹⁴, Angelita M Hensman¹⁴, Dan Gingras¹⁴, Susan Barnett¹⁴, Sarah Lillie¹⁴, Kim Francis¹⁴, Dawn Andrews¹⁴, Kristen Angela¹⁴, Michele C Walsh¹⁵, Avroy A Fanaroff¹⁵, Nancy S Newman¹⁵, Bonnie S Siner¹⁵, Kurt Schibler¹⁶, Edward F Donovan¹⁶, Vivek Narendran¹⁶, Kate Bridges¹⁶, Barbara Alexander¹⁶, Cathy Grisby¹⁶, Marcia Worley Mersmann¹⁶, Holly L Mincey¹⁶, Jody Hessling¹⁶, Ronald N Goldberg¹⁷, Kathy J Auten¹⁷, Kimberly A Fisher¹⁷, Katherine A Foy¹⁷, Gloria Siaw¹⁷, Barbara J Stoll¹⁸, Susie Buchter¹⁸, Anthony Piazza¹⁸, David P Carlton¹⁸, Ellen C Hale¹⁸, Stephanie Wilson Archer¹⁹, Brenda B Poindexter²⁰, James A Lemons²⁰, Faithe Hamer²⁰, Dianne E Herron²⁰, Lucy C Miller²⁰, Leslie D Wilson²⁰, Mary Anne Berberich²¹, Carol J Blaisdell²¹, Dorothy B Gail²¹, James P Kiley²¹, W Kenneth Poole²², Margaret Cunningham²², Betty K Hastings²², Amanda R Irene²², Jeanette O'Donnell Auman²², Carolyn Petrie Huitema²², James W Pickett 2nd²², Dennis Wallace²², Kristin M Zaterka-Baxter²², Krisa P Van Meurs²³, David K Stevenson²³, M Bethany Ball²³, Melinda S Proud²³, Ivan D Frantz 3rd²⁴, John M Fiascone²⁴, Anne Furey²⁴, Brenda L MacKinnon²⁴, Ellen Nylen²⁴, Monica V Collins²⁵, Shirley S Cosby²⁵, Vivien A Phillips²⁵, Maynard R Rasmussen²⁶, Paul R Wozniak²⁶, Wade Rich²⁶, Kathy Arnell²⁶, Renee Bridge²⁶, Clarence Demetrio²⁶, Edward F Bell²⁷, John A Widness²⁷, Jonathan M Klein²⁷, Karen J Johnson²⁷, Shahnaz Duara²⁸, Ruth Everett-Thomas²⁸, Kristi L Watterberg²⁹, Robin K Ohls²⁹, Julie Rohr²⁹, Conra Backstrom Lacy²⁹, Dale L Phelps³⁰, Nirupama Laroia³⁰, Linda J Reubens³⁰, Erica Burnell³⁰, Pablo J Sánchez³¹, Charles R Rosenfeld³¹, Walid A Salhab³¹, James Allen³¹, Alicia Guzman³¹, Gaynelle Hensley³¹, Melissa H Lepps³¹, Melissa Martin³¹, Nancy A Miller³¹, Araceli Solis³¹, Diana M Vasil³¹, Kerry Wilder³¹, Kathleen A Kennedy³², Jon E Tyson³², Brenda H Morris³², Beverly Foley Harris³², Anna E Lis³², Sarah Martin³², Georgia E McDavid³², Patti L Tate³², Sharon L Wright³², Bradley A Yoder³³, Roger G Faix³³, Jill Burnett³³, Jennifer J Jensen³³, Karen A Osborne³³, Cynthia Spencer³³, Kimberlee Weaver-Lewis³³, T Michael O'Shea³⁴, Nancy J Peters³⁴, Beena G Sood³⁵, Rebecca Bara³⁵, Elizabeth Billian³⁵, Mary Johnson³⁵, Richard A Ehrenkranz³⁶, Harris C Jacobs³⁶, Vineet Bhandari³⁶, Pat Cervone³⁶, Patricia Gettner³⁶, Monica Konstantino³⁶, JoAnn Poulsen³⁶, Janet Taft³⁶

Affiliations

¹ Department of Pediatrics, Wayne State University, Detroit, MI. Electronic address: schawla@dmc.org.
² Department of Pediatrics, Wayne State University, Detroit, MI.
³ Social, Statistical and Environmental Sciences Unit, Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC.
⁴ Department of Pediatrics, University of Southwestern Medical Center, Dallas, TX.
⁵ Department of Pediatrics, Women and Infant Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI.
⁶ Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL.
⁷ Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD.
⁸ Department of Pediatrics, UC San Diego Medical Center, UC San Diego School of Medicine, San Diego, CA.
⁹ Department of Pediatrics, Duke University School of Medicine, Durham, NC.
¹⁰ Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.
¹¹ University of Cincinnati.
¹² University of Chicago, Pritzker School of Medicine.
¹³ Division of Neonatology, College of Physicians and Surgeons, Columbia University.
¹⁴ Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island.
¹⁵ Case Western Reserve University, Rainbow Babies and Children's Hospital.
¹⁶ Cincinnati Children's Hospital Medical Center, University of Cincinnati Hospital and Good Samaritan Hospital.
¹⁷ Duke University School of Medicine, University Hospital, Alamance Regional Medical Center, and Durham Regional Hospital.
¹⁸ Emory University, Children's Healthcare of Atlanta, Grady Memorial Hospital, and Emory Crawford Long Hospital.
¹⁹ Eunice Kennedy Shriver National Institute of Child Health and Human Development.
²⁰ Indiana University, Indiana University Hospital, Methodist Hospital, Riley Hospital for Children, and Wishard Health Services.
²¹ National Heart, Lung, and Blood Institute.
²² RTI International.
²³ Stanford University, Lucile Packard Children's Hospital.
²⁴ Tufts Medical Center, Floating Hospital for Children.
²⁵ University of Alabama at Birmingham, Health System and Children's Hospital of Alabama.
²⁶ University of California-San Diego, Medical Center and Sharp Mary Birch Hospital for Women.
²⁷ University of Iowa.
²⁸ University of Miami, Holtz Children's Hospital.
²⁹ University of New Mexico, Health Sciences Center.
³⁰ University of Rochester Medical Center, Golisano Children's Hospital.
³¹ University of Texas Southwestern Medical Center at Dallas, Parkland Health and Hospital System and Children's Medical Center Dallas.
³² University of Texas Health Science Center at Houston, Medical School and Children's Memorial Hermann Hospital.
³³ University of Utah Medical Center, Intermountain Medical Center, LDS Hospital, and Primary Children's Medical Center.
³⁴ Wake Forest University Baptist Medical Center, Brenner Children's Hospital and Forsyth Medical Center.
³⁵ Wayne State University, Hutzel Women's Hospital and Children's Hospital of Michigan.
³⁶ Yale University, Yale-New Haven Children's Hospital and Bridgeport Hospital.

Abstract

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.

Keywords: bronchopulmonary dysplasia; extremely preterm; extubation; neonatal morbidity.

Publication types

Randomized Controlled Trial
Research Support, N.I.H., Extramural

MeSH terms

Airway Extubation / adverse effects
Airway Extubation / methods*
Female
Humans
Infant, Extremely Premature
Infant, Newborn
Infant, Premature
Male
Morbidity
Pulmonary Surfactants / therapeutic use*
Respiratory Distress Syndrome, Newborn / mortality
Respiratory Distress Syndrome, Newborn / therapy*
Treatment Failure

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

Authors

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Affiliations

Abstract

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